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Davis’s Comprehensive
Handbook of Laboratory
and Diagnostic Tests—
with Nursing Implications
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Davis’s Comprehensive
Handbook of Laboratory
and Diagnostic Tests—
with Nursing
Implications
Second Edition

Anne M. Van Leeuwen, MA, BS, MT (ASCP)


Todd R. Kranpitz, MS, BS, ARRT (R) (N),
NM (NMTCB), ASCP (N)
Lynette S. Smith, FNP-BC, MSN, RN, MLT (ASCP)

F. A. DAVIS COMPANY • PHILADELPHIA


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F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2006 by F. A. Davis Company

All rights reserved. This book is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Lisa B. Deitch


Production Manager: Robert C. Butler

As new scientific information becomes available through basic and clinical research,
recommended treatments and drug therapies undergo changes. The authors and publisher have
done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. The authors, editors, and publisher are not responsible for
errors or omissions or for consequences from application of the book, and make no warranty,
expressed or implied, in regard to the contents of the book. Any practice described in this
book should be applied by the reader in accordance with professional standards of care used in
regard to the unique circumstances that may apply in each situation. The reader is advised
always to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especially
urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Van Leeuwen, Anne M.


Davis’s comprehensive handbook of laboratory and diagnostic tests : with nursing implications
/ Anne M. Van Leeuwen, Todd R. Kranpitz, Lynette Smith.— 2nd ed.
p. ; cm.
Rev. ed. of: Davis’s comprehensive handbook of laboratory and diagnostic tests / Zoanne
Burgess Schnell, Anne M. Van Leeuwen, Todd R. Kranpitz. c2003.
Includes bibliographical references and index.
ISBN 0-8036-1464-0
1. Diagnosis, Laboratory—Handbooks, manuals, etc. 2. Nursing—Handbooks, manuals, etc.
[DNLM: 1. Laboratory Techniques and Procedures—Handbooks. 2. Laboratory Techniques
and Procedures—Nurses’ Instruction. 3. Nursing Diagnosis—methods. 4. Diagnostic
Techniques and Procedures—Handbooks. 5. Diagnostic Techniques and Procedures—Nurses’
Instruction. QY 39 V217d 2006] I. Title: Comprehensive handbook of laboratory and diag-
nostic tests. II. Kranpitz, Todd R. III. Smith, Lynette. IV. Schnell, Zoanne Burgess. Davis’s
comprehensive handbook of laboratory and diagnostic tests. V. Title.
RB38.2.S37 2006
616.07′5—dc22
2005053757

Authorization to photocopy items for internal or personal use, or the internal or personal
use of specific clients, is granted by F. A. Davis Company for users registered with the
Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee
of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For
those organizations that have been granted a photocopy license by CCC, a separate system of
payment has been arranged. The fee code for users of the Transactional Reporting Service is:
8036-1042/03 0  $.10
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-Aminolevulinic Acid v

DEDICATION

I
nspiration springs from Passion.… Passion is born from unconstrained love, commit-
ment, and a vision no one else can own. Thank you Lynda, Mom & Dad, Adele, Gram,
Regina & Mark, Helen & Ricky, Todd, Kent & Cathy, JT, Bev, Cathy, Ev, Ruth, and
Lois…I am truly blessed by your friendship, love, and support. A huge hug for my daugh-
ters, Sarah and Margaret—I love you very much. To my puppies, Maggie and Tayor, for
their endless and unconditional love. With appreciation and in recognition of Stacey for her
assistance with this edition. My thanks and welcome to Lynette for her contributions to this
second edition; I look forward to our continued collaboration. Very special thanks to Lisa
Deitch, Acquisitions Editor, for her friendship, excellent direction, and unwavering encour-
agement.
Anne M. Van Leeuwen, MA, BS, MT (ASCP)
Chief Technologist
Highlands Regional Medical Center
Sebring, Florida
To my wife, Mindy, for her never ending support, and my son, Jake, for his demonstration
of commitment to a goal. I could not have done this book without them. To my coauthors,
for their dedication, endless commitment, and organizational skills. To Lisa Deitch, for her
continued faith in us, and support.
Todd R. Kranpitz, MS, BS, ARRT (R) (N), NM (NMTCB), ASCP (N)
Director of Imaging Services
King’s Daughters Medical Center
Ashland, Kentucky
To my husband, Steve, whose unconditional love, support, and encouragement holds me
steadfast in all my endeavors. To my sons, Eric and Michael, for their wisdom and humor
beyond their ages, you rock my world. To Anne, Todd, and Lisa, humble thanks for taking
this novice writer under your wings and believing in what I had to offer for this edition. I
look forward to future editions with this great team. And lastly, I wish to thank Dr. Mary
Bennett for her years of friendship and look forward to our continual mentoring of minds
in years to come.
Lynette S. Smith, FNP-BC, MSN, RN, MLT (ASCP)
Family Nurse Practitioner
Office of Lynette Smith FNP
Clinton, Indiana
Adjunct Faculty, Family Nurse Practitioner Program
College of Nursing, Indiana State University
Terre Haute, Indiana
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ABOUT THIS BOOK

L
aboratory and diagnostic studies are essential components of a complete patient
assessment. Examined in conjunction with an individual’s history and physical exam-
ination, laboratory and diagnostic data provide clues about health status. Nurses
are increasingly expected to integrate an understanding of laboratory and diagnostic proce-
dures and expected outcomes in assessment, planning, implementation, and evaluation of
nursing care. The data help develop and support nursing diagnoses, interventions, and
outcomes.
Nurses may interface with laboratory and diagnostic testing on several levels,
including:
• Interacting with patients and families of patients undergoing diagnostic tests
or procedures, and providing pretest, intratest, and post-test information and
support
• Maintaining quality control to prevent or eliminate problems that may inter-
fere with the accuracy and reliability of test results
• Ensuring completion of testing in a timely and accurate manner
• Collaborating with other health care professionals in interpreting findings as
they relate to planning and implementing total patient care
• Communicating significant alterations in test outcomes to other appropriate
health care team members
• Coordinating interdisciplinary efforts

Whether the nurse’s role at each level is direct or indirect, the underlying responsi-
bility to the patient, family, and community remains the same.
This book is a reference for nurses, nursing students, and other health care profes-
sionals. It is useful as a clinical tool as well as a supportive text to supplement clinical
courses. It guides the nurse in planning what needs to be assessed, monitored, treated,
and taught regarding pretest requirements, intratest procedures, and post-test care. It
can be used by nursing students at all levels as a textbook in theory classes, integrating
laboratory and diagnostic data as one aspect of nursing care; by practicing nurses, to
update information; and in clinical settings as a quick reference. Designed for use in
academic and clinical settings, Davis’s Comprehensive Handbook of Laboratory and
Diagnostic Procedures—with Nursing Implications provides the user with a comprehen-
sive reference that allows easy access to information about laboratory and diagnostic
tests and procedures. A general overview of how all the tests and procedures included
in this book relate to body systems can be found in tables at the end of the mono-

vii
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viii About This Book

graphs. All tests and procedures are listed in alphabetical order by their complete
name, allowing the user to locate information quickly without having to place tests in
a specific category or body system. Each monograph is presented in a consistent format
for easy identification of specific information at a glance. The following information
is provided for each laboratory and diagnostic test:
• Test Name for each monograph is given as a commonly used designation, and
all test monographs in the book are organized in alphabetical order by name.
• Synonyms/Acronyms for each test are listed where appropriate.
• Specimen Type includes the amount of specimen usually collected and, where
appropriate, the type of collection tube or container commonly recom-
mended. Specimen requirements vary from laboratory to laboratory. The
amount of specimen collected is usually more than what is minimally
required so that additional specimen is available, if needed, for repeat testing
(quality control failure, dilutions, or confirmation of unexpected results). In
the case of diagnostic tests, the type of test procedure (e.g., nuclear medicine,
x-ray) is given.
• Reference Values for each monograph include age-specific and gender-specific
variations, when indicated. It is important to give consideration to the
normal variation of laboratory values over the life span and across cultures;
sometimes what might be considered an abnormal value in one circumstance
is actually what is expected in another. Reference values for laboratory tests
are given in conventional and standard international (SI) units. The factor
used to convert conventional to SI units is also given. Because laboratory
values can vary by method, each laboratory reference range is listed along
with the associated methodology.
• Description & Rationale of the study’s purpose and insight into how and why
the test results can affect health are included.
• Indications are a list of what the test is used for in terms of assessment, evalu-
ation, monitoring, screening, identifying, or assisting in the diagnosis of a
clinical condition.
• Results present a list of conditions in which values may be increased or
decreased and, in some cases, an explanation of variations that may be
encountered.
• Critical Values, or findings that may be life-threatening or for which particu-
lar concern may be indicated, are given along with age span considerations
where applicable. This section also includes signs and symptoms associated
with a critical value as well as possible nursing interventions.
• Interfering Factors are substances or circumstances that may influence the
results of the test, rendering the results invalid or unreliable. Knowledge of
interfering factors is an important aspect of quality assurance and includes
pharmaceuticals, foods, natural and additive therapies, timing of test in rela-
tion to other tests or procedures, collection site, handling of specimen, and
underlying patient conditions.
• Nursing Implications and Procedure provides an outline of pretest, intratest,
and post-test concerns.
• Pretest section addresses the need to:
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About This Book ix

• Obtain pertinent clinical, laboratory, dietary, and therapeutic history of


the patient, especially as it pertains to comparison of previous test
results, preparation for the test, and identification of potentially interfer-
ing factors.
• Understand the interrelationship between various body systems. In this
section, the reader is informed of the body systems that may be involved
in the study of interest and is referred to system tables where related
studies are alphabetically cross-referenced.
• Explain the requirements and restrictions related to the procedure as well
as what to expect; provide the education necessary for the patient to be
properly informed.
• Anticipate and allay patient concerns or anxieties.
• Provide for patient safety.
• Intratest section can be used in a quality control assessment by the nurse or as
a guide to the nurse who may be called on to participate in specimen collec-
tion or perform preparatory procedures and gives:
• Specific directions for specimen collection and test performance.
• Important information such as patient sensation and expected duration
of the procedure.
• Precautions to be taken by the nurse and patient.
• Post-test section provides guidelines regarding:
• Specific monitoring and therapeutic measures that should be performed
after the procedure (e.g., maintaining bed rest, obtaining vital signs to
compare with baseline values, signs and symptoms of complications).
• Specific instructions for the patient and family, such as when to resume
usual diet, medications, and activity.
• General nutritional guidelines related to excess or deficit as well as
common food sources for dietary replacement.
• Indications for interventions from public health representatives or for
special counseling related to test outcomes.
• Indications for follow-up testing that may be required within specific
time frames.
• Related tests for consideration and evaluation, an alphabetical listing of
related laboratory and/or diagnostic tests that is intended to provoke a
deeper and broader investigation of multiple pieces of information; the
tests provide related data that, when combined, can form a more
complete picture of health or illness.

Color and icons have been used to facilitate locating critical information at a glance.
The nursing process is evident throughout the laboratory and diagnostic mono-
graphs. Within each phase of the testing procedure, the nurse has certain potential
roles and responsibilities. These should be evident in reading each monograph.
Information provided in the appendices includes a summary of specimen collection
procedures and materials, describing specific tube tops used for various blood tests and
their recommended order of draw; a summary chart of transfusion reactions, their
signs and symptoms, associated laboratory findings, and potential nursing interven-
tions; an introduction to CLIA with an explanantion of the different levels of testing
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x About This Book

complexity; a summary chart that details suggested approaches to persons at various


developmental stages to assist the provider in facilitating cooperation and understand-
ing; a list of some of the herbs and nutraceuticals that have been associated with
adverse clinical reactions or have been associated with drug interactions related to the
affected body system; and guidelines for Standard and Universal Precautions.
Finally, additional supportive materials are provided for the instructor and student
in an Instructor’s Guide. Presentations and case studies with emphasis on laboratory and
diagnostic test–related information and nursing implications have been developed for
selected conditions and body systems. Open-ended and NCLEX-type, multiple-choice
questions are provided as well as suggested critical thinking activities. This supple-
mental material will aid the instructor in integrating laboratory and diagnostic mate-
rials in assessment and clinical courses and provide examples of activities to enhance
student learning.
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PREFACE

L
aboratory and diagnostic testing. The words themselves often conjure up cold and
impersonal images of needles, specimens lined up in collection containers, and high-
tech electronic equipment. But they do not stand alone. They are tied to, bound with,
and tell of health or disease in the blood and tissue of a person. Laboratory and diagnostic
studies augment the health care provider’s assessment of the quality of an individual’s phys-
ical being. Test results guide the plans and interventions geared toward strengthening life’s
quality and endurance. Beyond the pounding noise of the MRI, the cold steel of the x-ray
table, the sting of the needle, the invasive collection of fluids and tissue, and the probing
and inspection is the gathering of evidence that supports the health care provider’s ability
to discern the course of a disease and the progression of its treatment. Laboratory and diag-
nostic data must be viewed with thought and compassion, however, as well as with micro-
scopes and machines. We must remember that behind the specimen and test result is the
person from whom it came, a person who is someone’s son, daughter, mother, father,
husband, wife, friend.
This book is written to help health care providers in their understanding and inter-
pretation of laboratory and diagnostic procedures and their outcomes. Just as impor-
tant, it is dedicated to all health care professionals who experience the wonders in the
science of laboratory and diagnostic testing, performed and interpreted in a caring and
efficient manner.

xi
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CONSULTANTS

Connie J. Frisch, RN, MA Deborah Little, MSN, RN, CCRN, CNRN,


Nursing Instructor APRN, BC
Central Lakes College Faculty Instructor
Brainerd, Minnesota Mountainside Hospital School of Nursing
Montclair, New Jersey
Mary K. Gerepka, MS, APRN, BC
Instructor Brooke C. Martin, RN, MSN, CNM,
Mountainside Hospital School of Nursing ARNP
Montclair, New Jersey Associate Professor Practical Nursing Program
Ivy Tech State College
Peggy L. Hawkins, RN, MSN, PHD, BC Indianapolis, Indiana
Professor of Nursing, Nursing Programs
Director Patricia A. Parsons RN, MSN, MS
College of Saint Mary Director of Associate Degree Nursing
Omaha, Nebraska Program
Riverland Community College
Beth Langlois, RN, MSN, APRN, BC Austin, Minnesota
CCU and Heart Failure Center Coordinator
Overlook Hospital, Atlantic Health System
Summit, New Jersey

xiii
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CONTENTS

DEDICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

ABOUT THIS BOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi

MONOGRAPHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

SYSTEM TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1387

APPENDIX A

Patient Preparation and Specimen Collection 1403


APPENDIX B

Potential Nursing Diagnoses Associated with Laboratory


and Diagnostic Testing 1416
APPENDIX C

Guidelines for Age-Specific Communication 1418


APPENDIX D

Transfusion Reactions: Laboratory Findings and Potential


Nursing Interventions 1422
APPENDIX E

Introduction to CLIA 1988 & 1992 1427


APPENDIX F
Effects of Natural Products on Laboratory Values 1428
APPENDIX G

Standard Precautions (CDC Isolation Precautions) 1431

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1453

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1459
xv
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ACETYLCHOLINE RECEPTOR
ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: AChR.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay) Less than 0.03 nmol/L.

DESCRIPTION & RATIONALE: Nor- moma. The relationship between the


mally when impulses travel down a thymus gland and MG is not com-
nerve, the nerve ending releases a neu- pletely understood. It is believed that
rotransmitter called acetylcholine. miscommunication in the thymus
Acetylcholine binds to receptor sites gland directed at developing immune
in the neuromuscular junction, which cells may trigger the development of
eventually results in muscle contrac- autoantibodies responsible for MG.
tion. When present, acetylcholine Remission after thymectomy is associ-
receptor (AChR) antibodies block ated with a progressive decrease in
acetylcholine from binding to recep- antibody level. Other markers used in
tor sites on the muscle membrane. the study of MG include muscle
AChR antibodies also destroy acetyl- AChR binding antibodies, muscle
choline receptor sites, interfering with AChR blocking antibodies, muscle
neuromuscular transmission and caus- AChR modulating antibodies, stria-
ing muscle weakness. Antibodies to tional antibodies, thyroglobulin,
AChR sites are present in 90% of HLA-B8, and HLA-DR3. These anti-
patients with generalized myasthenia bodies are often undetectable in the
gravis (MG) and in 55% to 70% of early stages of MG. ■
patients who either have ocular forms
of MG or are in remission. MG is an INDICATIONS:
acquired autoimmune disorder that • Confirm the presence, but not the
can occur at any age. It seems to strike severity, of MG
women between the ages of 20 and 40 • Monitor the effectiveness of immuno-
years; men appear to be affected later suppressive therapy for MG
in life than women. It can affect any • Monitor the remission stage of MG
voluntary muscle, but muscles that
control eye, eyelid, and facial move-
ment and swallowing are most fre- RESULT
quently affected. Antibodies may not Increased in:
be detected in the first six to twelve • Generalized MG
months, after the first appearance of • Thymoma associated with MG
symptoms. MG is the most common
complication associated with thy- Decreased in: Post-thymectomy
1
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2 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s mus-


culoskeletal system and results of
previously performed laboratory
INTERFERING FACTORS: tests, surgical procedures, and other
• Drugs that may increase AChR levels diagnostic procedures. For related
include penicillamine. tests, refer to the Musculoskeletal
System table.
• Biologic false-positive results may be ➤ Note any recent procedures that can
associated with amyotrophic lateral scle- interfere with test results.
rosis, autoimmune hepatitis, patients ➤ Obtain a list of the medications the
who have had a bone marrow trans- patient is taking, especially immuno-
plant, Eaton-Lambert myasthenic syn- suppressive drugs or prednisone.
drome, first-degree relatives of patients Include herbs, nutritional supple-
with MG (rare), thymoma with no evi- ments, and nutraceuticals. The
dence of MG, primary biliary cirrhosis, requesting health care practitioner
and laboratory should be advised if
encephalomyeloneuropathies associ-
the patient regularly uses these prod-
ated with carcinoma of the lung, and ucts so that their effects can be taken
elderly patients prone to autoimmune into consideration when reviewing
disorders. results.
• Immunosuppressive therapy is the rec- ➤ Review the procedure with the
ommended treatment for MG; prior patient. Inform the patient that spec-
imen collection takes approximately
immunosuppressive drug administra- 5 to 10 minutes. Address concerns
tion may result in negative test results. about pain related to the procedure.
• Recent radioactive scans or radiation Explain to the patient that there may
be some discomfort during the
within 1 week of the test can interfere
venipuncture.
with test results when radioimmunoas-
say is the test method. ➤ There are no food, fluid, or medica-
tion restrictions unless by medical
• Inability of the patient to cooperate or direction.
remain still during the procedure
because of age, significant pain, or Intratest:
mental status may interfere with the ➤ If the patient has a history of severe
test results. allergic reaction to latex, care should
be taken to avoid the use of equip-
ment containing latex.
Nursing Implications and ➤ Instruct the patient to cooperate fully
Procedure ● ● ● ● ● ● ● ● ● ● ●
and to follow directions. Direct the
patient to breathe normally and to
Pretest: avoid unnecessary movement.
➤ Observe standard precautions, and
➤ Inform the patient that the test is follow the general guidelines in
used to identify antibodies responsi- Appendix A. Positively identify the
ble for decreased neuromuscular patient, and label the appropriate
transmission and associated muscle tubes with the corresponding patient
weakness. demographics, date, and time of
➤ Obtain a history of the patient’s com- collection. Perform a venipuncture;
plaints, including a list of known collect the specimen in a 5-mL red-
allergens (especially allergies or sen- top tube.
sitivities to latex) and any prior com- ➤ Remove the needle, place gauze
plications with general anesthesia, over the puncture site and apply gen-
and inform the appropriate health tle pressure to stop bleeding.
care practitioner accordingly. Observe venipuncture site for bleed-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 3

Acid Phosphatase, Prostatic 3

ing or hematoma formation. Apply implications of the test results as


paper tape to hold gauze in place or appropriate. Educate the patient
replace with adhesive bandage. regarding access to counseling serv-
➤ Promptly transport the specimen to ices. Provide contact information, if
the laboratory for processing and desired, for the Myasthenia Gravis
analysis. Foundation of America (http://www.
myasthenia.org) and Muscular
➤ The results are recorded manually or Dystrophy Association (http://www.
in a computerized system for recall mdausa.org).
and postprocedure interpretation by
the appropriate health care practi- ➤ Reinforce information given by the
tioner. patient’s health care provider regard-
ing further testing, treatment, or
referral to another health care
Post-test: provider. Answer any questions or
address any concerns voiced by the
➤ A written report of the examination
patient or family.
will be sent to the requesting health
care practitioner, who will discuss ➤ Depending on the results of this pro-
the results with the patient. cedure, additional testing may be
performed to evaluate or monitor
➤ Recognize anxiety related to test progression of the disease process
results, and be supportive of impai- and determine the need for a change
red activity related to lack of neuro- in therapy. If a diagnosis of MG is
muscular control, perceived loss of made, a computed tomography scan
independence, and fear of shortened of the chest should be performed to
life expectancy. Discuss the implica- rule out thymoma. Evaluate test
tions of positive test results on the results in relation to the patient’s
patient’s lifestyle. It is important to symptoms and other tests per-
note that a diagnosis of MG should formed.
be based on positive results from
two different diagnostic tests. These Related laboratory tests:
tests include AChR antibody assay,
edrophonium test, repetitive nerve ➤ Related laboratory tests include anti-
stimulation, and single-fiber elec- nuclear antibodies, antithyroglobulin
tromyography. Evaluate test results and antithyroid peroxidase antibod-
in relationship to a future general ies, myoglobin, rheumatoid factor,
anesthesia. Provide teaching and thyroid-stimulating hormone, and
information regarding the clinical thyroxine.

ACID PHOSPHATASE, PROSTATIC


● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Prostatic acid phosphatase, o-phosphoric monoester


phosphohydrolase, AcP.

SPECIMEN: Serum (1 mL) collected in a red-top tube.


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4 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

A swab with vaginal secretions may be submitted in the appropriate trans-


fer container. Other material such as clothing may be submitted for analysis.
Consult the laboratory or emergency services department for the proper
specimen collection instructions and containers.

REFERENCE VALUE: (Method: Spectrophotometric)

Conventional & SI Units


Less than 2.5 ng/mL

effective treatment. Rising levels are


DESCRIPTION & RATIONALE: Acid associated with a poor prognosis.
phosphatases are enzymes found in
many tissues, including the prostate • Investigate or evaluate an enlarged
gland, bone, spleen, liver, and kidney, prostate gland, especially if prostatic
as well as in red blood cells and carcinoma is suspected.
platelets. Seminal fluid also contains
RESULT
high concentrations of acid phos-
phatase, and detection of this enzyme Increased in:
in vaginal swabs or from other physi- • Acute myelogenous leukemia
cal evidence is used to investigate rape. • After prostate surgery or biopsy
Acid phosphatase activity is highest in
• Benign prostatic hypertrophy
the prostate gland; however, prostatic
acid phosphatase (AcP) levels are not • Gaucher’s disease
significantly increased in the early • Liver disease
stages of prostatic cancer, so this test is • Metastatic bone cancer
not recommended as a screening • Niemann-Pick disease
tool. Prostate-specific antigen has • Paget’s disease
replaced AcP for the staging of carci-
• Prostatic cancer
noma of the prostate and diagnosis of
metastatic adenocarcinoma of the • Prostatic infarct
prostate. ■ • Prostatitis
• Sickle cell crisis
INDICATIONS: • Thrombocytosis
• Assist in the investigation of sexual
assault and rape. Decreased in: N/A

• Assist with differential diagnosis of


other disorders associated with elevated CRITICAL VALUES: N/A
AcP of nonprostatic origin.
INTERFERING FACTORS:
• Evaluate the effectiveness of treatment • Drugs that may increase AcP levels
for prostatic cancer (recurrence after include androgens (females), and clofi-
prostatectomy). Levels decrease with brate.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 5

Acid Phosphatase, Prostatic 5

• Drugs that may decrease AcP levels can be taken into consideration
include alcohol, ketoconazole, busere- when reviewing results.
lin and leuprolide. ➤ Review the procedure with the
patient. Inform the patient that spec-
• There is growing evidence that rectal imen collection takes approximately
palpation does not cause elevated AcP. 5 to 10 minutes. Address concerns
However, increases can occur due to about pain related to the procedure.
prostatic needle biopsy, cytoscopy, pro- Explain to the patient that there may
static infarction either by undergoing be some discomfort during the
catheterization or the presence of an venipuncture.
indwelling catheter, and rupture of a ➤ There are no food, fluid, or medica-
prostatic cyst (rare). tion restrictions unless by medical
direction.
• Specimens should be drawn in the
morning because AcP exhibits diurnal Intratest:
variation.
➤ If the patient has a history of severe
• Hemolysis interferes with the test allergic reaction to latex, care should
methodology. be taken to avoid the use of equip-
ment containing latex.
➤ Instruct the patient to cooperate fully
Nursing Implications and and to follow directions. Direct the
patient to breathe normally and to
Procedure ● ● ● ● ● ● ● ● ● ● ●
avoid unnecessary movement.
➤ Observe standard precautions, and
Pretest:
follow the general guidelines in
➤ Inform the patient that the test is pri- Appendix A. Positively identify the
marily used to assist in monitoring patient, and label the appropriate
treatment for prostate cancer. tubes with the corresponding patient
demographics, date, and time of
➤ Obtain a history of the patient’s com-
collection. Perform a venipuncture;
plaints, especially alterations in uri-
collect the specimen in a 5-mL red-
nary elimination. Obtain a list of
top tube.
known allergens, especially allergies
or sensitivities to latex, and inform ➤ Remove the needle, place gauze
the appropriate health care practi- over the puncture site and apply gen-
tioner accordingly. tle pressure to stop bleeding.
Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s gen-
ing or hematoma formation. Apply
itourinary, immune, and reproductive
paper tape over gauze or replace
systems and results of previously
with adhesive bandage.
performed laboratory tests, surgical
procedures, and other diagnostic ➤ Promptly transport the specimen to
procedures. For related laboratory the laboratory for processing and
tests, refer to the Genitourinary, analysis. AcP is very labile. Imme-
Immune, and Reproductive System diate seperation from blood cells and
tables. freezing of the serum stabilizes AcP.
➤ Note any recent procedures that can ➤ The results are recorded manually or
interfere with test results. in a computerized system for recall
and postprocedure interpretation by
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and nutra-
ceuticals. The requesting health care Post-test:
practitioner and laboratory should be
advised if the patient regularly uses ➤ A written report of the examination
these products so that their effects will be sent to the requesting health
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6 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

care practitioner, who will discuss guilt, depression, anger) as a victim


the results with the patient. of rape or sexual assault.
➤ Social and cultural considerations: ➤ Reinforce information given by the
Recognize anxiety related to test patient’s health care provider re-
results, and offer support. Provide garding further testing, treatment,
teaching and disease information, as or referral to another health care
appropriate. Counsel the male provider. Answer any questions or
patient, as appropriate, that sexual address any concerns voiced by the
dysfunction related to altered body patient or family.
function, drugs, or radiation may
➤ Depending on the results of this pro-
occur. Educate the patient regard-
cedure, additional testing may be
ing counseling services, as appro-
performed to evaluate or monitor
priate.
progression of the disease process
➤ Social and cultural considerations: and determine the need for a change
Offer support, as appropriate, to in therapy. Evaluate test results in
patients who may be the victim of relation to the patient’s symptoms
rape or sexual assault. Educate the and other tests performed.
patient regarding access to counsel-
ing services. Provide a nonjudgmen- Related laboratory tests:
tal, nonthreatening atmosphere for
discussing the risks of sexually trans- ➤ Related laboratory tests include
mitted diseases. Discuss problems prostate biopsy, prostate-specific
the patient may experience (e.g., antigen, and semen analysis.

ADRENAL GLAND SCAN


● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: Adrenal scintiscan.


AREA OF APPLICATION: Adrenal gland.
CONTRAST: Intravenous radioactive NP-59 (iodomethyl-19-norcholesterol)
or metaiodobenzylguanidine (MIBG).

DESCRIPTION & RATIONALE: This adenoma in primary aldosteronism


nuclear medicine study evaluates func- when computed tomography (CT)
tion of the adrenal glands. The secre- and magnetic resonance imaging
tory function of the adrenal glands is (MRI) findings are equivocal. High
controlled primarily by the anterior concentrations of cholesterol (the
pituitary, which produces adrenocorti- precursor in the synthesis of adreno-
cotropic hormone (ACTH). ACTH corticosteroids, including aldosterone)
stimulates the adrenal cortex to pro- are stored in the adrenal cortex.
duce cortisone and secrete aldos- This allows the radionuclide, which
terone. Adrenal imaging is most useful attaches to the cholesterol, to be used
in differentiation of hyperplasia versus in identifying pathology in the secre-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 7

Adrenal Gland Scan 7

tory function of the adrenal cortex. • Adrenal tumor


The uptake of the radionuclide occurs • Hyperplasia
gradually over time; imaging is per- • Infection
formed within 24 to 48 hours of injec-
tion of the radionuclide dose and • Pheochromocytoma
continued daily for 3 to 5 days.
Imaging reveals increased uptake, uni- INTERFERING FACTORS
lateral or bilateral uptake, or absence
This procedure is
of uptake in the detection of patho- contraindicated for:
logic processes. Following prescanning
• Patients who are pregnant or suspected
treatment with corticosteroids, sup- of being pregnant, unless the potential
pression studies can be done to differ- benefits of the procedure far outweigh
entiate the presence of tumor from the risks to the fetus and mother.
hyperplasia of the glands. ■
Factors that may impair
clear imaging:
INDICATIONS:
• Aid in the diagnosis of Cushing’s syn- • Inability of the patient to cooperate or
drome and aldosteronism remain still during the procedure
because of age, significant pain, or
• Aid in the diagnosis of gland tissue mental status
destruction caused by infection, infarc-
tion, neoplasm, or suppression • Retained barium from a previous radi-
ologic procedure
• Aid in locating adrenergic tumors
• Obesity, because patients may exceed
• Determine adrenal suppressibility with the weight limit for the equipment
prescan administration of corticos- • Incorrect positioning of the patient,
teroid to diagnose and localize adrenal which may produce poor visualization
adenoma, aldosteronomas, androgen of the area to be examined
excess, and low-renin hypertension
• Differentiate between asymmetric Other considerations:
hyperplasia and asymmetry from aldos- • Improper injection of the radionuclide
teronism with dexamethasone suppres- may allow the tracer to seep deep into
sion test the muscle tissue, producing erroneous
hot spots.
RESULT • Consultation with a physician should
occur before the procedure for radia-
Normal Findings: tion safety concerns regarding youn-
• No evidence of tumors, infection, ger patients or patients who are lactat-
infarction, or suppression ing.
• Normal bilateral uptake of radionuclide • Risks associated with radiologic overex-
and secretory function of adrenal cortex posure can result from frequent x-ray
procedures. Personnel in the room with
• Normal salivary glands and urinary
the patient should wear a protective
bladder; vague shape of the liver and
lead apron, stand behind a shield, or
spleen sometimes seen
leave the area while the examination is
Abnormal Findings: being done. Badges that reveal the level
of exposure to radiation should be
• Adrenal gland suppression
worn by persons working in the area
• Adrenal infarction where the examination is being done.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 8

8 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Make sure a written and informed


Nursing Implications and consent has been signed prior to the
Procedure ● ● ● ● ● ● ● ● ● ● ● procedure and before administering
any medications.
Pretest:
➤ Inform the patient that the procedure Intratest:
detects adrenal gland function.
➤ Ensure that the patient has removed
➤ Obtain a history of the patient’s com- jewelry, dentures, all external metal-
plaints and symptoms, including a lic objects, and the like prior to the
list of known allergens. procedure.
➤ Obtain a history of results of previ- ➤ Have emergency equipment readily
ously performed diagnostic proce- available.
dures, surgical procedures, and
laboratory tests. All adrenal blood ➤ Patients are given a gown, robe, and
tests should be done before doing foot coverings to wear and instructed
this test. For related tests, refer to to void prior to the procedure.
the Endocrine System table. ➤ Insert an intravenous line, and inject
➤ Record the date of last menstrual the radionuclide intravenously on day
period and determine the possibility 1; images are taken on days 1, 2, and
of pregnancy in perimenopausal 3. Imaging is done from the urinary
women. bladder to the base of the skull to
scan for a primary tumor. Each image
➤ Obtain a list of the patient’s current
takes 20 minutes, and total imaging
medications.
time is 1 to 2 hours per day.
➤ Review the procedure with the
patient. Address concerns about pain ➤ Instruct the patient to cooperate fully
related to the procedure. Explain to and to follow directions. Instruct the
the patient that some pain may be patient to remain still throughout the
experienced during the test, and procedure because movement pro-
there may be moments of discom- duces unreliable results.
fort. Inform the patient that the pro- ➤ Observe standard precautions, and
cedure is performed in a nuclear follow the general guidelines in
medicine department, usually by a Appendix A.
nuclear medicine technologist with
➤ The images are recorded on film or
support staff, and takes approx-
stored electronically for recall and
imately 60 minutes to 120 minutes
postprocedure interpretation by a
each day. Inform the patient the test
health care practitioner specializing
usually involves a prolonged scan-
in this branch of medicine.
ning schedule over a period of days.
➤ Administer saturated solution of Post-test:
potassium iodide (SSKI) 24 hours
before the study to prevent thyroid ➤ Unless contraindicated, advise pati-
uptake of the free radioactive iodine. ent to drink increased amounts of
➤ Sensitivity to cultural and social fluids for 24 to 48 hours to eliminate
issues, as well as concern for mod- the radionuclide from the body. Tell
esty, is important in providing psy- the patient that radionuclide is elimi-
chological support before, during, nated from the body within 24 to 48
and after the procedure. hours.
➤ There are no food, fluid, or medica- ➤ No other radionuclide tests should
tion restrictions unless by medical be scheduled for 24 to 48 hours after
direction. this procedure.
➤ Instruct the patient to remove den- ➤ Instruct the patient in the care and
tures, jewelry (including watches), assessment of the injection site;
hairpins, credit cards, and other observe for bleeding, hematoma for-
metallic objects. mation, and inflammation.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 9

Adrenocorticotropic Hormone (and Challenge Tests) 9

➤ If a woman who is breast-feeding practitioner, who will discuss the


must have a nuclear scan, she results with the patient.
should not breast-feed the infant ➤ Reinforce information given by the
until the radionuclide has been elimi- patient’s health care provider regard-
nated. This could take as long as ing further testing, treatment, or
3 days. She should be instructed to referral to another health care pro-
express the milk and discard it dur- vider. Advise the patient that SSKI
ing the 3-day period to prevent ces- (120 mg/day) will be administered for
sation of milk production. 10 days after the injection of the
➤ Instruct the patient to immediately radionuclide. Answer any questions
flush the toilet and to meticulously or address any concerns voiced by
wash hands with soap and water the patient or family.
after each voiding for 48 hours after
➤ Depending on the results of this pro-
the procedure.
cedure, additional testing may be
➤ Instruct all caregivers to wear gloves needed to evaluate or monitor pro-
when discarding urine for 48 hours gression of the disease process and
after the procedure. Wash gloved determine the need for a change in
hands with soap and water before therapy. Evaluate test results in rela-
removing gloves. Then wash ung- tion to the patient’s symptoms and
loved hands after the gloves are other tests performed.
removed.
➤ A written report of the examination Related diagnostic tests:
will be completed by a health care
practitioner specializing in this ➤ Computed tomography of the abdo-
branch of medicine. The report will men and magnetic resonance imag-
be sent to the requesting health care ing of the abdomen.

ADRENOCORTICOTROPIC HORMONE
(AND CHALLENGE TESTS)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: Corticotropin, ACTH.


SPECIMEN: Plasma (2 mL) from lavender-top (EDTA) tube for adrenocorti-
cotropic hormone (ACTH), and serum (1 mL) from a red-top tube for cor-
tisol. Collect specimens in a prechilled heparinized plastic syringe, and
carefully transfer into collection containers by gentle injection to avoid
hemolysis. Alternatively, specimens can be collected in prechilled lavender-
and red-top tubes. Tiger- and green-top (heparin) tubes are also acceptable
for cortisol, but take care to use the same type of collection container for
serial measurements. Immediately transport specimen tightly capped and
in an ice slurry to the laboratory. The specimens should be immediately
processed. Plasma for ACTH analysis should be transferred to a plastic
container.
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10 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Medication
Administered, Recommended
Procedure Adult Dosage Collection Times
ACTH stimulation, 1 g (low-dose 3 cortisol levels: baseline
rapid test protocol) cosyntropin immediately before bolus,
IM 30 min after bolus, and
60 min after bolus
Corticotropin- IV dose of 1 g/kg 8 cortisol and 8 ACTH levels:
releasing ovine CRH at 9 a.m. baseline collected 15 min
hormone (CRH) or 8 p.m. before injection, 0 minutes
stimulation before injection, and then
5, 15, 30, 60, 120, and 180
min after injection
Dexamethasone Oral dose of 1 mg Collect cortisol at 8 a.m. on
suppression dexamethasone the morning after the
(overnight) (Decadron) at 11 p.m. dexamethasone dose
Metyrapone Oral dose of 30 mg/kg Collect cortisol and ACTH at
stimulation metyrapone with 8 a.m. on the morning
(overnight) snack at midnight after the metyrapone dose
IM  intramuscular, IV  intravenous.

REFERENCE VALUE: (Method: Immunoradiometric assay)


ACTH

Conventional SI Units (Conventional


Age Units Units  0.22)
Cord blood 50–570 pg/mL 11–125 pmol/L
Newborn 10–185 pg/mL 2–41 pmol/L
Adult supine specimen 9–52 pg/mL 2–11 pmol/L
collected in morning
Women on oral 5–29 pg/mL 1–6 pmol/L
contraceptives

ACTH Challenge Tests

ACTH (Cosyntropin) SI Units


Stimulated, (Conversion
Rapid Test Conventional Units Factor  27.6)
Baseline Cortisol greater than Greater than 138
5 g/dL nmol/L
30- or 60-min Cortisol 18–20 g/dL 496–552 nmol/L
response or incremental
increase of 7 g/dL
over baseline value
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 11

Adrenocorticotropic Hormone (and Challenge Tests) 11

Corticotropin- SI Units
Releasing Hormone (Conventional
Stimulated Conventional Units Units  27.6)
Cortisol 10 a.m. 359 nmol/L or
13 g/dL or 470 nmol/L
9 p.m. 17 g/dL
ACTH 9:30 a.m. 17.6 pmol/L or
80 pg/ml or 6.4 pmol/L
8:30 p.m. 29pg/ml

Dexamethasone SI Units
Suppressed (Conventional
Overnight Test Conventional Units Units  27.6)
Cortisol less than Less than 83
3 g/dL next day nmol/L

Metyrapone SI Units
Stimulated (Conventional
Overnight Test Conventional Units Units  0.22)
ACTH greater than Greater than
75 pg/mL 16.5 pmol/L

Cortisol less than Less than


3 g/dL next day 83 nmol/L

DESCRIPTION & RATIONALE: source is termed Cushing syndrome.


Hypothalamic-releasing factor stimu- Cortisol excess resulting from ACTH
lates the release of adrenocorticotropin excess produced by the pituitary is
hormone (ACTH) from the anterior termed Cushing disease. ACTH levels
pituitary gland. This hormone stimu- exhibit a diurnal variation, peaking
lates adrenal cortex secretion of gluco- between 6 and 8 a.m. and reaching the
corticoids, androgens, and, to a lesser lowest point between 6 and 11 p.m.
degree, mineralocorticoids. Angioten- Evening levels are generally one-half to
sin II is the other primary adrenal cor- two-thirds lower than morning levels.
tex stimulant. Cortisol is the major Cortisol levels also vary diurnally, with
glucocorticoid secreted by the adrenal the lowest values occurring during the
cortex. ACTH and cortisol test results morning hours and peak levels occur-
are evaluated together because nor- ring in the evening. ■
mally a change in one causes a change
in the other. ACTH secretion is stim- INDICATIONS:
ulated by insulin, metyrapone, and • Determine adequacy of replacement
vasopressin. It is decreased by dexam- therapy in congenital adrenal hyper-
ethasone. Cortisol excess from any plasia
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 12

12 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Determine adrenocortical dysfunction is secreted ectopically (e.g., tumors not


located in the pituitary gland that secrete
• Differentiate between increased ACTH ACTH). Patients with pituitary tumors
release with decreased cortisol levels tend to respond to CRH stimula-
and decreased ACTH release with tion, whereas those with ectopic tumors
increased cortisol levels do not. Patients with adrenal insuffi-
ciency demonstrate one of three patterns
RESULT: depending on the underlying cause:
ACTH Result: • Primary adrenal insufficiency—high
baseline ACTH (in response to intra-
Because ACTH and cortisol secretion
venous [IV] ACTH) and low cortisol
exhibits diurnal variation with values
levels pre- and post-IV ACTH.
being highest in the morning, a lack of
change in values from morning to • Secondary adrenal insufficiency (pitu-
evening is clinically significant. Decreased itary)—low baseline ACTH that does
concentrations of hormones secreted by not respond to ACTH stimulation.
the pituitary gland and its target organs Cortisol levels do not increase after
are observed in hypopituitarism. In pri- stimulation.
mary adrenal insufficiency (Addison’s dis-
• Tertiary adrenal insufficiency (hypo-
ease) due to adrenal gland destruction by
thalmic)—low baseline ACTH with an
tumor, infectious process, or immune
exaggerated and prolonged response to
reaction, ACTH levels are elevated while
stimulation. Cortisol levels usually do
cortisol levels are decreased. Both ACTH
not reach 20 g/dL.
and cortisol levels are decreased in sec-
ondary adrenal insufficiency (i.e., second- The DST is useful in differentiating
ary to pituitary insufficiency). Excess the causes of increased cortisol levels.
ACTH can be produced ectopically by Dexamethasone is a synthetic glucocorti-
various lung cancers such as oat cell carci- coid that is 64 times more potent than
noma and large-cell carcinoma of the cortisol. It works by negative feedback. It
lung and by benign bronchial carcinoid suppresses the release of ACTH in
tumor. patients with a normal hypothalamus. A
cortisol level less than 3.0 g/dL usually
excludes Cushing’s syndrome. With the
Challenge Tests and Results:
DST, a baseline morning cortisol level is
The ACTH (cosyntropin) stimulated rapid collected, and the patient is given a 1-mg
test directly evaluates adrenal gland func- dose of dexamethasone at bedtime. A
tion and indirectly evaluates pituitary second specimen is collected the follow-
gland and hypothalmus function. Cosyn- ing morning. If cortisol levels have not
tropin is a synthetic form of ACTH. A been suppressed, adrenal adenoma is
baseline cortisol level is collected before suspected. The DST also produces abnor-
the injection of cosyntropin. Specimens mal results in the presence of certain
are subsequently collected at 30- and 60- psychiatric illnesses (e.g., endogenous
minute intervals. If the adrenal glands depression).
function normally, cortisol levels rise sig- The metyrapone stimulation test is used
nificantly after administration of cosyn- to distinguish corticotropin-dependent
tropin. causes (pituitary Cushing’s disease and
The CRH stimulation test works as ectopic Cushing’s disease) from corti-
well as the dexamethasone suppression cotropin-independent causes (e.g., carci-
test (DST) in distinguishing Cushing’s noma of the lung or thyroid) of increased
disease from conditions in which ACTH cortisol levels. Metyrapone inhibits the
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 13

Adrenocorticotropic Hormone (and Challenge Tests) 13

conversion of 11-deoxycortisol to corti- CRITICAL VALUES: N/A


sol. Cortisol levels should decrease to less
than 3 g/dL if normal pituitary stimula- INTERFERING FACTORS:
tion by ACTH occurs after an oral dose • Drugs that may increase ACTH levels
of metyrapone. Specimen collection and include aminoglutethimide, ampheta-
administration of the medication are per- mines, calcium gluconate, estrogens,
formed as with the overnight dexametha- insulin, levodopa, metoclopramide,
sone test. metyrapone, mifepristone (RU 486),
pyrogens, spironolactone, and vaso-
ACTH Increased in: pressin.
• Addison’s disease (primary adrenocorti- • Drugs that may decrease ACTH levels
cal hypofunction) include adrenal corticosteroids, dexam-
• Carcinoid syndrome ethasone, ethanol, and lithium carbon-
ate.
• Congenital adrenal hyperplasia
• Test results are affected by the time the
• Cushing’s disease (pituitary dependent) test is done because ACTH levels vary
• Depression diurnally, with the highest values
occurring between 6 and 8 a.m. and
• Ectopic ACTH-producing tumors the lowest values occurring at night.
• Lung cancer Samples should be collected at the
same time of day, between 6 and 8 a.m.
• Menstruation
• Excessive physical activity can produce
• Nelson’s syndrome (ACTH-producing elevated levels.
pituitary tumors)
• Recent radioactive scans or radiation
• Non–insulin-dependent diabetes within 1 week before the test can inter-
• Pregnancy fere with test results when immunora-
diometric assay is the test method.
• Sepsis
• The metyrapone stimulation test
• Septic shock is contraindicated in patients with
• Stress suspected adrenal insufficiency.
• Metyrapone may cause gastroin-
ACTH Decreased in:
testinal distress and/or confusion.
• Adrenal adenoma Administer oral dose of metyrapone
• Adrenal cancer with milk and snack.

• Adrenal cortical hyperfunction • Rapid clearance of metyrapone,


resulting in falsely increased corti-
• Glucocorticoid excess (in Cushing sol levels, may occur if the patient is
patients with primary adrenocortical taking drugs that enhance steroid
tumor) metabolism (e.g., phenytoin, rifam-
• Hemochromatosis pin, phenobarbital, mitotane, and
corticosteroids). The primary care prac-
• Hypopituitarism titioner should be consulted prior to
• Major depressive order a metyrapone stimulation test regarding
a decision to withhold these medica-
• Secondary adrenocortical insufficiency tions.
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14 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

some discomfort during the venipu-


Nursing Implications and ncture.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ There are no food, fluid, or medica-
tion restrictions unless by medical
Pretest: direction.
➤ Inform the patient that the test is ➤ Drugs that enhance steroid metabo-
used to assess for pituitary hormone lism may be withheld by medical
deficiency. direction prior to metyrapone stimu-
lation testing.
➤ Obtain a history of the patient’s com-
plaints, including a list of known ➤ Instruct the patient to refrain from
allergens (especially allergies or sen- strenuous exercise for 12 hours
sitivities to latex), and inform the before the test and to remain in bed
appropriate health care practitioner or at rest for 1 hour immediately
accordingly. before the test. Avoid smoking and
ETOH use.
➤ Weigh patient and report weight to
➤ Prepare an ice slurry in a cup or plas-
lab for 30 mg/kg dosing of metyra-
tic bag to have on hand for immedi-
pone.
ate transport of the specimen to the
➤ Obtain a history of the patient’s laboratory.
endocrine system and results of pre-
viously performed laboratory tests, Intratest:
surgical procedures, and other diag-
nostic procedures. For related tests, ➤ Ensure that strenuous exercise was
refer to the Endocrine System table. avoided for 12 hours before the test
and that 1 hour of bed rest was
➤ Note any recent procedures that can
taken immediately before the test.
interfere with test results.
Samples should be collected bet-
➤ Obtain a list of the medications the ween 6 and 8 a.m.
patient is taking, especially drugs ➤ Have emergency equipment readily
that enhance steroid metabolism available in case of adverse reaction
and include herbs, nutritional supple- to metyrapone.
ments, and nutraceuticals. The
requesting health care practitioner ➤ If the patient has a history of severe
and laboratory should be advised if allergic reaction to latex, care should
the patient regularly uses these be taken to avoid the use of equip-
products so that their effects can be ment containing latex.
taken into consideration when ➤ Instruct the patient to cooperate fully
reviewing results. and to follow directions. Direct the
patient to breathe normally and to
➤ Review the procedure with the pati- avoid unnecessary movement.
ent. When ACTH hypersecretion is
suspected, a second sample may be ➤ Observe standard precautions, and
requested between 6 and 8 p.m. to follow the general guidelines in
determine if changes are the result Appendix A. Positively identify the
of diurnal variation in ACTH levels. patient, and label the appropriate
Inform the patient that more than tubes with the corresponding patient
one sample may be necessary to demographics, date, and time of col-
ensure accurate results and that the lection. Perform a venipuncture; col-
samples are obtained at specific lect the specimen in a prechilled
times to determine high and low lev- plastic heparinized syringe or in
els of the hormone. Inform the prechilled collection containers as
patient that each specimen collec- listed under “Specimen.”
tion takes approximately 5 to 10 min- ➤ Adverse reactions to metyrapone
utes. Address concerns about pain include nausea and vomiting (N/V),
related to the procedure. Explain abdominal pain, headache, dizziness,
to the patient that there may be sedation, allergic rash, decreased
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 15

Alanine Aminotransferase 15

white blood cell count, or bone ➤ A written report of the examination


marrow depression. Signs and sym- will be sent to the requesting health
ptoms of overdose or acute adreno- care practitioner, who will discuss
cortical insuffiency include cardiac the results with the patient.
arrhythmias, hypotension, dehydra-
➤ Reinforce information given by the
tion, anxiety, confusion, weakness,
patient’s health care provider regard-
impairment of consciousness, N/V,
ing further testing, treatment, or
epigastric pain, diarrhea, hypona-
referral to another health care pro-
tremia, and hyperkalemia.
vider. Answer any questions or
➤ Remove the needle, place a gauze address any concerns voiced by the
over the puncture site and apply gen- patient or family.
tle pressure. Observe venipuncture
site for bleeding or hematoma for- ➤ Depending on the results of this pro-
mation. Apply paper tape over gauze cedure, additional testing may be
or replace with adhesive bandage. performed to evaluate or monitor
progression of the disease process
➤ Promptly transport the specimen to and determine the need for a change
the laboratory for processing and in therapy. If a diagnosis of Cushing’s
analysis. The tightly capped sample disease is made, pituitary computed
should be placed in an ice slurry tomography (CT) or magnetic reso-
immediately after collection. Infor- nance imaging (MRI) may be indi-
mation on the specimen label can be cated prior to surgery. If a diagnosis
protected from water in the ice of ectopic corticotropin syndrome is
slurry if the specimen is first placed made, abdominal CT or MRI may be
in a protective plastic bag. indicated prior to surgery. Evaluate
➤ The results are recorded manually or test results in relation to the patient’s
in a computerized system for recall symptoms and other tests per-
and postprocedure interpretation by formed.
the appropriate health care practi-
tioner.
Related laboratory tests:

Post-test: ➤ Related laboratory tests include cor-


tisol, follicle-stimulating hormone,
➤ Instruct the patient to resume nor- growth hormone, luteinizing hor-
mal activity as directed by the health mone, testosterone, thyroid-stimu-
care practitioner. lating hormone, and thyroxine.

ALANINE AMINOTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYMS: Serum glutamic pyruvic transaminase


(SGPT), ALT.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma


(1 mL) collected in a green-top (heparin) tube is also acceptable.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 16

16 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

REFERENCE VALUE: (Method: Spectrophotometry)

Conventional
than 1.5 times the upper limits of nor-
Age & SI Units
mal.

Newborn–1 y 13–45 U/L


2 y–adult
RESULT
Male 10–40 U/L
Increased in:
Female 7–35 U/L
• Acute pancreatitis
• Biliary tract obstruction
• Burns (severe)
DESCRIPTION & RATIONALE: Alanine • Chronic alcohol abuse
aminotransferase (ALT), formerly
known as serum glutamic pyruvic • Cirrhosis
transaminase (SGPT), is an enzyme • Fatty liver
produced by the liver. It acts as a cata-
• Hepatic carcinoma
lyst in the reversible transfer of an
amino group between alanine and - • Hepatitis
ketoglutarate. The highest concentra- • Infectious mononucleosis
tion of ALT is found in liver cells,
moderate amounts are found in kid- • Muscle injury from intramuscular injec-
tions, trauma, infection, and seizures
ney cells, and smaller amounts are
(recent)
found in heart and skeletal muscle
cells. When liver damage occurs, • Muscular dystrophy
serum levels of ALT rise to 50 times • Myocardial infarction
normal, making this a useful test in
• Myositis
evaluating liver injury. ALT is also
used to screen donated blood before • Pre-eclampsia
transfusion because the enzyme may • Shock (severe)
be elevated in the absence of detectable
serologic markers of hepatitis. ■ Decreased in:
• Pyridoxal phosphate deficiency
INDICATIONS:
• Compare serially with aspartate amino-
transferase (AST) levels to track the CRITICAL VALUES: N/A
course of liver disease.
Interfering Factors
• Monitor liver damage resulting from • Drugs that may increase ALT levels by
hepatotoxic drugs. causing cholestasis include amitripty-
• Monitor response to treatment of liver line, anabolic steroids, androgens,
disease, with tissue repair indicated by benzodiazepines, chlorothiazide, chlor-
gradually declining levels. propamide, dapsone, erythromycin,
estrogens, ethionamide, gold salts,
• In blood banks, use as a routine screen imipramine, mercaptopurine, nitrofu-
for hepatitis in donor blood samples. rans, oral contraceptives, penicillins,
Samples are rejected if levels are greater phenothiazines, progesterone, propoxy-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 17

Alanine Aminotransferase 17

phene, sulfonamides, tamoxifen, and these products so that their effects


tolbutamide. can be taken into consideration
when reviewing results.
• Drugs that may increase ALT levels by
➤ Review the procedure with the
causing hepatocellular damage include
patient. Inform the patient that spec-
acetaminophen (toxic), acetylsalicylic imen collection takes approximately
acid, allopurinol, amiodarone, anabolic 5 to 10 minutes. Address concerns
steroids, anticonvulsants, asparaginase, about pain related to the procedure.
azithromycin, bromocriptine, capto- Explain to the patient that there may
pril, cephalosporins, chloramphenicol, be some discomfort during the
clindamycin, clofibrate, danazol, enflu- venipuncture.
rane, ethambutol, ethionamide, fenofi- ➤ There are no food, fluid, or medica-
brate, fluconazole, fluoroquinolones, tion restrictions unless by medical
foscarnet, gentamicin, indomethacin, direction.
interferon, interleukin-2, levamisole,
levodopa, lincomycin, low-molecular- Intratest:
weight heparin, methyldopa, mono- ➤ If the patient has a history of severe
amine oxidase inhibitors, naproxen, allergic reaction to latex, care should
nifedipine, nitrofurans, oral contra- be taken to avoid the use of equip-
ceptives, probenecid, procainamide, ment containing latex.
quinine, ranitidine, retinol, ritodrine, ➤ Instruct the patient to cooperate fully
sulfonylureas, tetracyclines, tobramy- and to follow directions. Direct the
cin, and verapamil. patient to breathe normally and to
avoid unnecessary movement.
• Drugs that may decrease ALT levels
➤ Observe standard precautions, and
include cyclosporine and interferon. follow the general guidelines in
Appendix A. Positively identify the
Nursing Implications and patient, and label the appropriate
Procedure ● ● ● ● ● ● ● ● ● ● ● tubes with the corresponding patient
demographics, date, and time of col-
Pretest: lection. Perform a venipuncture; col-
lect the specimen in a 5-mL red- or
➤ Inform the patient that the test is tiger-top tube.
used to assess liver function.
➤ Remove the needle, place a gauze
➤ Obtain a history of the patient’s com- over the puncture site and apply gen-
plaints, including a list of known tle pressure to stop bleeding.
allergens (especially allergies or sen- Observe venipuncture site for bleed-
sitivities to latex), and inform the ing and hematoma formation. Apply
appropriate health care practitioner paper tape over gauze or replace
accordingly. with adhesive bandage.
➤ Obtain a history of the patient’s ➤ Promptly transport the specimen to
hepatobiliary system and results of the laboratory for processing and
previously performed laboratory analysis.
tests, surgical procedures, and other
diagnostic procedures. For related ➤ The results are recorded manually or
laboratory tests, refer to the Hepa- in a computerized system for recall
tobiliary System table. and postprocedure interpretation by
the appropriate health care practi-
➤ Obtain a list of the medications the tioner.
patient is taking, including herbs,
nutritional supplements, and nutra- Post-test:
ceuticals. The requesting health care
practitioner and laboratory should be ➤ Instruct the patient to resume usual
advised if the patient regularly uses diet, fluids, medications, or activity,
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 18

18 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

as directed by the health care practi- ➤ A written report of the examination


tioner. will be sent to the requesting health
➤ Nutritional considerations: Increased care practitioner, who will discuss
ALT levels may be associated with the results with the patient.
liver disease. Dietary recommenda- ➤ Reinforce information given by the
tions may be indicated and vary patient’s health care provider regard-
depending on the severity of the ing further testing, treatment, or
condition. A low-protein diet may be referral to another health care pro-
in order if the patient’s liver has lost vider. Answer any questions or
the ability to process the end prod- address any concerns voiced by the
ucts of protein metabolism. A diet of patient or family.
soft foods may be required if
esophageal varices have developed. ➤ Depending on the results of this pro-
Ammonia levels may be used to cedure, additional testing may be
determine whether protein should performed to evaluate or monitor
be added to or reduced from the progression of the disease process
diet. Patients should be encouraged and determine the need for a change
to eat simple carbohydrates and in therapy. Evaluate test results in
emulsified fats (as in homogenized relation to the patient’s symptoms
milk or eggs), as opposed to com- and other tests performed.
plex carbohydrates (e.g., starch,
fiber, and glycogen [animal carbohy-
drates]) and complex fats, which Related laboratory tests:
would require additional bile to emul-
sify them so that they can be used. ➤ Related laboratory tests include acet-
The cirrhotic patient should be care- aminophen, ammonia, AST, bilirubin,
fully observed for the development electrolytes, -glutamyl transpepti-
of ascites, in which case fluid and dase, hepatitis antigens and antibod-
electrolyte balance requires strict ies, lactate dehydrogenase, and liver
attention. biopsy.

ALBUMIN AND ALBUMIN/


GLOBULIN RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: Alb, A/G ratio.


SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma
(1 mL) collected in a green-top (heparin) tube is also acceptable.

REFERENCE VALUE: (Method: Spectrophotometry) Normally the


albumin/globulin (A/G) ratio is greater than 1.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 19

Albumin and Albumin/Globulin Ratio 19

Conventional SI Units (Conventional


Age Units Units  10)
Newborn–4 d 2.8–4.4 g/dL 28–44 g/L
5 d–14 y 3.8–5.4 g/dL 38–54 g/L
15–18 y 3.2–4.5 g/dL 32–45 g/L
19–60 y 3.4–4.8 g/dL 34–48 g/L
61–90 y 3.2–4.6 g/dL 32–46 g/L
Greater than 90 y 2.9–4.5 g/dL 29–45 g/L

INDICATIONS:
DESCRIPTION & RATIONALE: Most
• Assess nutritional status of hospital-
of the body’s total protein is a com-
ized patients, especially geriatric pati-
bination of albumin and globulins. ents
Albumin, the protein present in
• Evaluate chronic illness
the highest concentrations, is the
main transport protein in the body. • Evaluate liver disease
Albumin also maintains plasma
oncotic pressure. Serum albumin RESULT
values are affected by the process of
synthesis, distribution, and degrada- Increased in:
tion. Low levels may be the result of • Any condition that results in a decrease
either inadequate production or exces- of plasma water (e.g., dehydration);
sive loss. Albumin levels are more use- look for increase in hemoglobin and
ful as an indicator of chronic hematocrit
deficiency than of short-term defi-
• Hyperinfusion of albumin
ciency.
Albumin levels are affected by pos-
ture. Results from specimens collected Decreased in:
in an upright posture are higher than • Insufficient intake:
results from specimens collected in a Malabsorption
supine position. Malnutrition
The A/G ratio is useful in the eval- • Decreased synthesis by the liver:
uation of liver and kidney disease. The Acute and chronic liver disease
ratio is calculated using the following (e.g., alcoholism, cirrhosis,
formula: hepatitis)
albumin/(total protein – albumin) Genetic analbuminemia

where globulin is the difference • Inflammation and chronic diseases:


between the total protein value and Amyloidosis
the albumin value. For example, with Bacterial infections
a total protein of 7 g/dL and albumin Monoclonal gammopathies (e.g.,
of 4 g/dL, the A/G ratio is calculated multiple myeloma,
as 4/(7 – 4) or 4/3  1.33. A reversal Waldenström’s
in the ratio, where globulin exceeds macroglobulinemia)
albumin (i.e., ratio less than 1.0), is Neoplasm
clinically significant. ■ Parasitic infestations
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 20

20 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Peptic ulcer
Nursing Implications and
Prolonged immobilization
Procedure ● ● ● ● ● ● ● ● ● ● ●
Rheumatic diseases
Severe skin disease Pretest:
• Increased loss over body surface: ➤ Inform the patient that the test is
Burns used as a general indicator of nutri-
Enteropathies related to sensitivity tional status, hydration, and chronic
to ingested substances (e.g., disease.
gluten sensitivity, Crohn’s ➤ Obtain a history of the patient’s com-
disease, ulcerative colitis) plaints, including a list of known
Fistula (gastrointestinal or allergens (especially allergies or sen-
lymphatic) sitivities to latex), and inform the
appropriate health care practitioner
Hemorrhage accordingly.
Kidney disease ➤ Obtain a history of the patient’s gas-
Rapid hydration or overhydration trointestinal, genitourinary, and
Repeated thoracentesis or hepatobiliary systems and results of
paracentesis previously performed laboratory
tests, surgical procedures, and other
Trauma and crush injuries
diagnostic procedures. For related
• Increased catabolism: tests, refer to the Gastrointestinal,
Genitourinary, and Hepatobiliary
Fever
System and Therapeutic/Toxicology
Cushing’s disease tables.
Pre-eclampsia ➤ Obtain a list of the medications the
Thyroid dysfunction patient is taking, including herbs,
nutritional supplements, and nutra-
• Increased blood volume (hyperv- ceuticals. The requesting health care
olemia): practitioner and laboratory should be
Congestive heart failure advised if the patient regularly uses
these products so that their effects
Monoclonal gammopathies
can be taken into consideration
(Waldenström’s disease, when reviewing results.
myeloma)
➤ Review the procedure with the
Pregnancy patient. Inform the patient that spec-
imen collection takes approximately
CRITICAL VALUES: N/A 5 to 10 minutes. Address concerns
about pain related to the procedure.
Explain to the patient that there may
INTERFERING FACTORS: be some discomfort during the
• Drugs that may increase albumin levels venipuncture.
include enalapril. ➤ There are no food, fluid, or medica-
• Drugs that may decrease albumin levels tion restrictions unless by medical
include acetaminophen (poisoning), direction.
dapsone, dextran, estrogens, ibuprofen,
nitrofurantoin, oral contraceptives, Intratest:
phenytoin, prednisone (high doses),
trazodone, and valproic acid. ➤ If the patient has a history of severe
allergic reaction to latex, care should
• Availability of administered drugs is be taken to avoid the use of equip-
affected by variations in albumin levels. ment containing latex.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 21

Aldolase 21

➤ Instruct the patient to cooperate fully may be used to determine whether


and to follow directions.Direct the protein should be added to or
patient to breathe normally and to reduced from the diet.
avoid unnecessary movement.
➤ A written report of the examination
➤ Observe standard precautions, and will be sent to the requesting health
follow the general guidelines in care practitioner, who will discuss
Appendix A. Positively identify the the results with the patient.
patient, and label the appropriate
tubes with the corresponding patient ➤ Reinforce information given by the
demographics, date, and time of col- patient’s health care provider regard-
lection. Perform a venipuncture; col- ing further testing, treatment, or
lect the specimen in a 5-mL red- or referral to another health care pro-
tiger-top tube. vider. Answer any questions or
address any concerns voiced by the
➤ Remove the needle, place a gauze patient or family.
over the puncture site and apply gen-
tle pressure to stop bleeding. ➤ Depending on the results of this
Observe venipuncture site for bleed- procedure, additional testing may be
ing or hematoma formation. Apply performed to evaluate or monitor
paper tape over gauze or replace progression of the disease process
with adhesive bandage. and determine the need for a change
in therapy. Evaluate test results in
➤ Promptly transport the specimen to
relation to the patient’s symptoms
the laboratory for processing and
and other tests performed.
analysis.
➤ The results are recorded manually or Related laboratory tests:
in a computerized system for recall
and postprocedure interpretation by ➤ Related laboratory tests include ala-
the appropriate health care practi- nine aminotransferase, alkaline phos-
tioner. phatase, ammonia, anti-aspartate
aminotransferase, bilirubin, elec-
Post-test: trolytes, -glutamyl transpeptidase,
hematocrit, hemoglobin, hepatitis
➤ Nutritional considerations: Dietary antibodies and antigens, liver biopsy,
recommendations may be indicated osmolality, prealbumin, protein, pro-
and vary depending on the severity tein electrophoresis, and smooth
of the condition. Ammonia levels muscle antibody.

ALDOLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: ALD.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Spectrophotometry)
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 22

22 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Conventional
• Hemolytic anemias
Age & SI Units • Hepatitis (acute viral or toxic)
Newborn–2 y 3.4–11.8 U/L • Infectious mononucleosis
25 m–16 y 1.2–8.8 U/L • Leukemia (granulocytic and megalob-
Adult Less than 7.4 U/L lastic)
• Limb girdle muscular dystrophy
• Myocardial infarction
DESCRIPTION & RATIONALE: • Pancreatitis (acute)
Aldolase (ALD), an enzyme found • Polymyositis
throughout the body, catalyzes the
• Psychoses and schizophrenia (acute)
breakdown of glucose to lactate.
Highest concentrations of this enzyme • Severe crush injuries
are found in skeletal and cardiac mus- • Tetanus
cle, liver, and pancreas. When trauma • Trichinosis
or disease causes cellular breakdown
of these muscles or organs, large Decreased in:
amounts of ALD are released into the • Hereditary fructose intolerance
blood. Measuring serum levels helps
to determine the presence, and in CRITICAL VALUES: N/A
some cases the progress, of disease.
This test is not commonly requested INTERFERING FACTORS:
because the assay of other liver • Drugs that may increase aldolase
enzymes and creatine kinase is gener- levels include aminocaproic acid, car-
ally sufficient to provide the necessary benoxolone, chlorinated and organo-
phosphorus insecticides, clofibrate,
information. ■
labetalol, and thiabendazole.
INDICATIONS: • Drugs that may decrease aldolase levels
• Assist in the diagnosis of Duchenne’s include phenothiazines (in schizo-
muscular dystrophy phrenic patients with high initial val-
ues) and probucol.
• Differentiate neuromuscular disorders
from neurologic disorders, such as mul- • Intramuscular injections may increase
tiple sclerosis or myasthenia gravis aldolase levels as a result of muscle
trauma.
RESULT • Red blood cells contain aldolase;
hemolysis may cause a false elevation in
Increased in: values.
• Carcinoma (lung, breast, and geni-
tourinary tract, and metastasis to liver)
Nursing Implications and
• Central nervous system tumors
Procedure ● ● ● ● ● ● ● ● ● ● ●

• Delirium tremens
Pretest:
• Dermatomyositis
➤ Inform the patient that the test is
• Duchenne’s muscular dystrophy
used to assess general liver, pancre-
• Gangrene atic, and musculoskeletal function.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 23

Aldolase 23

➤ Obtain a history of the patient’s tubes with the corresponding patient


complaints, including a list of known demographics, date, and time of col-
allergens (especially allergies or sen- lection. Perform a venipuncture; col-
sitivities to latex), and inform the lect the specimen in a 5-mL red- or
appropriate health care practitioner tiger-top tube.
accordingly. ➤ Remove the needle, place a gauze
➤ Obtain a history of neuromuscular over the puncture site and apply gen-
disorders, related treatments, and tle pressure to stop bleeding.
complaints of muscle fatigue or loss Observe venipuncture site for bleed-
of strength. ing or hematoma formation. Apply
➤ Obtain a history of the patient’s paper tape over gauze or replace
hepatobiliary and musculoskeletal with adhesive bandage.
system and results of previously ➤ Promptly transport the specimen to
performed laboratory tests, surgical the laboratory for processing and
procedures, and other diagnostic analysis.
procedures. For related laboratory ➤ The results are recorded manually or
tests, refer to the Hepatobiliary and in a computerized system for recall
Musculoskeletal System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and nutra-
ceuticals. The requesting health care Post-test:
practitioner and laboratory should be
advised if the patient regularly uses ➤ A written report of the examination
these products so that their effects will be sent to the requesting health
can be taken into consideration care practitioner, who will discuss
when reviewing results. the results with the patient.
➤ Review the procedure with the ➤ Reinforce information given by the
patient. Inform the patient that spec- patient’s health care provider regard-
imen collection takes approximately ing further testing, treatment, or
5 to 10 minutes. Address concerns referral to another health care pro-
about pain related to the procedure. vider. Answer any questions or
Explain to the patient that there address any concerns voiced by the
may be some discomfort during the patient or family.
venipuncture.
➤ Depending on the results of this pro-
➤ There are no food, fluid, or medica- cedure, additional testing may be
tion restrictions unless by medical performed to evaluate or monitor
direction. progression of the disease process
and determine the need for a change
Intratest: in therapy. Evaluate test results in
relation to the patient’s symptoms
➤ If the patient has a history of severe and other tests performed.
allergic reaction to latex, care should
be taken to avoid the use of equip-
ment containing latex. Related laboratory tests:
➤ Instruct the patient to cooperate fully ➤ Related laboratory tests include
and to follow directions. Direct the alkaline phosphatase, antimitochon-
patient to breathe normally and to drial antibody, aspartate amino-
avoid unnecessary movement. transferase, creatine kinase and
➤ Observe standard precautions, and isoenzymes, Jo-1 antibody, lactate
follow the general guidelines in dehydrogenase and isoenzymes,
Appendix A. Positively identify the liver biopsy, muscle biopsy, and myo-
patient, and label the appropriate globin.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 24

24 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ALDOSTERONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma
(1 mL) collected in green-top (heparin) or lavender-top (EDTA) tube is also
acceptable.

REFERENCE VALUE: (Method: Radioimmunoassay)

Conventional SI Units (Conventional


Age Units Units  0.0277)
Cord blood 40–200 ng/dL 1.11–5.54 nmol/L
3 d–1 wk 7–184 ng/dL 0.19–5.10 nmol/L
1 mo–1 y 5–90 ng/dL 0.14–2.49 nmol/L
13–23 mo 7–54 ng/dL 0.19–1.50 nmol/L
2–10 y
Supine 3–35 ng/dL 0.08–0.97 nmol/L
Upright 5–80 ng/dL 0.14–2.22 nmol/L
11–15 y
Supine 2–22 ng/dL 0.06–0.61 nmol/L
Upright 4–48 ng/dL 0.11–1.33 nmol/L
Adult
Supine 3–16 ng/dL 0.08–0.44 nmol/L
Upright 7–30 ng/dL 0.19–0.83 nmol/L

These values reflect a normal-sodium diet. Values for a low-sodium diet are three to five
times higher.

DESCRIPTION & RATIONALE: Aldos- sodium intake, certain medications,


terone is a mineralocorticoid secreted and activity. This test is of little diag-
by the zona glomerulosa of the adrenal nostic value unless plasma renin activ-
cortex in response to decreased serum ity is measured simultaneously (see
sodium, decreased blood volume, and monograph titled “Renin”). Patients
increased serum potassium. Aldos- with serum potassium less than 3.6
terone increases sodium reabsorption mEq/L and 24-hour urine potassium
in the renal tubules, resulting in potas- greater than 40 mEq/L fit the general
sium excretion and increased water criteria to test for aldosteronism.
retention, blood volume, and blood Renin is low in primary aldosteronism
pressure. A variety of factors influence and high in secondary aldosteronism.
serum aldosterone levels, including A ratio of plasma aldosterone to
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 25

Aldosterone 25

plasma renin activity greater than 50 is • Hypoaldosteronism secondary to renin


significant. ■ deficiency
• Isolated aldosterone deficiency
INDICATIONS:
• Evaluate hypertension of unknown With hypertension:
cause, especially with hypokalemia not • Acute alcohol intoxication
induced by diuretics • Diabetes
• Investigate suspected hyperaldostero-
• Excess secretion of deoxycorticosterone
nism, as indicated by elevated levels
• Investigate suspected hypoaldostero- • Turner’s syndrome (25% of cases)
nism, as indicated by decreased levels
CRITICAL VALUES: N/A
RESULT INTERFERING FACTORS:
Increased with Decreased • Drugs that may increase aldosterone
Renin Levels levels include amiloride, ammonium
chloride, angiotensin, angiotensin II,
Primary hyperaldosteronism:
dobutamine, dopamine, endralazine,
• Adenomas (Conn’s syndrome) fenoldopam, hydralazine, hydrochloro-
• Bilateral hyperplasia of the aldos- thiazide, laxatives (abuse), metoclopra-
terone-secreting zona glomerulosa cells mide, nifedipine, opiates, potassium,
spironolactone, and zacopride.
Increased with Increased • Drugs that may decrease aldosterone
Renin Levels levels include atenolol, captopril, car-
Secondary hyperaldosteronism: vedilol, cilazapril, enalapril, fadrozole,
• Bartter’s syndrome glycyrrhiza, ibopamine, indomethacin,
lisinopril, nicardipine, nonsteroidal
• Cardiac failure anti-inflammatory drugs, perindopril,
ranitidine, saline, sinorphan, and vera-
• Chronic obstructive pulmonary disease pamil. Prolonged heparin therapy also
• Cirrhosis with ascites formation decreases aldosterone levels.

• Diuretic abuse • Upright body posture, stress, strenuous


exercise, and late pregnancy can lead to
• Hypovolemia secondary to hemor- increased levels.
rhage and transudation
• Recent radioactive scans or radiation
• Laxative abuse within 1 week before the test can inter-
fere with test results when radioim-
• Nephrotic syndrome munoassay is the test method.
• Starvation (after 10 days) • Diet can significantly affect results. A
• Thermal stress low-sodium diet can increase serum
aldosterone, whereas a high-sodium
• Toxemia of pregnancy diet can decrease levels. Decreased
serum sodium and elevated serum
Decreased potassium increase aldosterone secre-
Without hypertension:
tion. Elevated serum sodium and
decreased serum potassium suppress
• Addison’s disease aldosterone secretion.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 26

26 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

tained for 2 hours before specimen


Nursing Implications and collection.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ The patient should be on a normal-
sodium diet (1 to 2 g of sodium
Pretest: per day) for 2 to 4 weeks before the
test.
➤ Inform the patient that the test is
used to evaluate hypertension and ➤ Under medical direction, the patient
possible hyperaldosteronism. should avoid diuretics, antihyperten-
sive drugs and herbals, and cyclic
➤ Obtain a history of the patient’s com- progestogens and estrogens for 2 to
plaints, including a list of known 4 weeks before the test.
allergens (especially allergies or sen-
sitivities to latex), and inform the Intratest:
appropriate health care practitioner
accordingly. ➤ Ensure that the patient has complied
➤ Obtain a history of known or sus- with dietary, medication, and pretes-
pected fluid or electrolyte imbalance, ting preparations regarding activity.
hypertension, renal function, or stage ➤ If the patient has a history of severe
of pregnancy. Note the amount of allergic reaction to latex, care should
sodium ingested in the diet over the be taken to avoid the use of equip-
past 2 weeks. ment containing latex.
➤ Obtain a history of the patient’s ➤ Instruct the patient to cooperate fully
endocrine and genitourinary sys- and to follow directions. Direct the
tems and results of previously patient to breathe normally and to
performed laboratory tests, surgical avoid unnecessary movement.
procedures, and other diagnostic ➤ Observe standard precautions, and
procedures. For related laboratory follow the general guidelines in
tests, refer to the Endocrine and Appendix A. Positively identify the
Genitourinary System tables. patient, and label the appropriate
➤ Note any recent procedures that can tubes with the corresponding patient
interfere with test results. demographics, date, time of collec-
➤ Obtain a list of the medications the tion, patient position (upright or
patient is taking, including herbs, supine), and exact source of speci-
nutritional supplements, and nutra- men (peripheral versus arterial).
ceuticals. The requesting health Perform a venipuncture after the
care practitioner and laboratory patient has been in the upright (sit-
should be advised if the patient is ting or standing) position for 2 hours.
regularly using these products so If a supine specimen is requested on
that their effects can be taken into an inpatient, the specimen should be
consideration when reviewing collected early in the morning before
results. rising. Collect the specimen in a 5-
mL red- or tiger-top tube.
➤ Review the procedure with the
patient. Inform the patient that spec- ➤ Remove the needle, place gauze
imen collection takes approximately over the puncture site and apply gen-
5 to 10 minutes. Inform the patient tle pressure to stop bleeding.
that multiple specimens may be Observe venipuncture site for bleed-
required. Address concerns about ing or hematoma formation. Apply
pain related to the procedure. Explain paper tape over gauze or replace
to the patient that there may be with adhesive bandage.
some discomfort during the veni- ➤ Promptly transport the specimen on
puncture. ice to the laboratory for processing
➤ Inform the patient that the required and analysis.
position, supine/lying down or ➤ The results are recorded manually or
upright/sitting up, must be main- in a computerized system for recall
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 27

Aldosterone 27

and postprocedure interpretation by sodium diets should avoid beverages


the appropriate health care practi- such as colas, ginger ale, Gatorade,
tioner. lemon-lime sodas, and root beer.
Many over-the-counter medications,
Post-test: including antacids, laxatives, anal-
gesics, sedatives, and antitussives,
➤ Instruct the patient to resume usual contain significant amounts of
diet, medication, and activity as sodium. The best advice is to empha-
directed by the health care practi- size the importance of reading all
tioner. food, beverage, and medicine labels.
➤ A written report of the examination In 1989, the Subcommittee on the
will be sent to the requesting health 10th Edition of the RDAs established
care practitioner, who will discuss 500 mg as the recommended
the results with the patient. minimum limit for dietary intake
of sodium. There are no RDAs estab-
➤ Instruct the patient to notify the lished for potassium, but the esti-
health care practitioner of any signs mated minimum intake for adults
and symptoms of dehydration or is 200 mEq/d. Potassium is present
fluid overload related to elevated in all plant and animal cells, mak-
aldosterone levels or compromised ing dietary replacement simple. A
sodium regulatory mechanisms. health care practitioner or nutritionist
➤ Nutritional considerations: Aldos- should be consulted before consider-
terone levels are involved in the reg- ing the use of salt substitutes.
ulation of body fluid volume. Educate ➤ Reinforce information given by the
patients about the importance of patient’s health care provider regard-
proper water balance. Although ing further testing, treatment, or
there is no recommended dietary referral to another health care pro-
allowance (RDA) for water, adults vider. Answer any questions or
need 1 mL/kcal per day. Infants need address any concerns voiced by the
more water because their basal patient or family.
metabolic heat production is much
higher than in adults. Tap water may ➤ Depending on the results of this pro-
also contain other nutrients. Water- cedure, additional testing may be
softening systems replace minerals performed to evaluate or monitor
(e.g., calcium, magnesium, iron) with progression of the disease process
sodium, so caution should be used if and determine the need for a change
a low-sodium diet is prescribed. in therapy. Evaluate test results in
relation to the patient’s symptoms
➤ Nutritional considerations: Because and other tests performed.
aldosterone levels have an effect on
sodium levels, some consideration
may be given to dietary adjustment if Related laboratory tests:
sodium allowances need to be regu-
lated. Educate patients with low ➤ Related laboratory tests include cat-
sodium levels that the major source echolamines (blood and urine), corti-
of dietary sodium is table salt. Many sol, creatinine (blood and urine),
foods, such as milk and other dairy glucose, kidney biopsy, magne-
products, are also good sources of sium (blood and urine), osmolality
dietary sodium. Most other dietary (blood and urine), potassium (blood
sodium is available through con- and urine), renin, sodium (blood and
sumption of processed foods. urine), urea nitrogen, urinalysis, and
Patients who need to follow low- urine protein.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 28

28 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ALKALINE PHOSPHATASE
AND ISOENZYMES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Alk Phos, ALP and fractionation, heat-stabile ALP.


SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma
(1 mL) collected in a green-top (heparin) tube is also acceptable.

REFERENCE VALUE: (Method: Spectrophotometry for total alkaline phos-


phatase, inhibition/electrophoresis for fractionation)

Total Conventional
ALP & SI Units Bone Fraction Liver Fraction
1–5 y
Male 56–350 U/L 39–308 U/L Less than 8–101 U/L
Female 73–378 U/L 56–300 U/L Less than 8–53 U/L
6–7 y
Male 70–364 U/L 50–319 U/L Less than 8–76 U/L
Female 73–378 U/L 56–300 U/L Less than 8–53 U/L
8y
Male 70–364 U/L 50–258 U/L Less than 8–62 U/L
Female 98–448 U/L 78–353 U/L Less than 8–62 U/L
9–12 y
Male 112–476 U/L 78–339 U/L Less than 8–81 U/L
Female 98–448 U/L 78–353 U/L Less than 8–62 U/L
13 y
Male 112–476 U/L 78–389 U/L Less than 8–48 U/L
Female 56–350 U/L 28–252 U/L Less than 8–50 U/L
14 y
Male 112–476 U/L 78–389 U/L Less than 8–48 U/L
Female 56–266 U/L 31–190 U/L Less than 8–48 U/L
15 y
Male 70–378 U/L 48–311 U/L Less than 8–39 U/L
Female 42–168 U/L 20–115 U/L Less than 8–53 U/L
16 y
Male 70–378 U/L 48–311 U/L Less than 8–39 U/L
Female 28–126 U/L 14–87 U/L Less than 8–50 U/L
17 y
Male 56–238 U/L 34–190 U/L Less than 8–39 U/L
Female 28–126 U/L 17–84 U/L Less than 8–53 U/L
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 29

Alkaline Phosphatase and Isoenzymes 29

Total Conventional
ALP & SI Units Bone Fraction Liver Fraction

18 y
Male 56–182 U/L 34–146 U/L Less than 8–39 U/L
Female 28–126 U/L 17–84 U/L Less than 8–53 U/L
19 y
Male 42–154 U/L 25–123 U/L Less than 8–39 U/L
Female 28–126 U/L 17–84 U/L Less than 8–53 U/L
20 y
Male 45–138 U/L 25–73 U/L Less than 8–48 U/L
Female 33–118 U/L 17–56 U/L Less than 8–50 U/L
Adult
Male 35–142 U/L 11–73 U/L 0–93 U/L
Female 25–125 U/L 11–73 U/L 0–93 U/L

DESCRIPTION & RATIONALE: ALP is in children are higher than in adults


an enzyme found in the liver, in because of the level of bone growth
Kupffer cells lining the biliary tract, and development. An immunoassay
and in bones, intestines, and placenta. method is available for measur-
Additional sources of ALP include the ing bone specific ALP as an indicator
proximal tubules of the kidneys, pul- of increased bone turnover and estro-
monary alveolar cells, germ cells, vas- gen deficiency in post-menopausal
cular bed, lactating mammary glands, women. ■
and granulocytes of circulating blood.
ALP is referred to as alkaline because
it functions optimally at a pH of 9.0. INDICATIONS:
This test is most useful for determin- • Evaluate signs and symptoms of various
ing the presence of liver or bone dis- disorders associated with elevated ALP
ease. levels, such as biliary obstruction, hepa-
Isoelectric focusing methods can iden- tobiliary disease, and bone disease,
tify 12 isoenzymes of ALP. Certain including malignant processes
cancers produce small amounts of dis-
• Differentiate obstructive hepatobiliary
tinctive Regan and Nagao ALP isoen-
tract disorders from hepatocellular dis-
zymes. Four main ALP isoenzymes, ease; greater elevations of ALP are seen
however, are of clinical significance: in the former
ALP1 of liver origin, ALP2 of bone
origin, ALP3 of intestinal origin (occa- • Determine effects of renal disease on
sionally present in individuals with bone metabolism
blood type O and B), and ALP4 of • Determine bone growth or destruction
placental origin (third trimester). ALP in children with abnormal growth pat-
levels vary by age and gender. Values terns
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30 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

RESULT Hodgkin’s disease


Hyperparathyroidism (primary or
Increased in: secondary to chronic renal
• Liver disease: disease)
Biliary atresia Perforated bowel
Biliary obstruction (acute Pneumonia
cholecystitis, cholelithisis, Pulmonary and myocardial
intrahepatic cholestasis of infarctions
pregnancy, primary biliary Pulmonary embolism
cirrhosis) Sarcoidosis
Cancer Ulcerative colitis
Chronic active hepatitis
Cirrhosis Decreased in:
Diabetes (diabetic hepatic lipidosis) • Anemia (severe)
Extrahepatic duct obstruction • Celiac disease
Granulomatous or infiltrative liver
diseases • Cretinism
Infectious mononucleosis • Folic acid deficiency
Intrahepatic biliary hypoplasia
Toxic hepatitis • HIV-1 infection
Viral hepatitis • Hypervitaminosis D
• Bone disease: • Hypophosphatasia (congenital, rare)
Healing fractures
• Hypothyroidism (characteristic in
Metabolic bone diseases (rickets, infantile and juvenile cases)
osteomalacia)
Metastatic tumors in bone • Milk alkali syndrome
Osteogenic sarcoma • Kwashiorkor
Osteoporosis
Paget’s disease (osteitis • Nutritional deficiency of zinc or mag-
deformans) nesium
Parasitic infections (histoplasmosis, • Pernicious anemia
leptospirosis, malaria,
schistosomiasis) • Scurvy
• Other conditions: • Vitamin C deficiency
Adrenal cortical hyperfunction • Whipple’s disease (indication of vita-
Advanced pregnancy min D and calcium malabsorption)
Amyloidosis
• Zollinger-Ellison syndrome (indication
Atherosclerosis
of vitamin D and calcium malabsorp-
Cancer of the breast, colon, tion)
gallbladder, lung, or pancreas
Cancer of the lung or pancreas
Chronic renal failure
CRITICAL VALUES: N/A
Congestive heart failure INTERFERING FACTORS:
Familial hyperphosphatemia • Drugs that may increase ALP levels by
Galactosemia causing cholestasis include amitripty-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 31

Alkaline Phosphatase and Isoenzymes 31

line, anabolic steroids, androgens, plaints, including a list of known


benzodiazepines, chlorothiazide, chlor- allergens (especially allergies or sen-
propamide, dapsone, erythromycin, sitivities to latex), and inform the
estrogens, ethionamide, gold salts, appropriate health care practitioner
accordingly.
imipramine, mercaptopurine, nitrofu-
rans, oral contraceptives, penicillins, ➤ Obtain a history of the patient’s
phenothiazines, progesterone, pro- hepatobiliary and musculoskeletal
poxyphene, sulfonamides, tamoxifen, systems and results of previously
performed laboratory tests, surgical
and tolbutamide. procedures, and other diagnostic
• Drugs that may increase ALP levels by procedures. For related tests, refer
causing hepatocellular damage include to the Hepatobiliary and Musculo-
acetaminophen (toxic), acetylsalicylic skeletal System tables.
acid, allopurinol, amiodarone, anabolic ➤ Obtain a list of the medications the
steroids, anticonvulsants, asparaginase, patient is taking, including herbs,
azithromycin, bromocriptine, capto- nutritional supplements, and nutra-
pril, cephalosporins, chloramphenicol, ceuticals. The requesting health care
practitioner and laboratory should be
clindamycin, clofibrate, danazol, enflu-
advised if the patient is regularly
rane, ethambutol, ethionamide, fenofi- using these products so that their
brate, fluconazole, fluoroquinolones, effects can be taken into considera-
foscarnet, gentamicin, indomethacin, tion when reviewing results.
interferon, interleukin-2, levamisole,
➤ Review the procedure with the
levodopa, lincomycin, low-molecular- patient. Inform the patient that spec-
weight heparin, methyldopa, mono- imen collection takes approximately
amine oxidase inhibitors, naproxen, 5 to 10 minutes. Address concerns
nifedipine, nitrofurans, oral contracep- about pain related to the procedure.
tives, probenecid, procainamide, qui- Explain to the patient that there may
nine, ranitidine, retinol, ritodrine, be some discomfort during the
sulfonylureas, tetracyclines, tobramy- venipuncture.
cin, and verapamil. ➤ There are no food, fluid, or medica-
tion restrictions unless by medical
• Drugs that may cause an overall direction.
decrease in ALP levels include alendro-
late, clofibrate, and theophylline.
Intratest:
• Hemolyzed specimens may cause
falsely elevated results. ➤ If the patient has a history of severe
allergic reaction to latex, care should
• Elevations of ALP may occur if the be taken to avoid the use of equip-
patient is nonfasting, usually 2 to 4 h ment containing latex.
after a fatty meal, and especially if the ➤ Instruct the patient to cooperate fully
patient is a Lewis-positive secretor of and to follow directions. Direct the
blood group B or O. patient to breathe normally and to
avoid unnecessary movement.
➤ Observe standard precautions, and
Nursing Implications and follow the general guidelines in
Procedure ● ● ● ● ● ● ● ● ● ● ● Appendix A. Positively identify the
patient, and label the appropriate
Pretest: tubes with the corresponding patient
demographics, date, and time of col-
➤ Inform the patient that the test is lection. Perform a venipuncture; col-
used to assess liver function. lect the specimen in a 5-mL red- or
➤ Obtain a history of the patient’s com- tiger-top tube.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 32

32 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Remove the needle, place a gauze of ascites, in which case fluid and
over the puncture site and apply gen- electrolyte balance requires strict
tle pressure to stop bleeding. attention.
Observe venipuncture site for bleed- ➤ A written report of the examination
ing and hematoma formation. Apply will be sent to the requesting health
paper tape over gauze or replace care practitioner, who will discuss
with adhesive bandage. the results with the patient.
➤ Promptly transport the specimen to ➤ Reinforce information given by the
the laboratory for processing and patient’s health care provider regard-
analysis. ing further testing, treatment, or
➤ The results are recorded manually or referral to another health care pro-
in a computerized system for recall vider. Answer any questions or add-
and postprocedure interpretation by ress any concerns voiced by the
the appropriate health care practi- patient or family.
tioner. ➤ Depending on the results of this pro-
cedure, additional testing may be
Post-test: performed to evaluate or monitor
progression of the disease process
➤ Nutritional considerations: Increased and determine the need for a change
ALP levels may be associated with in therapy. Evaluate test results in
liver disease. Dietary recommenda- relation to the patient’s symptoms
tions may be indicated and vary and other tests performed.
depending on the severity of the
condition. A low-protein diet may be Related laboratory tests:
in order if the patient’s liver has lost
the ability to process the end prod- ➤ Related laboratory tests include
ucts of protein metabolism. A diet acetaminophen, alanine aminotrans-
of soft foods may be required if ferase, albumin, ammonia, anti-
esophageal varices have developed. DNA antibodies, antimitochondrial
Ammonia levels may be used to antibodies, antinuclear antibodies,
determine whether protein should anti–smooth muscle antibodies, a1-
be added to or reduced from the antitrypsin, 1-antitrypsin phenotyp-
diet. Patients should be encouraged ing, aspartate aminotransferase,
to eat simple carbohydrates and bilirubin (total, direct, and indirect),
emulsified fats (as in homogenized bone biopsy, calcium, ceruloplasmin,
milk or eggs), as opposed to com- C3 complement, C4 complement,
plex carbohydrates (e.g., starch, copper, electrolytes, -glutamyl tran-
fiber, and glycogen [animal carbohy- speptidase, hepatitis antigens and
drates]) and complex fats, which antibodies, liver biopsy, magnesium,
would require additional bile to emul- parathyroid hormone, phosphorus,
sify them so that they can be used. protein, protein electrophoresis, pro-
The cirrhotic patient should be care- thrombin time, salicylate, vitamin D,
fully observed for the development and zinc.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 33

Allergen-Specific Immunoglobulin E 33

ALLERGEN-SPECIFIC
IMMUNOGLOBULIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Allergen profile, radioallergosorbent test (RAST).


SPECIMEN: Serum (2 mL per group of six allergens, 0.5 mL for each addi-
tional individual allergen) collected in a red- or tiger-top tube.

REFERENCE VALUE: (Method: Radioimmunoassay)

Alternate Scoring
RAST Scoring Method (ASM): Increasing
Method Levels of Allergy Sensitivity

Specific IgE
Antibody Level kIU/L ASM Class ASM % Reference
Absent or Less than 0.35 0 Less than 70
undetectable
Low 0.35–0.70 1 70–109
Moderate 0.71–3.50 2 110–219
High 3.51–17.50 3 220–599
Very high Greater than 17.50 4 600–1999
5 2000–5999
6 Greater than 5999

DESCRIPTION & RATIONALE: antibiotics, dust, foods, grasses,


Allergen-specific immunoglobulin E insects, trees, mites, molds, venom,
(IgE) or a radioallergosorbent test and weeds. Allergen testing is useful
(RAST) is generally requested for for evaluating the cause of hay fever,
groups of allergens commonly known extrinsic asthma, atopic eczema, respi-
to incite an allergic response in the ratory allergies, and potentially fatal
affected individual. The test is based reactions to insect venom, penicillin,
on the use of a radiolabeled anti-IgE and other drugs or chemicals. RAST
reagent to detect IgE in the patient’s has largely replaced skin tests and
serum, produced in response to spe- provocation procedures, which were
cific allergens. The panels include inconvenient, painful, and potentially
allergens such as animal dander, hazardous to patients. ■
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 34

34 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

INDICATIONS: Nursing Implications and


• Evaluate patients who refuse to submit
to skin testing or who have generalized Procedure ● ● ● ● ● ● ● ● ● ● ●

dermatitis or other dermatopathic con-


Pretest:
ditions
• Monitor response to desensitization ➤ Inform the patient that the test is
used to identify types of allergens
procedures that may be responsible for causing
• Test for allergens when skin testing is an allergic response.
inappropriate, such as in infants ➤ Obtain a history of the patient’s com-
• Test for allergens when there is a known plaints, including a list of known
history of severe allergic reaction to skin allergens (especially allergies or sen-
sitivities to latex), and inform the
testing appropriate health care practitioner
• Test for specific allergic sensitivity accordingly.
before initiating immunotherapy or ➤ Obtain a history of the patient’s
desensitization shots immune and respiratory system and
• Test for specific allergic sensitivity results of previously performed labo-
ratory tests, surgical procedures,
when skin testing is unreliable and other diagnostic procedures. For
related tests, refer to the Immune
RESULT: Different scoring systems are and Respiratory System tables.
used in the interpretation of RAST
➤ Note any recent procedures that can
results.
interfere with test results.
Increased in: ➤ Obtain a list of the medications the
• Allergic rhinitis patient is taking, including herbs,
nutritional supplements, and nutra-
• Anaphylaxis ceuticals. The requesting health care
practitioner and laboratory should be
• Asthma (exogenous) advised if the patient regularly uses
• Atopic dermatitis these products so that their effects
can be taken into consideration
• Echinococcus infection when reviewing results.
• Eczema ➤ Review the procedure with the
• Hay fever patient. Inform the patient that spec-
imen collection takes approximately
• Hookworm infection 5 to 10 minutes. Address concerns
about pain related to the procedure.
• Schistosomiasis Explain to the patient that there may
• Visceral larva migrans be some discomfort during the
venipuncture.
Decreased in: ➤ There are no food, fluid, or medica-
• Asthma (endogenous) tion restrictions unless by medical
direction.
• Pregnancy
• Radiation therapy Intratest:
➤ If the patient has a history of severe
CRITICAL VALUES: N/A allergic reaction to latex, care should
be taken to avoid the use of equip-
INTERFERING FACTORS: Recent radioac- ment containing latex.
tive scans or radiation within 1 week ➤ Instruct the patient to cooperate fully
of the test can interfere with test results and to follow directions. Direct the
when radioimmunoassay is the test patient to breathe normally and to
method. avoid unnecessary movement.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 35

➤ Observe standard precautions, and present. Lifestyle adjustments may


follow the general guidelines in be necessary depending on the spe-
Appendix A. Positively identify the cific allergens identified.
patient, and label the appropriate ➤ A written report of the examination
tubes with the corresponding patient will be sent to the requesting health
demographics, date, and time of col- care practitioner, who will discuss
lection. Indicate the specific allergen the results with the patient.
group to be tested on the specimen
requisition. Perform a venipuncture; ➤ Reinforce information given by the
collect the specimen in a 5-mL red- patient’s health care provider regard-
or tiger-top tube. ing further testing, treatment, or
referral to another health care
➤ Remove the needle, place a gauze
provider. Answer any questions or
over the puncture site and apply gen-
address any concerns voiced by the
tle pressure to stop bleeding.
patient or family.
Observe venipuncture site for bleed-
ing and hematoma formation. Apply ➤ Depending on the results of this pro-
paper tape over gauze or replace cedure, additional testing may be
with adhesive bandage. performed to evaluate or monitor
➤ Promptly transport the specimen to progression of the disease process
the laboratory for processing and and determine the need for a change
analysis. in therapy. Evaluate test results in
relation to the patient’s symptoms
➤ The results are recorded manually or and other tests performed.
in a computerized system for recall
and postprocedure interpretation by Related laboratory tests:
the appropriate health care practi-
➤ Related laboratory tests include
tioner.
arterial/alveolar oxygen ratio, blood
Post-test: gases, complete blood count,
eosinophil count, hypersensitivity
➤ Nutritional considerations should be pneumonitis, IgE, ova and parasites,
given to diet if food allergies are and theophylline.

ALVEOLAR/ARTERIAL GRADIENT AND


ARTERIAL/ALVEOLAR OXYGEN RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYMS: Alveolar-arterial difference, A/a gradient, a/A ratio.


SPECIMEN: Arterial blood (1 mL) collected in a heparinized syringe.
Specimen should be transported tightly capped and in an ice slurry.

REFERENCE VALUE: (Method: Selective electrodes that measure pO2 and


pCO2)

Alveolar/arterial gradient Less than 10 mm Hg at rest (room air)


20–30 mm Hg at maximum exercise
activity (room air)
Arterial/alveolar oxygen ratio Greater than 0.75 (75%)

35
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36 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

DESCRIPTION & RATIONALE: A test a/A  paO2/ pAO2


of the ability of oxygen to diffuse from The A/a gradient increases as the
the alveoli into the lungs is of use concentration of oxygen the patient
when assessing a patient’s level of oxy- inspires increases. If the gradient is
genation. This test can help identify abnormally high, either there is a
the cause of hypoxemia (low oxygen problem with the ability of oxygen to
levels in the blood) and intrapul- pass across the alveolar membrane or
monary shunting that might result oxygenated blood is being mixed with
from one of the following three situa- nonoxygenated blood. The a/A ratio is
tions: ventilated alveoli without not dependent on FIO2; it does not
perfusion, unventilated alveoli with increase with a corresponding increase
perfusion, or collapse of alveoli and in inhaled oxygen. For patients on a
associated blood vessels. Information mechanical ventilator with a changing
regarding the alveolar/arterial (A/a) FIO2, the a/A ratio can be used to
gradient can be estimated indirectly determine if oxygen diffusion is
using the partial pressure of oxygen improving. ■
(pO2) (obtained from blood gas
analysis) in a simple mathematical INDICATIONS:
formula: • Assess intrapulmonary or coronary
artery shunting
A/a gradient  pO2 in alveolar air
(estimated) – pO2 in arterial blood • Assist in identifying the cause of
(measured) hypoxemia
An estimate of alveolar pO2 is RESULT
accomplished by subtracting the water
vapor pressure from the barometric Increased in:
pressure, multiplying the resulting • Acute respiratory distress syndrome
pressure by the fraction of inspired • Atelectasis
oxygen (FIO2; percentage of oxygen
the patient is breathing), and subtract- • Atrial-venous shunts
ing this from 1.25 times the arterial • Bronchospasm
partial pressure of carbon dioxide • Chronic obstructive pulmonary disease
(pCO2). The gradient is obtained by
subtracting the patient’s arterial pO2 • Congenital cardiac septal defects
from the calculated alveolar pO2: • Underventilated alveoli (mucus plugs)
Alveolar pO2  [(barometric pres- • Pneumothorax
sure – water vapor pressure)  FIO2] • Pulmonary edema
– [1.25  pCO2]
• Pulmonary embolus
A/a gradient  arterial pO2 (meas-
ured) – alveolar pO2 (estimated) • Pulmonary fibrosis

The arterial/alveolar (a/A) ratio CRITICAL VALUES: N/A


reflects the percentage of alveolar pO2
that is contained in arterial pO2. It is INTERFERING FACTORS:
calculated by dividing the arterial pO2 • Specimens should be collected before
by the alveolar pO2 administration of oxygen therapy.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 37

Alveolar/Arterial Gradient and Arterial/Alveolar Oxygen Ratio 37

• The temperature of the patient should time. For related laboratory tests,
be noted and reported to the laboratory refer to the Cardiovascular, Geni-
if significantly elevated or depressed so tourinary, and Respiratory System
that measured values can be corrected tables.
to actual body temperature. ➤ Note any recent procedures that can
interfere with test results.
• Exposure of sample to room air affects ➤ Obtain a list of medications the
test results. patient is taking, especially medica-
• Values normally increase with increas- tions known to affect bleeding,
ing age (see monograph titled “Blood including anticoagulants, aspirin and
other salicylates, herbals, and nutra-
Gases”).
ceuticals (see Appendix F: Effects of
• Samples for A/a gradient evalua- Natural Products on Laboratory
tion are obtained by arterial Tests). It is recommended that use of
puncture, which carries a risk of bleed- such products be discontinued 14
ing, especially in patients with bleeding days before dental or surgical proce-
dures. The requesting health care
disorders or who are taking medica-
practitioner and laboratory should be
tions for a bleeding disorder. advised if the patient regularly uses
• Prompt and proper specimen process- these products so that their effects
ing, storage, and analysis are important can be taken into consideration when
to achieve accurate results. Specimens reviewing results.
should always be transported to the ➤ Indicate the type of oxygen, mode of
laboratory as quickly as possible after oxygen delivery, and delivery rate as
collection. Delay in transport of the part of the test requisition process.
Wait 30 minutes after a change in
sample or transportation without ice type or mode of oxygen delivery or
may affect test results. rate for specimen collection.
➤ Review the procedure with the
patient, and advise rest for 30 min-
Nursing Implications and utes before specimen collection.
Procedure ● ● ● ● ● ● ● ● ● ● ● Address concerns about pain related
to the procedure. Be sure to explain
Pretest: to the patient that an arterial punc-
ture may be painful. The site may be
➤ Inform the patient that the test is anesthetized with 1% to 2% lido-
used to assess effective delivery of caine before puncture. Inform the
oxygen by comparing the difference patient that specimen collection usu-
between oxygen levels in the arter- ally takes 10 to 15 minutes.
ies and the alveoli of the lungs.
➤ If the sample is to be collected
➤ Obtain a history of the patient’s com- by radial artery puncture, per-
plaints, including a list of known form an Allen test before puncture to
allergens (especially allergies or sen- ensure that the patient has adequate
sitivities to latex or anesthetics), and collateral circulation to the hand. The
inform the appropriate health care modified Allen test is performed as
practitioner accordingly. follows: extend the patient’s wrist
➤ Obtain a history of the patient’s res- over a rolled towel. Ask the patient
piratory system and any bleeding to make a fist with the hand
disorders as well as results of previ- extended over the towel. Use the
ously performed laboratory tests, second and third fingers to locate
surgical procedures, and other diag- the pulses of the ulnar and radial
nostic procedures, especially bleed- arteries on the palmar surface of the
ing time, coagulation time, complete wrist. (The thumb should not be
blood count, platelets, partial throm- used to locate these arteries
boplastin time, and prothrombin because it has a pulse.) Compress
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 38

38 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

both arteries, and ask the patient to puncture site. Apply a pressure
open and close the fist several times dressing over the puncture site.
until the palm turns pale. Release Samples should be mixed by gentle
pressure on the ulnar artery only. rolling of the syringe to ensure
Color should return to the palm proper mixing of the heparin with the
within 5 seconds if the ulnar artery sample, which will prevent the for-
is functioning. This is a positive Allen mation of small clots leading to
test, and blood gases may be rejection of the sample. The tightly
drawn from the radial artery site. The capped sample should be placed in
Allen test should then be perfor- an ice slurry immediately after col-
med on the opposite hand. The lection. Information on the specimen
hand to which color is restored label can be protected from water in
fastest has better circulation and the ice slurry by first placing the
should be selected for specimen col- specimen in a protective plastic bag.
lection. Promptly transport the specimen to
➤ There are no food, fluid, or medica- the laboratory for processing and
tion restrictions unless by medical analysis.
direction. ➤ The results are recorded manually or
➤ Prepare an ice slurry in a cup or plas- in a computerized system for recall
tic bag to have ready for immediate and postprocedure interpretation by
transport of the specimen to the the appropriate health care practi-
laboratory. tioner.

Post-test:
Intratest:
➤ Pressure should be applied to the
➤ If the patient has a history of severe puncture site for at least 5 minutes in
allergic reaction to latex, care should the unanticoagulated patient and for
be taken to avoid the use of equip- at least 15 minutes in the case of a
ment containing latex. patient receiving anticoagulant ther-
➤ Instruct the patient to cooperate apy. Observe puncture site for bleed-
fully and to follow directions. ing or hematoma formation. Apply
Direct the patient to breathe nor- pressure bandage.
mally and to avoid unnecessary
➤ Teach the patient breathing exer-
movement.
cises to assist with the appropriate
➤ Observe standard precautions, and exchange of oxygen and carbon
follow the general guidelines in dioxide.
Appendix A. Positively identify the
patient, and label the appropriate ➤ Administer oxygen, if appropriate.
tubes with the corresponding patient ➤ Teach the patient how to properly
demographics, date, and time of col- use incentive spirometry or nebu-
lection. lizer, if ordered.
➤ Perform an arterial puncture, and col- ➤ Intervene appropriately for hypoxia
lect the specimen in an air-free and ventilatory disturbances.
heparinized syringe. There is no
demonstrable difference in results ➤ A written report of the examination
between samples collected in plastic will be sent to the requesting health
syringes and samples collected in care practitioner, who will discuss
glass syringes. It is very important the results with the patient.
that no room air be introduced into ➤ Reinforce information given by the
the collection container, because the patient’s health care provider regard-
gases in the room and in the sample ing further testing, treatment, or
will begin equilibrating immediately. referral to another health care
The end of the syringe must be stop- provider. Answer any questions or
pered immediately after the needle address any concerns voiced by the
is withdrawn and removed from the patient or family.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 39

Alzheimer’s Disease Markers 39

➤ Depending on the results of this Related laboratory tests:


procedure, additional testing may
be performed to evaluate or moni- ➤ Related laboratory tests include
tor progression of the disease allergen-specific immunoglobulin E
process and determine the need for (IgE), 1-antitrypsin, 1-antitrypsin
a change in therapy. Evaluate test phenotyping, blood gases, D-dimer,
results in relation to the patient’s electrolytes, eosinophil count, fib-
symptoms and other tests per- rinogen, hypersensitivity pneumoni-
formed. tis, IgE, and theophylline.

ALZHEIMER’S DISEASE MARKERS


● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYMS: CSF tau protein and -amyloid-42, AD.


SPECIMEN: Cerebrospinal fluid (CSF) (1 to 2 mL) collected in a plain plas-
tic conical tube.

REFERENCE VALUE: (Method: Enzyme-linked immunosorbent assay)


Simultaneous tau protein and -amyloid-42 measurements in CSF are used
in conjunction as biochemical markers of Alzheimer’s disease (AD). Scientific
studies indicate that a combination of elevated tau protein and decreased -
amyloid-42 protein levels are consistent with the presence of AD. Values are
highly dependent on the reagents and standards used in the assay. Ranges
vary among laboratories; the testing laboratory should be consulted for inter-
pretation of results.

DESCRIPTION & RATIONALE: AD is the main component of the classic


the most common cause of dementia neurofibrillary tangles found in
in the elderly population. AD is a dis- patients with AD. Tau protein concen-
order of the central nervous system tration is believed to reflect the num-
that results in progressive and pro- ber of neurofibrillary tangles and may
found memory loss followed by loss of be an indication of the severity of the
cognitive abilities and death. It may disease. -Amyloid-42 is a free-float-
follow years of progressive formation ing protein normally present in CSF. It
of amyloid plaques and brain tangles, is believed to accumulate in the central
or it may appear as an early-onset form nervous system of patients with AD,
of the disease. Two recognized patho- causing the formation of amyloid
logic features of AD are neurofibrillary plaques on brain tissue. The result is
tangles and amyloid plaques found in that these patients have lower CSF val-
the brain. Abnormal forms of the ues compared to age-matched non-
microtubule-associated tau protein are AD control subjects. ■
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40 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

INDICATIONS: can be taken into consideration


• Assist in establishing a diagnosis of AD when reviewing results.
➤ Review the procedure with the
patient. Inform the patient that the
RESULT procedure will be performed by a
health care practitioner and takes
Increased in: approximately 20 minutes. Address
• Acquired immunodeficiency syndrome concerns about pain related to the
procedure. Explain to the patient that
• AD there may be some discomfort dur-
ing the lumbar puncture. Inform the
• Cerebrovascular disease patient that a stinging sensation may
• Creutzfeldt-Jakob disease be felt as the local anesthetic is
injected. Tell the patient to report any
• Meningoencephalitis pain or other sensations that may
require repositioning of the spinal
• Pick’s disease needle.
➤ Inform the patient that the position
CRITICAL VALUES: N/A required for the lumbar puncture
may be awkward but that some-
INTERFERING FACTORS: one will assist. Stress the impor-
• Some patients with AD may have nor- tance of remaining still and breath-
mal levels of tau protein because of an ing normally throughout the proce-
insufficient number of neurofibrillary dure.
tangles. ➤ Sensitivity to social and cultural
issues, as well as concern for mod-
esty, is important in providing psy-
Nursing Implications and chological support before, during,
Procedure ● ● ● ● ● ● ● ● ● ● ●
and after the procedure.
➤ There are no food, fluid, or medica-
Pretest: tion restrictions unless by medical
direction.
➤ Inform the patient that the test is
used to assist in predictive testing ➤ Make sure a written and informed
for or confirmation of Alzheimer’s consent has been signed prior to the
disease, and to monitor progression procedure and before administering
of and therapy for the disease. any medications.
➤ Obtain a history of the patient’s com- Intratest:
plaints, including a list of known
allergens (especially allergies or sen- ➤ If the patient has a history of severe
sitivities to latex or anesthetics), and allergic reaction to latex, care should
inform the appropriate health care be taken to avoid the use of equip-
practitioner accordingly. ment containing latex.
➤ Obtain a history of the patient’s neu- ➤ Instruct the patient to cooperate fully
rologic system and results of previ- and to follow directions. Direct the
ously performed laboratory tests, patient to breathe normally and to
surgical procedures, and other diag- avoid unnecessary movement.
nostic procedures. ➤ Observe standard precautions, and
➤ Obtain a list of the medications the follow the general guidelines in
patient is taking, including herbs, Appendix A. Positively identify the
nutritional supplements, and nutra- patient, and label the appropriate
ceuticals. The requesting health care tubes with the corresponding patient
practitioner and laboratory should be demographics, date, and time of col-
advised if the patient regularly uses lection.
these products so that their effects ➤ Record baseline vital signs, and
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 41

Alzheimer’s Disease Markers 41

assess neurologic status. Protocols minutes for 1 hour, then every 2


may vary from facility to facility. hours for 4 hours, and as ordered.
➤ To perform a lumbar puncture, posi- Take the temperature every 4 hours
tion the patient in the knee-chest for 24 hours. Compare with baseline
position at the side of the bed. values. Protocols may vary from
Provide pillows to support the spine facility to facility.
or for the patient to grasp. The sitting ➤ Administer fluids, if permitted, to
position is an alternative. In this posi- replace lost CSF and help prevent or
tion, the patient must bend the neck relieve headache, which is a side
and chest to the knees. effect of lumbar puncture.
➤ Prepare the site (usually between L3 ➤ Check the puncture site for leakage,
and L4 or L4 and L5) with povidone- and frequently monitor body signs,
iodine, and drape the area. such as temperature and blood pres-
➤ A local anesthetic is injected. Using sure.
sterile technique, the health care
practitioner inserts the spinal needle ➤ Position the patient flat, either on the
through the spinous processes of back or abdomen, although some
the vertebrae and into the subarach- health care practitioners allow 30
noid space. The stylet is removed. degrees of elevation. Maintain this
CSF drips from the needle if it is position for 8 hours. Changing posi-
properly placed. tion is acceptable as long as the
body remains horizontal.
➤ Attach the stopcock and manometer,
and measure initial CSF pressure. ➤ Observe the patient for neurologic
Normal pressure for an adult in the changes, such as altered level of con-
lateral recumbent position is 90 to sciousness, change in pupils, reports
180 mm H2O. These values depend of tingling or numbness, and irritabil-
on the body position and are differ- ity.
ent in a horizontal or sitting position. ➤ Recognize anxiety related to test
➤ If the initial pressure is elevated, the results, and be supportive of per-
health care practitioner may perform ceived loss of independence and
Queckenstedt’s test. To perform this fear of shortened life expectancy.
test, apply pressure to the jugular Discuss the implications of abnormal
vein for about 10 seconds. CSF pres- test results on the patient’s lifestyle.
sure usually rises in response to the Provide teaching and information
occlusion, then rapidly returns to nor- regarding the clinical implications
mal within 10 seconds after the pres- of the test results, as appropriate.
sure is released. Sluggish response Educate the patient and family
may indicate CSF obstruction. members regarding access to
➤ Obtain CSF, and place in specimen counseling and other supportive
tubes. Take a final pressure reading, services.
and remove the needle. Clean the ➤ Reinforce information given by the
puncture site with an antiseptic solu- patient’s health care provider regard-
tion, and apply a small bandage. ing further testing, treatment, or
➤ Promptly transport the specimen to referral to another health care
the laboratory for processing and provider. Answer any questions or
analysis. address any concerns voiced by the
➤ The results are recorded manually or patient or family.
in a computerized system for recall ➤ Depending on the results of this pro-
and postprocedure interpretation by cedure, additional testing may be
the appropriate health care practi- performed to evaluate or monitor
tioner. progression of the disease process
Post-test: and determine the need for a change
in therapy. Evaluate test results in
➤ After lumbar puncture, monitor vital relation to the patient’s symptoms
signs and neurologic status every 15 and other tests performed.
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42 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

AMINO ACID SCREEN, BLOOD


● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma
(1 mL) collected in a green-top (heparin) tube is also acceptable.

REFERENCE VALUE: (Method: Chromatography) There are numerous amino


acids. The following table includes those most frequently screened. All units
are nanomoles per milliliter (nmol/mL).

-Amino-
-Amino N-butyric
Age Alanine -Alanine Anserine adipic Acid Acid
Premature 212–504 0 — 0 14–52
Newborn–1 131–710 0–10 0 0 8–24
mo
2 mo–2 y 143–439 0–7 0 0 3–26
2–18 y 152–547 0–7 0 0 4–31
Adult 177–583 0–12 0 0–6 5–41
-Amino- -Aminoiso- Aspartic
Age butyric Acid butyric Acid Arginine Asparagine Acid
Premature 0 0 34–96 90–295 24–50
Newborn–1 0–2 0 6–140 29–132 20–129
mo
2 mo–2 y 0 0 12–133 21–95 0–23
2–18 y 0 0 10–140 23–112 1–24
Adult 0 0 15–128 35–74 1–25
Cysta- Ethanol-
Age Carnosine Citrulline thionine Cystine amine
Premature — 20–87 5–10 15–70 —
Newborn–1 0–19 10–45 0–3 17–98 0–115
mo
2 mo-2 y 0 3–35 0–5 16–84 0–4
2–18 y 0 1–46 0–3 5–45 0–7
Adult 0 12–55 0–3 5–82 0–153
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 43

Amino Acid Screen, Blood 43

Glutamic Homo-
Age Acid Glutamine Glycine Histidine cystine
Premature 107–276 248–850 298–602 72–134 3–20
Newborn–1 62–620 376–709 232–740 30–138 0
mo
2 mo–2 y 10–133 246–1182 81–436 41–101 0
2–18 y 5–150 254–823 127–341 41–125 0–5
Adult 10–131 205–756 151–490 72–124 0
Hydroxy- Hydroxy-
Age lysine proline Isoleucine Leucine Lysine
Premature 0 0–80 23–85 151–220 128–255
Newborn–1 0–7 0–91 26–91 48–160 92–325
mo
2 mo–2 y 0–7 0–63 31–86 47–155 52–196
2–18 y 0–2 3–45 22–107 49–216 48–284
Adult 0 0–53 30–108 72–201 116–296
1-Methyl- 3-Methyl- Phenyl-
Age Methionine histidine histidine Ornithine alanine
Premature 37–91 4–28 5–33 77–212 98–213
Newborn–1 10–60 0–43 0–5 48–211 38–137
mo
2 mo–2 y 9–42 0–44 0–5 22–103 31–75
2–18 y 7–47 0–42 0–5 10–163 26–91
Adult 10–42 0–39 0–8 48–195 35–85

Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 5–35 10–45 92–310 0 127–248
Newborn–1 3–27 7–47 110–417 0–625 99–395
mo
2 mo–2 y 0–6 1–20 52–298 0 71–186
2–18 y 0–69 1–30 59–369 0–9 69–187
Adult 0–40 2–14 97–329 0 58–181

Age Taurine Threonine Tryptophan Tyrosine Valine

Premature 151–411 150–330 28–136 147–420 99–220


Newborn–1 46–492 90–329 0–60 55–147 86–190
mo
2 mo–2 y 15–143 24–174 23–71 22–108 64–294
2–18 y 10–170 35–226 0–79 24–115 74–321
Adult 54–210 60–225 10–140 34–112 119–336
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44 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Glomerulonephritis
DESCRIPTION & RATIONALE: Screen-
ing for inborn errors of amino acid • Hartnup disease
metabolism is generally performed on • Huntington’s chorea
infants after an initial blood test with
• Malnutrition
abnormal results. Certain congenital
enzyme deficiencies interfere with nor- • Nephrotic syndrome
mal amino acid metabolism and cause
• Pancreatitis (acute)
excessive accumulation of or deficien-
cies in amino acid levels. Reduced • Polycystic kidney disease
growth rates, mental retardation, or • Rheumatoid arthritis
various unexplained symptoms can
result unless the abnormality is identi-
fied and corrected early in life. ■ CRITICAL VALUES: N/A
Interfering factors:
INDICATIONS:
• Assist in the detection of noninherited • Drugs that may increase plasma amino
disorders evidenced by elevated amino acid levels include bismuth salts, gluco-
acid levels corticoids, levarterenol, 11-oxysteroids,
and testosterone (elderly).
• Detect inborn errors of amino acid
metabolism • Drugs that may decrease plasma amino
acid levels include cerulein, epineph-
RESULT rine, estrogens (males), glucose, oral
contraceptives, progesterone (males),
Increased (total amino acids) in: and secretin.
• Aminoacidopathies (usually inherited; • Amino acids exhibit a strong circadian
specific amino acids are implicated) rhythm; values are highest in the after-
• Brain damage (severe) noon and lowest in the morning.
Protein intake does not influence diur-
• Burns nal variation but significantly affects
• Diabetes absolute concentrations.
• Eclampsia • Failure to follow dietary restrictions
before the procedure may cause the
• Fructose intolerance (hereditary) procedure to be canceled or repeated.
• Malabsorption
• Renal failure (acute or chronic)
Nursing Implications and
• Reye’s syndrome Procedure ● ● ● ● ● ● ● ● ● ● ●

• Severe liver damage


Pretest:
• Shock ➤ Inform the patient (and/or caregiver)
that the test is used to screen for
Decreased (total amino acids) in: congenital errors of protein metabo-
• Adrenocortical hyperfunction lism and transport.
• Carcinoid syndrome ➤ Obtain a history of the patient’s
complaints, including a list of known
• Fever allergens (especially allergies or sen-
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Amino Acid Screen, Blood 45

sitivities to latex), and inform the normally and to avoid unnecessary


appropriate health care practitioner movement. The caregiver may assist
accordingly. in preventing unnecessary move-
ment.
➤ Obtain a history of the patient’s or
parents’ reproductive system as it ➤ Observe standard precautions, and
relates to genetic disease, as well follow the general guidelines in
as results of previously performed Appendix A. Positively identify the
laboratory tests, surgical proce- patient, and label the appropriate
dures, and other diagnostic proce- tubes with the corresponding patient
dures. For related laboratory tests, demographics, date, and time of col-
refer to the Reproductive System lection. Perform a venipuncture; col-
table. lect the specimen in a 5-mL red-top
tube.
➤ Obtain a list of the medications the
patient is taking, including herbs, ➤ Remove the needle, place a gauze
nutritional supplements, and nutra- over the puncture site and apply
ceuticals. The requesting health care gentle pressure to stop bleeding.
practitioner and laboratory should be Observe venipuncture site for bleed-
advised if the patient regularly uses ing or hematoma formation. Apply
these products so that their effects paper tape over gauze or replace
can be taken into consideration adhesive plastic bandage.
when reviewing results. ➤ Promptly transport the specimen to
➤ Review the procedure with the the laboratory for processing and
patient (and/or caregiver). Inform the analysis.
patient (and/or caregiver) that ➤ The results are recorded manually or
specimen collection takes approxi- in a computerized system for recall
mately 5 to 10 minutes. Address and postprocedure interpretation by
concerns about pain related to the the appropriate health care practi-
procedure. Explain to the patient tioner.
(and/or caregiver) that there may
be some discomfort during the
venipuncture. Post-test:
➤ Sensitivity to social and cultural ➤ Instruct the patient to resume usual
issues is important in providing psy- diet as directed by the health care
chological support before, during, practitioner.
and after the procedure. ➤ Nutritional considerations: Instruct
➤ There are no food, fluid or medica- the patient (and/or caregiver) in spe-
tion restrictions unless by medical cial dietary modifications, as appro-
direction. priate to treat deficiency, or refer
caregiver to a qualified nutritionist.
Amino acids are classified as essen-
Intratest: tial (i.e., must be present simultane-
➤ Ensure that the patient has complied ously in sufficient quantities);
with dietary and other pretesting conditionally or acquired essential
preparations; assure that food has (i.e., under certain stressful condi-
been restricted for at least 12 hours tions, they become essential); and
prior to the procedure. nonessential (i.e., can be produced
by the body, when needed, if diet
➤ If the patient has a history of severe does not provide them). Essential
allergic reaction to latex, care should amino acids include lysine, threo-
be taken to avoid the use of equip- nine, histidine, isoleucine, methion-
ment containing latex. ine, phenylalanine, tryptophan, and
➤ Instruct the patient (and/or caregiver) valine. Conditionally essential amino
to cooperate fully and to follow direc- acids include cysteine, tyrosine, argi-
tions. Direct the patient to breathe nine, citrulline, taurine, and carnitine.
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46 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Nonessential amino acids include giver) regarding access to genetic or


alanine, glutamic acid, aspartic other counseling services.
acid, glycine, serine, proline, gluta- ➤ Reinforce information given by the
mine, and asparagine. A high intake patient’s health care provider regard-
of specific amino acids can cause ing further testing, treatment, or
other amino acids to become essen- referral to another health care provi-
tial. der. Answer any questions or add-
➤ A written report of the examination ress any concerns voiced by the
will be sent to the requesting health patient or family.
care practitioner, who will discuss ➤ Depending on the results of this pro-
the results with the patient (and/or cedure, additional testing may be
caregiver). performed to evaluate or monitor
➤ Recognize anxiety related to test progression of the disease process
results, and be supportive of per- and determine the need for a change
ceived loss of independence and in therapy. Evaluate test results in
fear of shortened life expectancy. relation to the patient’s symptoms
Discuss the implications of abnormal and other tests performed.
test results on the patient’s lifestyle.
Provide teaching and information
Related laboratory tests:
regarding the clinical implications of ➤ Related laboratory tests include
the test results, as appropriate. ammonia and urine amino acid
Educate the patient (and/or care- screen.

AMINO ACID SCREEN, URINE


● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (10 mL) from a random or timed specimen collected in a
clean plastic collection container with hydrochloric acid as a preservative.

REFERENCE VALUE: (Method: Chromatography) There are numerous amino


acids. The following table includes those most frequently screened. All units
are nanomoles per milligram (nmol/mg) creatinine.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 47

Amino Acid Screen, Urine 47

a-Amino- a-Amino-
adipic N-butyric
Age Alanine -Alanine Anserine Acid Acid
Premature 1320–4040 1020–3500 — 70–460 50–710
Newborn– 982–3055 25–288 0–3 0–180 8–65
1 mo
2 mo–2 y 767–6090 0–297 0–5 45–268 30–136
2–18 y 231–915 0–65 0 2–88 0–77
Adult 240–670 0–130 0 40–110 0–90
-Amino- -Aminoiso- Aspartic
Age butyric Acid butyric Acid Arginine Asparagine Acid
Premature 20–260 50–470 190–820 1350–5250 580–1520
Newborn– 0–15 421–3133 35–214 185–1550 336–810
1 mo
2 mo–2 y 0–105 802–4160 38–165 252–1280 230–685
2–18 y 15–30 291–1482 31–109 72–332 0–120
Adult 15–30 10–510 10–90 99–470 60–240
Cystath- Ethano
Age Carnosine Citrulline ionine Cystine amine
Premature 260–370 240–1320 260–1160 480–1690 —
Newborn– 97–665 27–181 16–147 212–668 840–3400
1 mo
2 mo–2 y 203–635 22–180 33–470 68–710 0–2230
2–18 y 72–402 10–99 0–26 25–125 0–530
Adult 10–90 8–50 20–50 43–210 0–520
Glutamic Homo-
Age Acid Glutamine Glycine Histidine cystine
Premature 380–3760 520–1700 7840– 1240–7240 580–2230
23,600
Newborn– 70–1058 393–1042 5749– 908–2528 0–88
1 mo 16,423
2 mo–2 y 54–590 670–1562 3023– 815–7090 6–67
11,148
2–18 y 0–176 369–1014 897–4500 644–2430 0–32
Adult 39–330 190–510 730–4160 460–1430 0–32
Hydroxy- Hydroxy-
Age lysine proline Isoleucine Leucine Lysine
Premature — 560–5640 250–640 190–790 1860–15,460
Newborn– 10–125 40–440 125–390 78–195 270–1850
1 mo
2 mo–2 y 0–97 0–4010 38–342 70–570 189–850
2–18 y 40–102 0–3300 10–126 30–500 153–634
Adult 40–90 0–26 16–180 30–150 145–634

(Continued on the following page)


01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 48

48 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

1-Methyl- 3-Methyl- Phenyl-


Age Methionine histidine histidine Ornithine alanine
Premature 500–1230 170–880 420–1340 260–3350 920–2280
Newborn– 342–880 96–499 189–680 118–554 91–457
1 mo
2 mo–2 y 174–1090 106–1275 147–391 55–364 175–1340
2–18 y 16–114 170–1688 182–365 31–91 61–314
Adult 38–210 170–1680 160–520 20–80 51–250
Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 80–340 500–1690 1350– 0 1680–6000
10,460
Newborn– 0–155 150–339 370–2323 0–56 1444–3661
1 mo
2 mo–2 y 108–533 112–304 254–2195 30–358 845–3190
2–18 y 18–150 70–138 0 0–26 362–1100
Adult 20–100 40–510 0 0–80 240–670
Age Taurine Threonine Tryptophan Tyrosine Valine
Premature 5190– 840–5700 0 1090–6780 180–890
23,620
Newborn– 1650–6220 445–1122 0 220–1650 113–369
1 mo
2 mo–2 y 545–3790 252–1528 0–93 333–1550 99–316
2–18 y 639–1866 121–389 0–108 122–517 58–143
Adult 380–1850 130–370 0–70 90–290 27–260

DESCRIPTION & RATIONALE: Urine rates, and various unexplained symp-


amino acid testing is used in the initial toms. Values are age dependent. A
screening for congenital defects and positive screen on a random sample
disorders of amino acid metabolism. should be followed up with a timed
The major genetic disorders include collection. Amino acid concentrations
phenylketonuria, tyrosinuria, and demonstrate a significant circadian
alcaptonuria, a defect in the phenyl- rhythm with values being lowest in
alanine-tyrosine conversion pathway. the morning and highest in midafter-
Renal aminoaciduria is also associated noon. ■
with conditions marked by defective
tubular reabsorption from congenital INDICATIONS:
disorders, such as hereditary fructose • Assist in the detection of noninherited
intolerance, cystinuria, and Hartnup disorders evidenced by elevated amino
disease. Early diagnosis and treatment acid levels
of certain aminoacidurias can prevent • Screen for inborn errors of amino acid
mental retardation, reduced growth metabolism
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 49

Amino Acid Screen, Urine 49

RESULT INTERFERING FACTORS:


• Drugs that may increase urine amino
Increased (total amino acids) in: acid levels include acetaminophen,
• Primary causes (inherited): acetosalicylic acid, amikacin, amino-
Aminoaciduria (specific) caproic acid, amphetamine, bismuth,
Cystinosis (may be masked cephalosporins, colistin, corticotropin,
because of decreased glomerular dopamine, ephedrine, epinephrine,
filtration rate, so values may be erythromycin, ethylenediamine, gen-
in normal range) tamicin, hydrocortisone, hydroxyami-
Fanconi’s syndrome nobutyric acid, insulin, kanamycin,
Fructose intolerance levarterenol, levodopa, mafenide, meta-
nephrine, methamphetamine, methyl-
Galactosemia
dopa, neomycin, normetanephrine,
Hartnup disease penicillins, phenacetin, phenobarbital,
Lactose intolerance phenylephrine, phenylpropanolamine,
Lowe’s syndrome polymixin, polythiazide, primidone,
Maple syrup urine disease proSobee, pseudoephedrine, strepto-
Tyrosinemia type I zocin, tetracycline, triamcinolone, val-
proic acid, and vigabatrin.
Tyrosinosis
Wilson’s disease • Drugs that may decrease urine amino
• Secondary causes (noninherited): acid levels include antihistamines.
Acute leukemia • Amino acids exhibit a strong circadian
Chronic renal failure (reduced GFR) rhythm; values are highest in the after-
Chronic renal failure noon and lowest in the morning.
Diabetic ketosis Protein intake does not influence diur-
nal variation but significantly affects
Epilepsy (transient increase due to
disturbed renal function during absolute concentrations.
grand mal seizure) • Dilute urine (specific gravity less than
Folic acid deficiency 1.010) should be rejected for analysis.
Hyperparathyroidism
Liver necrosis and cirrhosis • Failure to follow dietary restrictions
before the procedure may cause the
Multiple myeloma
procedure to be canceled or repeated.
Muscular dystrophy (progressive)
Osteomalacia (secondary to
parathyroid hormone excess)
Pernicious anemia
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
Thalassemia major
Vitamin deficiency (B, C, and D;
vitamin D–deficiency rickets, Pretest:
vitamin D–resistant rickets)
➤ Inform the patient (and/or caregiver)
Viral hepatitis (reflects the degree that the test is used to screen for
of hepatic involvement) congenital errors of protein metabo-
lism and transport.
Decreased in: N/A ➤ Obtain a history of the patient’s com-
plaints, including a list of known
CRITICAL VALUES: N/A allergens (especially allergies or sen-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 50

50 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

sitivities to latex), and inform the contamination of the specimen.


appropriate health care practitioner Place a sign in the bathroom to
accordingly. remind the patient to save all urine.
➤ Obtain a history of the patient’s and ➤ Instruct the patient to void all urine
parents’ reproductive system as it into the collection device and pour
relates to genetic disease, as well as the urine into the laboratory collec-
results of previously performed labo- tion container. Alternatively, the
ratory tests, surgical procedures, specimen can be left in the collection
and other diagnostic procedures. For device for a health care staff mem-
related laboratory tests, refer to the ber to add to the laboratory collec-
Reproductive System table. tion container.
➤ Obtain a list of the medications the
patient is taking, including herbs, Intratest:
nutritional supplements, and nutra-
ceuticals. The requesting health care ➤ Ensure that the patient has complied
practitioner and laboratory should be with dietary and other pretesting
advised if the patient regularly uses preparations; assure that food has
these products so that their effects been restricted for at least 12 hours
can be taken into consideration prior to the procedure.
when reviewing results. ➤ Observe standard precautions, and
➤ Review the procedure with the follow the general guidelines in
patient (and/or caregiver). Inform the Appendix A. Positively identify the
patient and caregiver that random patient, and label the appropriate
urine specimen collection takes specimen container with the corre-
approximately 5 minutes. Address sponding patient demographics,
concerns about pain related to the date, and time of collection. Include
procedure. Explain to the patient on the timed specimen label the
(and/or caregiver) that no pain will be amount of urine and test start and
experienced during the test. stop times.
➤ Sensitivity to social and cultural ➤ Promptly transport the specimen to
issues is important in providing psy- the laboratory for processing and
chological support before, during, analysis.
and after the procedure. ➤ The results are recorded manually or
➤ There are no fluid or medication in a computerized system for recall
restrictions unless by medical direc- and postprocedure interpretation by
tion. the appropriate health care practi-
tioner.
➤ The patient should avoid excessive
exercise and stress during the 24-
hour collection of urine. Random specimen (collect
in early morning):
➤ Review the procedure with the
patient (and/or caregiver). Provide a ➤ Infant: Clean and dry the genital
nonmetallic urinal, bedpan, or toilet- area, attach the collection device
mounted collection device. securely to prevent leakage, and
➤ If a timed collection is requested, observe for voiding. Remove collec-
inform the patient that all urine col- tion device carefully from the skin to
lected over a 24-hour period must be prevent irritation. Transfer the urine
saved; if a preservative has been into a specimen container. For dip-
added to the container, instruct the stick method, place dipstick or
patient not to discard the preserva- reagent pad into the urine specimen
tive. Instruct the patient not to void or on the diaper saturated with urine.
directly into the laboratory collection Remove, compare with color chart,
container. Instruct the patient to and record results.
avoid defecating in the collection ➤ Adult: Instruct the patient to obtain a
device and to keep toilet tissue out clean-catch specimen as described
of the collection device to prevent in Appendix A. If an indwelling
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 51

Amino Acid Screen, Urine 51

catheter is in place, it may be neces- Amino acids are classified as essen-


sary to clamp off the catheter for 15 tial (i.e., must be present simultane-
to 30 minutes before specimen col- ously in sufficient quantities);
lection. Cleanse specimen port with conditionally or acquired essential
antiseptic swab, and then aspirate 5 (i.e., under certain stressful condi-
mL of urine with a 21- to 25-gauge tions, they become essential); and
needle and syringe. Transfer urine to nonessential (i.e., can be produced
a properly labeled plastic container. by the body, when needed, if diet
does not provide them). Essential
Timed specimen: amino acids include lysine, threo-
nine, histidine, isoleucine, methion-
➤ Obtain a clean 3-L urine specimen
ine, phenylalanine, tryptophan, and
container, toilet-mounted collection
valine. Conditionally essential amino
device, and plastic bag (for transport
acids include cysteine, tyrosine, argi-
of the specimen container). The
nine, citrulline, taurine, and carnitine.
specimen must be refrigerated or
Nonessential amino acids include
kept on ice throughout the entire col-
alanine, glutamic acid, aspartic acid,
lection period. If an indwelling uri-
glycine, serine, proline, glutamine,
nary catheter is in place, the
and asparagine. A high intake of spe-
drainage bag must be kept on ice.
cific amino acids can cause other
➤ Begin the test between 6 and 8 a.m., amino acids to become essential.
if possible. Collect first voiding and
discard. Record the time the speci- ➤ A written report of the examination
men was discarded as the beginning will be sent to the requesting health
of the timed collection period. The care practitioner, who will discuss
next morning, ask the patient to void the results with the patient (and/or
at the same time the collection was caregiver).
started, and add this last voiding to ➤ Recognize anxiety related to test
the container. results, and be supportive of per-
➤ If an indwelling catheter is in place, ceived loss of independence and fear
replace the tubing and container sys- of shortened life expectancy. Discuss
tem at the start of the collection the implications of abnormal test
time. Keep the container system on results on the patient’s lifestyle.
ice during the collection period, or Provide teaching and information
empty the urine into a larger con- regarding the clinical implications of
tainer periodically during the collec- the test results, as appropriate. Edu-
tion period; monitor to ensure cate the patient regarding access to
continued drainage, and conclude genetic or other counseling services.
the test the next morning at the ➤ Reinforce information given by the
same hour the collection started. patient’s health care provider regard-
➤ At the conclusion of the test, com- ing further testing, treatment, or
pare the quantity of urine with the referral to another health care
urinary output record for the collec- provider. Answer any questions or
tion. If the specimen contains less address any concerns voiced by the
than what was recorded as output, patient or family.
some urine may have been dis- ➤ Depending on the results of this pro-
carded, invalidating the test. cedure, additional testing may be
performed to evaluate or monitor
Post-test: progression of the disease process
➤ Instruct the patient to resume usual and determine the need for a change
diet as directed by the health care in therapy. Evaluate test results in
practitioner. relation to the patient’s symptoms
and other tests performed.
➤ Nutritional considerations: Instruct
the patient (and/or caregiver) in spe- Related laboratory tests:
cial dietary modifications, as appro-
priate to treat deficiency, or refer ➤ Related laboratory tests include am-
caregiver to a qualified nutritionist. monia and blood amino acid screen.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 52

52 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

-AMINOLEVULINIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: -ALA.
SPECIMEN: Urine (25 mL) from a timed specimen collected in a dark plastic
container with hydrochloric acid as a preservative.

REFERENCE VALUE: (Method: Spectrophotometry)

Conventional Units SI Units (Conventional Units  7.626)


1.5–7.5 mg/24 h 11.4–57.2 mol/24 h

Decreased in:
DESCRIPTION & RATIONALE: - • Liver disease (alcoholic)
Aminolevulinic acid (-ALA) is
involved in the formation of por- CRITICAL VALUES: N/A
phyrins. Disturbances in porphyrin
metabolism can cause an increase in
-ALA excretion in urine. Although
INTERFERING FACTORS:
• Drugs that may increase -ALA levels
lead poisoning can cause increased include ammonia, glucosamine, and
urinary excretion, the measurement of penicillins.
-ALA is not useful to indicate lead
toxicity because it is not detectable in • Cisplatin may decrease -ALA levels.
the urine until the blood lead level • Numerous drugs are suspected as
approaches and exceeds 40 g/dL. ■ potential initiators of attacks of acute
porphyria, but those classified as unsafe
for high-risk individuals include
INDICATIONS: aminoglutethimide, aminopyrine, anti-
• Assist in the diagnosis of porphyrias pyrine, barbiturates, carbamazepine,
carbromal, chlorpropamide, danazol,
RESULT dapsone, diclofenac, diphenylhydan-
toin, ergot preparations, ethchlorvynol,
Increased in: ethinamate, glutethimide, griseofulvin,
• Acute porphyrias mephenytoin, meprobamate, methy-
prylone, N-isopropyl meprobamate,
• Aminolevulinic acid dehydrase defi- novobiocin, phenylbutazone, primi-
ciency done, pyrazolone preparations, succin-
• Hereditary tyrosinemia imides, sulfomethane, sulfonamides,
sulfonethylmethane, synthetic estro-
• Lead poisoning gens and progestins, tolazamide, tolbu-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 53

-Aminolevulinic Acid 53

tamide, trimethadione, and valproic lection container. Alternatively, the


acid. specimen can be left in the collection
device for a health care staff mem-
ber to add to the laboratory collec-
Nursing Implications and tion container.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Sensitivity to social and cultural
issues, as well as concern for mod-
Pretest: esty, is important in providing psy-
➤ Inform the patient that the test is pri- chological support before, during,
marily used to diagnose porphyrias. and after the procedure.
➤ Obtain a history of the patient’s com- ➤ There are no food, fluid, or medica-
plaints, including a list of known tion restrictions unless by medical
allergens (especially allergies or sen- direction.
sitivities to latex), and inform the
appropriate health care practitioner Intratest:
accordingly.
➤ If the patient has a history of severe
➤ Obtain a history of the patient’s allergic reaction to latex, care should
hematopoietic system and results of be taken to avoid the use of equip-
previously performed laboratory ment containing latex.
tests, surgical procedures, and other
diagnostic procedures. For related ➤ Instruct the patient to cooperate fully
laboratory tests, refer to the Hema- and to follow directions.
topoietic System table. ➤ Observe standard precautions, and
➤ Obtain a list of the medications the follow the general guidelines in
patient is taking, including herbs, Appendix A. Positively identify the
nutritional supplements, and nutra- patient, and label the appropriate col-
ceuticals. The requesting health care lection container with the correspon-
practitioner and laboratory should be ding patient demographics, date, and
advised if the patient regularly uses time of collection.
these products so that their effects
can be taken into consideration Timed specimen:
when reviewing results. ➤ Obtain a clean 3-L urine specimen
➤ Review the procedure with the container, toilet-mounted collection
patient. Provide a nonmetallic urinal, device, and plastic bag (for transport
bedpan, or toilet-mounted collection of the specimen container). The
device. Address concerns about pain specimen must be refrigerated or
related to the procedure. Explain to kept on ice throughout the entire
the patient that there should be no collection period. If an indwelling
discomfort during the procedure. urinary catheter is in place, the
➤ Usually a 24-hour time frame for drainage bag must be kept on ice.
urine collection is ordered. Inform ➤ Begin the test between 6 and 8 a.m.,
the patient that all urine must be if possible. Collect first voiding and
saved during that 24-hour period. discard. Record the time the speci-
Instruct the patient not to void men was discarded as the beginning
directly into the laboratory collection of the timed collection period. The
container. Instruct the patient to next morning, ask the patient to void
avoid defacating in the collection at the same time the collection was
device and to keep toilet tissue out started, and add this last voiding to
of the collection device to prevent the container.
contamination of the specimen. ➤ If an indwelling catheter is in place,
Place a sign in the bathroom to replace the tubing and container sys-
remind the patient to save all urine. tem at the start of the collection
➤ Instruct the patient to void all urine time. Keep the container system on
into the collection device and then to ice during the collection period, or
pour the urine into the laboratory col- empty the urine into a larger con-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 54

54 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

tainer periodically during the collec- care practitioner, who will discuss
tion period. Monitor to ensure con- the results with the patient.
tinued drainage, and conclude the ➤ Recognize anxiety related to test
test the next morning at the same results. Discuss the implications of
hour the collection was begun. abnormal test results on the
➤ At the conclusion of the test, com- patient’s lifestyle. Provide teaching
pare the quantity of urine with the and information regarding the clinical
urinary output record for the collec- implications of the test results, as
tion. If the specimen contains less appropriate.
than what was recorded as output,
some urine may have been dis- ➤ Reinforce information given by the
carded, invalidating the test. patient’s health care provider regard-
ing further testing, treatment, or
➤ Include on the specimen collection referral to another health care pro-
container’s label the amount of urine vider. Answer any questions or
as well as test start and stop times. address any concerns voiced by the
Note the ingestion of any medica- patient or family.
tions that may affect test results.
➤ Promptly transport the specimen to ➤ Depending on the results of this pro-
the laboratory for processing and cedure, additional testing may be
analysis. performed to evaluate or monitor
progression of the disease process
➤ The results are recorded manually or and determine the need for a change
in a computerized system for recall in therapy. Evaluate test results in
and postprocedure interpretation by relation to the patient’s symptoms
the appropriate health care practi- and other tests performed.
tioner.
Post-test: Related laboratory tests:
➤ A written report of the examination ➤ Related laboratory tests include lead
will be sent to the requesting health and urine porphyrins.

AMMONIA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: NH3.
SPECIMEN: Plasma (1 mL) collected in completely filled green-top (heparin)
tube. Specimen should be transported tightly capped and in an ice slurry.

REFERENCE VALUE: (Method: Spectrophotometry)

SI Units (Conventional
Age Conventional Units Units  0.714)
Newborn 90–150 g/dL 64–107 mol/L
Adult Male 27–102 g/dL 19–73 mol/L
Adult Female 19–87 g/dL 14–62 mol/L
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 55

Ammonia 55

nase, barbiturates, diuretics, ethanol,


DESCRIPTION & RATIONALE: Blood fibrin hydrolysate, fluorides, furose-
ammonia (NH3) comes from two mide, thiazides, and valproic acid.
sources: deamination of amino acids • Drugs/organisms that may decrease
during protein metabolism and degra- ammonia levels include diphenhy-
dation of proteins by colon bacteria. dramine, kanamycin, neomycin, tetra-
The liver converts ammonia in the cycline, and Lactobacillus acidophilus.
portal blood to urea, which is excreted • Hemolysis falsely increases ammonia
by the kidneys. When liver function is levels.
severely compromised, especially in
situations in which decreased hepato- • Prompt and proper specimen process-
ing, storage, and analysis are important
cellular function is combined with
to achieve accurate results. The speci-
impaired portal blood flow, ammonia men should be collected on ice; the
levels rise. Ammonia is potentially collection tube should be filled com-
toxic to the central nervous system. ■ pletely, and then kept tightly stop-
pered. Ammonia increases rapidly in
INDICATIONS: the collected specimen, so analysis
• Evaluate advanced liver disease or other should be performed within 20 min-
disorders associated with altered serum utes of collection.
ammonia levels
• Identify impending hepatic enceph-
alopathy with known liver disease Nursing Implications and
• Monitor the effectiveness of treatment Procedure ● ● ● ● ● ● ● ● ● ● ●

for hepatic encephalopathy, indicated


by declining levels Pretest:
• Monitor patients receiving hyperali- ➤ Inform the patient that the test is
mentation therapy used to assess liver function, partic-
ularly in the diagnosis of urea cycle
RESULT deficiencies in neonates and the
identification of Reye’s syndrome.
Increased in: ➤ Obtain a history of the patient’s com-
• Gastrointestinal hemorrhage plaints, including a list of known
allergens (especially allergies or sen-
• Genitourinary tract infection with dis-
sitivities to latex), and inform the
tention and stasis appropriate health care practitioner
• Hepatic coma accordingly.
• Inborn enzyme deficiency ➤ Obtain a history of the patient’s gas-
trointestinal, genitourinary, and
• Liver failure, late cirrhosis hepatobiliary systems, as well as
results of previously performed labo-
• Reye’s syndrome
ratory tests, surgical procedures,
• Total parenteral nutrition and other diagnostic procedures. For
related laboratory tests, refer to the
Decreased in: N/A Gastrointestinal, Genitourinary, and
Hepatobiliary System tables.
CRITICAL VALUES: N/A ➤ Obtain a list of the medications
the patient is taking, including
INTERFERING FACTORS: herbs, nutritional supplements, and
• Drugs that may increase ammonia lev- nutraceuticals. The requesting health
els include ammonium salts, asparagi- care practitioner and laboratory
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 56

56 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

should be advised if the patient in a computerized system for recall


regularly uses these products so and postprocedure interpretation by
that their effects can be taken into the appropriate health care practi-
consideration when reviewing tioner.
results.
➤ Review the procedure with the
Post-test:
patient. Inform the patient that spec-
imen collection takes approximately ➤ Nutritional considerations: Increased
5 to 10 minutes. Address concerns ammonia levels may be associated
about pain related to the procedure. with liver disease. Dietary recom-
Explain to the patient that there may mendations may be indicated,
be some discomfort during the depending on the severity of the
venipuncture. condition. A low-protein diet may be
➤ There are no food, fluid, or medica- in order if the patient’s liver has lost
tion restrictions unless by medical the ability to process the end prod-
direction. ucts of protein metabolism. A diet of
soft foods may be required if
Intratest: esophageal varices have developed.
Ammonia levels may be used to
➤ If the patient has a history of severe determine whether protein should
allergic reaction to latex, care should be added to or reduced from the
be taken to avoid the use of equip- diet. Patients should be encouraged
ment containing latex. to eat simple carbohydrates and
➤ Instruct the patient to cooperate fully emulsified fats (as in homogenized
and to follow directions. Direct the milk or eggs), as opposed to com-
patient to breathe normally and to plex carbohydrates (e.g., starch,
avoid unnecessary movement. fiber, and glycogen [animal carbohy-
drates]) and complex fats, which
➤ Observe standard precautions, and would require additional bile to emul-
follow the general guidelines in sify them so that they could be used.
Appendix A. Positively identify the The cirrhotic patient should be care-
patient, and label the appropriate fully observed for the development
tubes with the corresponding patient of ascites, in which case fluid and
demographics, date, and time of electrolyte balance requires strict
collection. Perform a venipuncture; attention.
collect the specimen in a 5-mL
➤ A written report of the examination
green-top tube.
will be sent to the requesting health
➤ Remove the needle, place a gauze care practitioner, who will discuss
over the puncture site and apply the results with the patient.
gentle pressure to stop bleeding.
➤ Reinforce information given by the
Observe the venipuncture site for
patient’s health care provider regard-
bleeding or hematoma formation.
ing further testing, treatment, or
Apply paper tape over gauze or
referral to another health care
replace with adhesive bandage.
provider. Answer any questions or
➤ Promptly transport the specimen to address any concerns voiced by the
the laboratory for processing and patient or family.
analysis. The tightly capped sample ➤ Depending on the results of this pro-
should be placed in an ice slurry cedure, additional testing may be
immediately after collection. Infor- performed to evaluate or monitor
mation on the specimen label can be progression of the disease process
protected from water in the ice and determine the need for a change
slurry by first placing the specimen in therapy. Evaluate test results in
in a protective plastic bag. relation to the patient’s symptoms
➤ The results are recorded manually or and other tests performed.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 57

Amniotic Fluid Analysis 57

ses, blood calcium, complete blood


Related laboratory tests:
count, electrolytes, glucose, ketones,
➤ Related laboratory tests include acet- lactic acid, osmolality, protein, pro-
aminophen, alanine aminotransfe- thrombin time, urea nitrogen, and uric
rase, albumin, anion gap, aspartate acid.
aminotransferase, bilirubin, blood ga-

AMNIOTIC FLUID ANALYSIS


● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: N/A.
SPECIMEN: Amniotic fluid (10 to 20 mL) collected in a clean amber glass or
plastic container.

REFERENCE VALUE: (Method: Macroscopic observation of fluid for color and


appearance, immunochemiluminometric assay [ZCMA] for 1-fetoprotein,
electrophoresis for acetylcholinesterase, spectrophotometry for creatinine and
bilirubin, chromatography for lecithin/sphingomyelin [L/S] ratio and phos-
phatidylglycerol, tissue culture for chromosome analysis, dipstick for leuko-
cyte esterase, and automated cell counter for white blood cell count and
lamellar bodies)

Test Reference Value


Color Colorless to pale yellow
Appearance Clear
1-Fetoprotein Less than 2.0 MoM
Acetylcholinesterase Absent
Creatinine 1.8–4.0 mg/dL at term
Bilirubin Less than 0.075 mg/dL in early
pregnancy
Less than 0.025 mg/dL at term
L/S ratio Greater than 2:1 at term
Phosphatidylglycerol Present at term
Chromosome analysis Normal karyotype
White blood cell count None seen
Leukocyte esterase Negative
Lamellar bodies 30,000–50,000 platelet equivalents

MoM  multiples of the median.


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58 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

maternal age (some of the aforemen-


DESCRIPTION & RATIONALE: Amni- tioned tests are routinely requested in
otic fluid is formed in the membra- mothers age 35 years and older).
nous sac that surrounds the fetus. The • Evaluate fetus in mothers with a history
total volume of fluid at term is 500 to of miscarriage or stillbirth.
2500 mL. In amniocentesis, fluid is
obtained by ultrasound-guided needle • Evaluate known or suspected hemolytic
disease involving the fetus in an Rh-
aspiration from the amniotic sac. This
sensitized pregnancy, indicated by ris-
procedure is generally performed ing bilirubin levels, especially after the
between 14 and 16 weeks’ gestation, 30th week of gestation.
but it also can be done between 26
and 35 weeks’ gestation if fetal distress • Evaluate suspected neural tube defects,
such as spina bifida or myelomeningo-
is suspected. Amniotic fluid is tested
cele, as indicated by elevated 1-
to identify genetic and neural tube fetoprotein (see monograph titled
defects, hemolytic diseases of the new- “1-Fetoprotein” for information re-
born, fetal infection, fetal renal mal- lated to triple-marker testing).
function, or maturity of the fetal lungs
(see monograph titled “Lecithin/ RESULT:
Sphingomyelin Ratio”). ■ • Yellow, green, red, or brown fluid indi-
cates the presence of bilirubin, blood
INDICATIONS: (fetal or maternal), or meconium,
• Assist in the diagnosis of (in utero) which indicate fetal distress or death,
metabolic disorders, such as cystic hemolytic disease, or growth retar-
fibrosis; or errors of lipid, carbohy- dation.
drate, or amino acid metabolism. • Elevated bilirubin levels indicate fetal
• Detect infection secondary to ruptured hemolytic disease or intestinal obstruc-
membranes. tion. Measurement of bilirubin is not
usually performed before 20 to 24
• Detect fetal ventral wall defects.
weeks’ gestation because no action can
• Determine fetal maturity when preterm be taken before then. The severity of
delivery is being considered. Fetal hemolytic disease is graded by optical
maturity is indicated by an L/S ratio of density (OD) zones: A value of 0.28 to
2:1 or greater (see monograph titled 0.46 OD at 28 to 31 weeks’ gestation
“Lecithin/Sphingomyelin Ratio”). indicates mild hemolytic disease, which
• Determine fetal sex when the mother is probably will not affect the fetus; 0.47
a known carrier of a sex-linked abnor- to 0.90 OD indicates a moderate effect
mal gene that could be transmitted to on the fetus; and 0.91 to 1.0 OD indi-
male offspring, such as hemophilia or cates a significant effect on the fetus. A
Duchenne’s muscular dystrophy. trend of increasing values with serial
measurements may indicate the need
• Determine the presence of fetal distress for intrauterine transfusion or early
in late-stage pregnancy. delivery, depending on the fetal age.
• Evaluate fetus in families with a history After 32 to 33 weeks’ gestation, early
of genetic disorders, such as Down syn- delivery is preferred over intrauterine
drome, Tay-Sachs disease, chromosome transfusion, because early delivery is
or enzyme anomalies, or inherited more effective in providing the
hemoglobinopathies. required care to the neonate.
• Evaluate fetus in mothers of advanced • Creatinine concentration greater than
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 59

Amniotic Fluid Analysis 59

2.0 mg/dL indicates fetal maturity (at • Maternal serum creatinine should be
36 to 37 weeks) if maternal creatinine measured simultaneously for compari-
is also within the expected range. This son with amniotic fluid creatinine for
value should be interpreted in conjunc- proper interpretation. Even in circum-
tion with other parameters evaluated in stances in which the maternal serum
amniotic fluid and especially with the value is normal, the results of the amni-
L/S ratio, because normal lung devel- otic fluid creatinine may be misleading.
opment depends on normal kidney A high fluid creatinine value in the
development. fetus of a diabetic mother may reflect
• An L/S ratio less than 2:1 and absence the increased muscle mass of a larger
of phosphatidylglycerol at term indi- fetus. If the fetus is big, the creatinine
cate fetal lung immaturity and possible may be high, and the fetus may still
respiratory distress syndrome. The have immature kidneys.
expected L/S ratio for the fetus of an • Contamination of the sample with
insulin-dependent diabetic mother is blood or meconium or complications
higher (3.5:1). (See monograph titled in pregnancy may yield inaccurate L/S
“Lecithin/Sphingomyelin Ratio.”) ratios.
• Lamellar bodies are specialized alveolar • 1-Fetoprotein and acetylcholines-
cells in which lung surfactant is stored. terase may be falsely elevated if the
They are approximately the size of sample is contaminated with fetal
platelets. Their presence in sufficient blood.
quantities is an indicator of fetal lung
maturity. • Karyotyping cannot be performed
under the following conditions: (1)
• Elevated 1-fetoprotein levels and pres- failure to promptly deliver samples for
ence of acetylcholinesterase indicate a chromosomal analysis to the laboratory
neural tube defect (see monograph performing the test, or (2) improper
titled “1-Fetoprotein”). incubation of the sample, which causes
• Abnormal karyotype indicates genetic cell death.
abnormality (e.g., Tay-Sachs disease, • Amniocentesis is contraindicated in
mental retardation, chromosome or women with a history of premature
enzyme anomalies, and inherited labor or incompetent cervix. It is also
hemoglobinopathies). (See monograph contraindicated in the presence of pla-
titled “Chromosome Analysis, Blood.”) centa previa or abruptio placentae.
• Elevated white blood cell count and
positive leukocyte esterase are indica-
tors of infection. Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
CRITICAL VALUES: N/A
INTERFERING FACTORS: Pretest:
• Bilirubin may be falsely elevated if
maternal hemoglobin or meconium is ➤ Inform the patient that the test is
present in the sample; fetal acidosis used to evaluate fetal well-being.
may also lead to falsely elevated biliru- ➤ Obtain a history of the patient’s com-
bin levels. plaints, including a list of known
allergens (especially allergies or sen-
• Bilirubin may be falsely decreased if the sitivities to latex or anesthetics), and
sample is exposed to light or if amni- inform the appropriate health care
otic fluid volume is excessive. practitioner accordingly.
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60 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Obtain a history of the patient’s weeks’ gestation or beyond do not


reproductive system, previous preg- need to drink extra fluids and should
nancies, and results of previously void before the test, because an
performed laboratory tests, surgical empty bladder is less likely to be
procedures, and other diagnostic accidentally punctured during speci-
procedures. Include any family his- men collection. Encourage relaxation
tory of genetic disorders such as cys- and controlled breathing during the
tic fibrosis, Duchenne’s muscular procedure to aid in reducing any mild
dystrophy, hemophilia, sickle cell discomfort. Inform the patient that
disease, Tay-Sachs disease, tha- specimen collection is performed by
lassemia, and trisomy 21. Obtain a health care provider specializing in
maternal Rh type. If Rh-negative, this procedure and usually takes
check for prior sensitization. A stan- approximately 20 to 30 minutes to
dard RhoGAM dose is indicated after complete.
amniocentesis; repeat doses should ➤ Sensitivity to social and cultural
be considered if repeated amnio- issues, as well as concern for mod-
centesis is performed. For related esty, is important in providing psy-
laboratory tests, refer to the Repro- chological support before, during,
ductive System table. and after the procedure.
➤ Note any recent procedures that can ➤ There are no food, fluid, or medica-
interfere with test results. tion restrictions unless by medical
direction.
➤ Record the date of the last menstrual
period and determine the pregnancy ➤ Make sure a written and informed
weeks’ gestation and expected deliv- consent has been signed prior to the
ery date. procedure and before administering
any medications.
➤ Obtain a list of the medications the
patient is taking. Include herbs, nutri- Intratest:
tional supplements, and nutraceuti-
cals. The requesting health care ➤ Ensure that the patient has a full
practitioner and laboratory should be bladder before the procedure if ges-
advised if the patient regularly uses tation is 20 weeks or less; have
these products so that their effects patient void before the procedure if
can be taken into consideration gestation is 21 weeks or more.
when reviewing results. ➤ Positively identify the patient, and
➤ Review the procedure with the label the appropriate collection con-
patient. Warn the patient that normal tainers with the corresponding
results do not guarantee a normal patient demographics, date, time of
fetus. Assure the patient that pre- collection, and site location.
cautions to avoid injury to the fetus ➤ Have patient remove clothes below
will be taken by localizing the fetus the waist. Assist the patient to a
with ultrasound. Address concerns supine position on the exam table
about pain related to the procedure. with the abdomen exposed. Drape
Explain that, during the transabdomi- the patient’s legs, leaving the
nal procedure, any discomfort asso- abdomen exposed. Raise her head
ciated with a needle biopsy will be or legs slightly to promote comfort
minimized with local anesthetics. If and to relax the abdominal muscles.
the patient is less than 20 weeks’ If the uterus is large, place a pillow or
gestation, instruct her to drink extra rolled blanket under the patient’s
fluids 1 hour before the test and to right side to prevent hypertension
refrain from urination. The full blad- caused by great-vessel compres-
der assists in raising the uterus up sion. Instruct the patient to cooper-
and out of the way to provide better ate fully and to follow directions.
visualization during the ultrasound Direct the patient to breathe nor-
procedure. Patients who are at 20 mally and to avoid unnecessary
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Amniotic Fluid Analysis 61

movement during the local anes- ➤ Place samples in properly labeled


thetic and the procedure. specimen container, and promptly
➤ Record maternal and fetal baseline transport the specimen to the labo-
vital signs, and continue to monitor ratory for processing and analysis.
throughout the procedure. Monitor ➤ The results are recorded manually or
for uterine contractions. Monitor in a computerized system for recall
fetal vital signs using ultrasound. and postprocedure interpretation by
Protocols may vary from facility to the appropriate health care practi-
facility. tioner.
➤ After the administration of local
anesthesia, shave and cleanse the Post-test:
site with an antiseptic solution, and
drape the area with sterile towels. ➤ After the procedure, fetal heart
rate and maternal life signs (i.e.,
➤ Have emergency equipment readily
heart rate, blood pressure, pulse,
available.
and respiration) should be compared
➤ Observe standard precautions, and with baseline values and closely
follow the general guidelines in monitored every 15 minutes for 30
Appendix A. to 60 minutes after the amniocente-
➤ Assess the position of the amniotic sis procedure. Protocols may vary
fluid, fetus, and placenta using ultra- from facility to facility.
sound. ➤ Observe for delayed allergic reac-
➤ Assemble the necessary equipment, tions, such as rash, urticaria, tachy-
including an amniocentesis tray with cardia, hyperpnea, hypertension,
solution for skin preparation, local palpitations, nausea, or vomiting.
anesthetic, 10- or 20-mL syringe, ➤ Observe the amniocentesis site for
needles of various sizes (including a bleeding, inflammation, or hema-
22-gauge, 5-inch spinal needle), ster- toma formation.
ile drapes, sterile gloves, and foil- ➤ Instruct the patient in the care and
covered or amber-colored specimen assessment of the amniocentesis
collection containers. site. Instruct the patient to report any
➤ Cleanse suprapubic area with an redness, edema, bleeding, or pain at
antiseptic solution, and protect with the biopsy site. Instruct the patient
sterile drapes. A local anesthetic is to keep the site clean and change
injected. Explain that this may cause the dressing as needed.
a stinging sensation. ➤ Instruct the patient to expect mild
➤ A 22-gauge, 5-inch spinal needle is cramping, leakage of small amount
inserted through the abdominal and of amniotic fluid, and vaginal spotting
uterine walls. Explain that a sensa- for up to 2 days following the proce-
tion of pressure may be experienced dure. Instruct the patient to report
when the needle is inserted. Explain moderate to severe abdominal pain
to the patient how to use focused or cramps, change in fetal activity,
and controlled breathing for relax- increased or prolonged leaking of
ation during the procedure. amniotic fluid from abdominal needle
➤ After the fluid is collected and the site, vaginal bleeding that is heavier
needle is withdrawn, apply slight than spotting, and either chills or
pressure to the site. If there is no fever.
evidence of bleeding or other ➤ Instruct the patient to rest until all
drainage, apply a sterile adhesive symptoms have disappeared before
bandage to the site. resuming normal levels of activity.
➤ Monitor the patient for complications ➤ Administer standard RhoGAM dose
related to the procedure (e.g., pre- to maternal Rh-negative patients to
mature labor, allergic reaction, ana- prevent maternal Rh sensitization
phylaxis). should the fetus be Rh-positive.
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62 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ A written report of the examination patient’s health care provider regard-


will be completed by a health care ing further testing, treatment, or
practitioner specializing in this referral to another health care
branch of medicine. A written report provider. Inform the patient that it
of the examination will be sent to the may be 2 to 4 weeks before all
requesting health care practitioner, results are available. Answer any
who will discuss the results with the questions or address any concerns
patient. voiced by the patient or family.
➤ Recognize anxiety related to test ➤ Instruct the patient in the use of any
results. Discuss the implications ordered medications. Explain the
of abnormal test results on the importance of adhering to the ther-
patient’s lifestyle. Provide teaching apy regimen. As appropriate, instruct
and information regarding the clinical the patient in significant side effects
implications of the test results, as and systemic reactions associated
appropriate. Encourage the family to with the prescribed medication.
seek appropriate counseling if con- Encourage her to review correspon-
cerned with pregnancy termination, ding literature provided by a pharma-
and to seek genetic counseling if a cist.
chromosomal abnormality is deter-
mined. Decisions regarding elective ➤ Depending on the results of this pro-
abortion should take place in the cedure, additional testing may be
presence of both parents. Provide performed to evaluate or monitor
a nonjudgmental, nonthreatening progression of the disease process
atmosphere for discussing the risks and determine the need for a change
and difficulties of delivering and rais- in therapy. Evaluate test results in
ing a developmentally challenged relation to the patient’s symptoms
infant, as well as exploring other and other tests performed.
options (termination of pregnancy
or adoption). It is also important to
discuss problems the mother and
Related laboratory tests:
father may experience (guilt, depres- ➤ Related laboratory tests include 1-
sion, anger) if fetal abnormalities are fetoprotein, blood groups and anti-
detected. bodies, chromosome analysis, and
➤ Reinforce information given by the L/S ratio.

AMYLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma
(1 mL) collected in a green-top (heparin) tube is also acceptable.

REFERENCE VALUE: (Method: Spectrophotometry)


01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 63

Amylase 63

Conventional & SI Units


• Carcinoma of the head of the pancreas
(advanced)
30–110 U/L
• Common bile duct obstruction
• Diabetic ketoacidosis
• Duodenal obstruction
DESCRIPTION & RATIONALE: Amy-
• Ectopic pregnancy
lase, a digestive enzyme, splits starch
into disaccharides. Although many • Gastric resection
cells have amylase activity (e.g., liver, • Macroamylasemia
small intestine, ovaries, skeletal mus-
• Mumps
cles), circulating amylase is derived
from the parotid glands and the pan- • Pancreatic cyst and pseudocyst
creas. Amylase is a sensitive indicator • Pancreatitis
of pancreatic acinar cell damage and
pancreatic obstruction. Newborns • Parotitis
and children up to 2 years old have • Perforated peptic ulcer involving the
little measurable serum amylase. In pancreas
the early years of life, most of this • Peritonitis
enzyme is produced by the salivary
glands. ■ • Postoperative period
• Some tumors of the lung and ovaries
INDICATIONS: • Viral infections
• Assist in the diagnosis of early acute
pancreatitis; serum amylase begins to Decreased in:
rise within 6 to 24 hours after onset • Cystic fibrosis (advanced)
and returns to normal in 2 to 7 days
• Hepatic disease (severe)
• Assist in the diagnosis of macroamy-
lasemia, a disorder seen in alcoholism, • Pancreatectomy
malabsorption syndrome, and other • Pancreatic insufficiency
digestive problems
• Assist in the diagnosis of pancreatic
CRITICAL VALUES: N/A
duct obstruction, which causes serum
amylase levels to remain elevated
INTERFERING FACTORS:
• Drugs and substances that may increase
• Detect blunt trauma or inadvertent
amylase levels include asparaginase,
surgical trauma to the pancreas
captopril, cimetidine, clofibrate, corti-
• Differentiate between acute pancreati- costeroids, estrogens, ethacrynic acid,
tis and other causes of abdominal pain furosemide, ibuprofen, methyldopa,
that require surgery nitrofurantoin, oral contraceptives,
pentamidine, sulfonamides, tetracy-
RESULT cline, thiazide diuretics, valproic acid,
zalcitabine, and alcohol.
Increased in:
• Drugs that may decrease amylase levels
• Abdominal trauma include anabolic steroids, citrates, and
• Alcoholism fluorides.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 64

64 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

mally and to avoid unnecessary


Nursing Implications and movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Observe standard precautions, and
follow the general guidelines in
Pretest: Appendix A. Positively identify the
patient, and label the appropriate
➤ Inform the patient that the test is pri- tubes with the corresponding patient
marily used to assess pancreatic demographics, date, and time of col-
function. lection. Perform a venipuncture; col-
➤ Obtain a history of the patient’s com- lect the specimen in a 5-mL red- or
plaints, including a list of known tiger-top tube.
allergens (especially allergies or sen- ➤ Remove the needle, place a gauze
sitivities to latex), and inform the over the puncture site and apply gen-
appropriate health care practitioner tle pressure to stop bleeding.
accordingly. Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
endocrine, gastrointestinal, and paper tape over gauze or replace with
hepatobiliary systems, as well as adhesive bandage.
results of previously performed labo- ➤ Promptly transport the specimen to
ratory tests, surgical procedures, the laboratory for processing and
and other diagnostic procedures. For analysis.
related laboratory tests, refer to the ➤ The results are recorded manually or
Endocrine, Gastrointestinal, and in a computerized system for recall
Hepatobiliary System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and nutra-
ceuticals. The requesting health care Post-test:
practitioner and laboratory should be
advised if the patient regularly uses ➤ Nutritional considerations: Increased
these products so that their effects amylase levels may be associated
can be taken into consideration with gastrointestinal disease or alco-
when reviewing results. holism. Small, frequent meals work
best for patients with gastrointesti-
➤ Review the procedure with the nal disorders. Consideration should
patient. Inform the patient that spec- be given to dietary alterations in the
imen collection takes approximately case of gastrointestinal disorders.
5 to 10 minutes. Address concerns Usually after acute symptoms sub-
about pain related to the procedure. side and bowel sounds return,
Explain to the patient that there may patients are given a clear liquid diet,
be some discomfort during the progressing to a low-fat, high-carbo-
venipuncture. hydrate diet. Vitamin B12 may be
➤ There are no food, fluid, or medica- ordered for parenteral administration
tion restrictions unless by medical to patients with decreased levels,
direction. especially if their disease prevents
adequate absorption of the vitamin.
Intratest: The alcoholic patient should be
encouraged to avoid alcohol and to
➤ If the patient has a history of severe seek appropriate counseling for sub-
allergic reaction to latex, care should stance abuse.
be taken to avoid the use of equip- ➤ A written report of the examination
ment containing latex. will be sent to the requesting health
➤ Instruct the patient to cooperate care practitioner, who will discuss
fully and to follow directions. the results with the patient.
Direct the patient to breathe nor- ➤ Reinforce information given by the
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 65

Analgesic and Antipyretic Drugs: Acetaminophen, Acetylsalicylic Acid 65

patient’s health care provider regard- relation to the patient’s symptoms


ing further testing, treatment, or and other tests performed.
referral to another health care
provider. Answer any questions or Related laboratory tests:
address any concerns voiced by the
➤ Related laboratory tests include
patient or family.
alanine aminotransferase, alkaline
➤ Depending on the results of this pro- phosphatase, amylase (fluid), aspar-
cedure, additional testing may be tate aminotransferase, bilirubin, CA
performed to evaluate or monitor 19–9, calcium, fecal fat, -glutamyl
progression of the disease process transpeptidase, lipase, magnesium,
and determine the need for a change mumps serology, triglycerides, and
in therapy. Evaluate test results in white blood cell count.

ANALGESIC AND ANTIPYRETIC


DRUGS: ACETAMINOPHEN,
ACETYLSALICYLIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Acetaminophen (Acephen, Apacet, Aspirin Free


Anacin, Banesin, Dapa, Datril, Dorcol, Gebapap, Halenol, Liquiprin, Meda
Cap, Panadol, Redutemp, Tempra, Tylenol, Ty-Pap, Uni-Ace); Acetylsalicylic
acid (salicylate, aspirin, Anacin, Aspergum, Bufferin, Ecotrin, Empirin,
Measurin, Synalgos, ZORprin, ASA).

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Immunoassay)

Therapeutic SI Half- Volume of Protein


Drug Dose* Units Life Distribution Binding Excretion
(SI  Conventional Units  6.62)
Acetamino- 10–30 66–199 1–3 h 0.95 20–50% 85–95%
phen g/mL mol/L L/kg hepatic,
metabo-
lites, renal
(SI  Conventional Units  0.073)
Salicylate 15–20 1.1–1.4 2–3 h 0.1–0.3 90–95% 1 hepatic,
mg/dL mmol/L L/kg metabo-
lites, renal
* Conventional units.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 66

66 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Liver disease
DESCRIPTION & RATIONALE: Aceta- Toxicity
minophen is used for headache, fever,
and pain relief, especially for individ- • ASA
uals unable to take salicylate products Toxicity
or who have bleeding conditions. It is
the analgesic of choice for children Decreased in:
less than 13 years of age; salicylates are • Noncompliance with therapeutic regi-
avoided in this age group because of men
the association between aspirin and
Reye’s syndrome. Acetaminophen is CRITICAL VALUES: Note: The ad-
rapidly absorbed from the gastroin- verse effects of subtherapeutic levels are
testinal tract and reaches peak concen- also important. Care should be taken to
tration within 30 to 60 minutes after investigate signs and symptoms of too lit-
administration of a therapeutic dose. tle and too much medication. Note and
It can be a silent killer because, by the immediately report to the health care
practitioner any critically increased values
time symptoms of intoxication appear
and related symptoms.
24 to 48 hours after ingestion, the
antidote is ineffective. Acetylsalicylic
acid (ASA) is also used for headache, Acetaminophen: Greater
fever, and pain relief. Some patients Than 150 g/mL (4 Hours
with cardiovascular disease take small Postingestion); Greater
prophylactic doses. The main site of Than 50 g/mL (12 Hours
Postingestion)
toxicity for both drugs is the liver, par-
ticularly in the presence of liver dis- Signs and symptoms of acetaminophen
ease or decreased drug metabolism intoxication occur in stages over a period
and excretion. of time. In stage I (0 to 24 hours after
Many factors must be considered in ingestion), symptoms may include gas-
trointestinal irritation, pallor, lethargy,
interpreting drug levels, including
diaphoresis, metabolic acidosis, and possi-
patient age, patient weight, interact- bly coma. In stage II (24 to 48 hours after
ing medications, electrolyte balance, ingestion), signs and symptoms may
protein levels, water balance, condi- include right upper quadrant abdominal
tions that affect absorption and excre- pain; elevated liver enzymes, aspartate
tion, and foods, herbals, vitamins, and aminotransferase (AST), and alanine
minerals that can potentiate or inhibit aminotransferase (ALT); and possible
the intended target concentration. ■ decreased renal function. In stage III (72
to 96 hours after ingestion), signs and
INDICATIONS: symptoms may include nausea, vomiting,
• Suspected overdose jaundice, confusion, coagulation disor-
ders, continued elevation of AST and
• Suspected toxicity ALT, decreased renal function, and
• Therapeutic monitoring coma. Intervention may include gas-
trointestinal decontamination (stomach
RESULT pumping) if the patient presents within 6
hours of ingestion or administration of N-
Increased in: acetylcysteine (Mucomyst) in the case of
• Acetaminophen an acute intoxication in which the patient
Alcoholic cirrhosis presents more than 6 hours after ingestion.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 67

Analgesic and Antipyretic Drugs: Acetaminophen, Acetylsalicylic Acid 67

ASA: Greater Than 50 mg/dL respiratory arrest, and tinnitus. Possible


interventions include administration of
Signs and symptoms of salicylate intoxi- activated charcoal as vomiting ceases,
cation include ketosis, convulsions, dizzi- alkalinization of the urine with bicarbon-
ness, nausea, vomiting, hyperactivity, ate, and a single dose of vitamin K (for
hyperglycemia, hyperpnea, hyperthermia, rare instances of hypoprothrombinemia).

Pediatric Serum Salicylate Level and Acetaminophen Toxicity Nomogram


Severity of Intoxication Single Dose
Acute Ingestion Nomogram 500

180

________________________
160 Probable hepatic toxicity
140 200
Probably Lethal 150
Acetaminophen (µg/mL plasma)

120
Possible
100 100
hepatic toxicity
Serum salicylate (µg/mL)

Severe
80 50
Moderate

unavailable. Image rights unavailable.


60
Image rights
Mild
40
10
Hepatic toxicity unlikely
25%
5

20
Asymptomatic
1
Asymptomatic 4 8 12 16 20 24
10 Hours after ingestion
0 12 24 36 48 60
Hours since ingestion The Rumack-Matthew nomogram, relating expected severity of
liver toxicity to serum acetaminophen concentrations.
Nomogram relating serum salicylate concentration and expected
severity of intoxication at varying intervals following the ingestion From Smilkstein MJ, Bronstein AC, Linden C, et al, "Acetamino-
of a single dose of salicylate. phen Overdose: A 48-Hour Intravenous N-Acetylcysteine Treat-
From Done AK, "Aspirin Overdosage: Incidence, Diagnosis, and ment Protocol," , 1991,20(10):1058, with
Management," ,1978, 62:890-7 with permission. permission.

INTERFERING FACTORS: • Drugs that may increase acetamino-


• Blood drawn in serum separator tubes phen levels include diflunisal, metoclo-
(gel tubes). pramide, and probenecid.
• Drugs that may decrease acetamino-
• Contraindicated in patients with liver phen levels include cholestyramine,
disease, and caution advised in patients iron, oral contraceptives, and propan-
with renal impairment. theline.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 68

68 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Drugs that increase ASA levels include chological support before, during,
sulfinpyrazone. and after the procedure.
➤ There are no food, fluid, or medica-
• Drugs and substances that decrease tion restrictions unless by medical
ASA levels include activated charcoal, direction.
antacids (aluminum hydroxide), and
iron.
Intratest:
➤ If the patient has a history of severe
Nursing Implications and allergic reaction to latex, care should
Procedure ● ● ● ● ● ● ● ● ● ● ●
be taken to avoid the use of equip-
ment containing latex.
Pretest:
➤ Instruct the patient to cooperate
➤ Inform the patient that the test is fully and to follow directions. Direct
used to monitor therapeutic levels the patient to breathe normally
and detect toxic levels of acetamino- and to avoid unnecessary move-
phen and salicylate. ment.
➤ Obtain a complete history of the ➤ Observe standard precautions, and
time and amount of drug ingested by follow the general guidelines in
the patient. Appendix A. Positively identify the
➤ Obtain a history of the patient’s com- patient, and label the appropriate
plaints, including a list of known tubes with the corresponding patient
allergens (especially allergies or sen- demographics, date, and time of
sitivities to latex), and inform the collection, noting the last dose of
appropriate health care practitioner medication taken. Perform a veni-
accordingly. puncture; collect the specimen in a
➤ Review results of previously per- 5-mL red-top tube.
formed laboratory tests, surgical pro- ➤ Remove the needle, place a gauze
cedures, and other diagnostic over the puncture site and apply gen-
procedures. For related laboratory tle pressure to stop the bleeding.
tests, refer to the Genitourinary, Observe the venipuncture site for
Hepatobiliary, and Therapeutic/Toxi- bleeding and hematoma formation.
cology System tables. Apply paper tape over gauze or
➤ Obtain a list of the medications the replace with adhesive bandage.
patient is taking, including herbs, ➤ Promptly transport the specimen to
nutritional supplements, and nutra- the laboratory for processing and
ceuticals. The requesting health care analysis.
practitioner and laboratory should be
advised if the patient is regularly ➤ The results are recorded manually or
using these products so that their in a computerized system for recall
effects can be taken into considera- and postprocedure interpretation by
tion when reviewing results. the appropriate health care practi-
tioner.
➤ Review the procedure with the
patient. Inform the patient that spec-
imen collection takes approximately Post-test:
5 to 10 minutes. Address concerns
about pain related to the procedure. ➤ Nutritional considerations include
Explain to the patient that there may the avoidance of alcohol consump-
be some discomfort during the tion.
venipuncture. ➤ A written report of the examination
➤ Sensitivity to cultural and social will be sent to the requesting health
issues, as well as concern for mod- care practitioner, who will discuss
esty, is important in providing psy- the results with the patient.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 69

Angiography, Abdomen 69

➤ Reinforce information given by the ➤ Depending on the results of this pro-


patient’s health care provider regard- cedure, additional testing may be
ing further testing, treatment, or performed to evaluate or monitor
referral to another health care progression of the disease process
provider. Explain to the patient the and determine the need for a change
importance of following the medica- in therapy. Evaluate test results in
tion regimen and instructions regard- relation to the patient’s symptoms
ing food and drug interactions. and other tests performed.
Answer any questions or address
any concerns voiced by the patient Related laboratory tests:
or family.
➤ Related laboratory tests include acti-
➤ Instruct the patient to be prepared to vated partial thromboplastin time,
provide the pharmacist with a list of ALT, AST, bilirubin, blood urea nitro-
other medications he or she is gen, complete blood count, creati-
already taking in the event that the nine, electrolytes, glucose, lactic
requesting health care practitioner acid, liver biopsy, and prothrombin
prescribes a medication. time.

ANGIOGRAPHY, ABDOMEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Abdominal angiogram, abdominal arteriography.


AREA OF APPLICATION: Abdomen.
CONTRAST: Intravenous iodine based.

DESCRIPTION & RATIONALE: Angiog- organ under study and associated ves-
raphy allows x-ray visualization of the sels are displayed on a monitor and
large and small arteries, veins, and recorded on film or stored electroni-
associated branches of the abdominal cally for future viewing and evalua-
vasculature and organ parenchyma tion. Patterns of circulation, organ
after contrast-medium injection. This function, and changes in vessel wall
visualization is accomplished by the appearance can be viewed to help
injection of contrast medium through diagnose the presence of vascular
a catheter, which most commonly has abnormalities, aneurysm, tumor,
been inserted into the femoral artery trauma, or lesions. The catheter used
or vein and advanced through the iliac to administer the contrast medium to
artery and aorta into the organ- confirm the diagnosis of organ lesions
specific artery or vein. Images of the may be used to deliver chemothera-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 70

70 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

peutic drugs or different types of RESULT


media to stop bleeding. Catheters
Normal Findings:
with attached inflatable balloons and
wire mesh stents are used to widen • Normal structure, function, and
patency of abdominal organ vessels
areas of stenosis and to keep the ves-
sels open, frequently replacing sur- • Contrast medium normally circulates
gery. Angiography is one of the throughout abdomen symmetrically
definitive tests for organ disease and and without interruption
may be used to evaluate chronic dis- • No evidence of obstruction, variations
ease, evaluate organ failure, treat arte- in number and size of vessels and
rial stenosis, differentiate a vascular organs, malformations, cysts, or tumors
cyst from hypervascular cancers, and
evaluate the effectiveness of medical Abnormal Findings:
or surgical treatment. ■ • Abscess or inflammation
• Arterial aneurysm
INDICATIONS: • Arterial stenosis, dysplasia, or organ
• Aid in angioplasty, atherectomy, or
infarction
stent placement
• Arteriovenous fistula or other abnor-
• Allow infusion of thrombolytic drugs
malities
into an occluded artery
• Congenital anomalies
• Detect arterial occlusion, which may be
evidenced by a transection of the artery • Cysts or tumors
caused by trauma or penetrating injury
• Organ hematoma
• Detect artery stenosis, evidenced by
• Trauma causing tears or other disrup-
vessel dilation, collateral vessels, or
tion
increased vascular pressure
• Detect nonmalignant tumors before INTERFERING FACTORS
surgical resection
This procedure is
• Detect thrombosis, arteriovenous fis- contraindicated for:
tula, aneurysms, or emboli in abdomi-
nal vessels • Patients with allergies to shellfish
or iodinated dye. The contrast
• Detect tumors and arterial supply, medium used may cause a life-threat-
extent of venous invasion, and tumor ening allergic reaction. Patients with a
vascularity known hypersensitivity to contrast
• Differentiate between tumors and cysts medium may benefit from premedica-
tion with corticosteroids or the use of
• Evaluate organ transplantation for nonionic contrast medium.
function or organ rejection
• Patients with bleeding disorders.
• Evaluate placement of a shunt or stent
• Patients who are pregnant or suspected
• Evaluate tumor vascularity before sur- of being pregnant, unless the potential
gery or embolization benefits of the procedure far outweigh
the risks to the fetus and mother.
• Evaluate the vascular system of
prospective organ donors before sur- • Elderly and other patients who
gery are chronically dehydrated before
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Angiography, Abdomen 71

the test, because of their risk of con- is being done should wear badges
trast-induced renal failure. that reveal their level of exposure to
radiation.
• Patients who are in renal failure.
• Failure to follow dietary restrictions
Factors that may impair and other pretesting preparations may
clear imaging: cause the procedure to be canceled or
• Gas or feces in the gastrointestinal tract repeated.
resulting from inadequate cleansing or
failure to restrict food intake before the
study Nursing Implications and
• Retained barium from a previous radi- Procedure ● ● ● ● ● ● ● ● ● ● ●

ologic procedure
Pretest:
• Metallic objects within the examina-
tion field (e.g., jewelry, body rings), ➤ Inform the patient that the procedure
which may inhibit organ visualization assesses cardiovascular function.
and can produce unclear images ➤ Obtain a history of the patient’s com-
plaints, including a list of known
• Improper adjustment of the radi- allergens (especially allergies or sen-
ographic equipment to accommodate sitivities to latex, iodine, seafood,
obese or thin patients, which can cause contrast medium, anesthetics, or
overexposure or underexposure and a dyes), and inform the appropriate
poor-quality study health care practitioner accordingly.
➤ Obtain a history of results of previ-
• Patients who are very obese, who may ously performed diagnostic proce-
exceed the weight limit for the equip- dures, surgical procedures, and
ment laboratory tests. Ensure that the
• Incorrect positioning of the patient, results of blood tests are obtained
and recorded before the procedure,
which may produce poor visualization especially coagulation tests, blood
of the area to be examined urea nitrogen, and creatinine, if con-
• Inability of the patient to cooperate or trast medium is to be used. For
remain still during the procedure related diagnostic tests, refer to the
Cardiovascular System table.
because of age, significant pain, or
mental status ➤ Note any recent procedures that can
interfere with test results, including
examinations using iodine-based
Other considerations: contrast medium or barium.
• Consultation with a health care practi- ➤ Record the date of the last menstrual
tioner should occur before the proce- period and determine the possibility
dure for radiation safety concerns of pregnancy in perimenopausal
regarding younger patients or patients women.
who are lactating. ➤ Obtain a list of the medications the
• Risks associated with radiographic patient is taking, especially medica-
overexposure can result from frequent tions known to affect bleeding,
x-ray procedures. Personnel in the including anticoagulant therapy,
aspirin and other salicylates. Include
room with the patient should wear a herbs, nutritional supplements, and
protective lead apron, stand behind a nutraceuticals (see Appendix F:
shield, or leave the area while the exam- Effects of Natural Products on
ination is being done. Personnel work- Laboratory Values). It is recom-
ing in the area where the examination mended that use of such products
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72 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

be discontinued 14 days before sur- ➤ Make sure a written and informed


gical procedures. The requesting consent has been signed prior to the
health care practitioner and labora- procedure and before administering
tory should be advised if the patient any medications.
regularly uses these products so that ➤ This procedure may be terminated if
their effects can be taken into con- chest pain, severe cardiac arrhyth-
sideration when reviewing results. mias, or signs of a cerebrovascular
➤ Patients receiving metformin (glu- accident occur.
cophage) for non–insulin-dependent
(type 2) diabetes should discontinue Intratest:
the drug on the day of the test and
continue to withhold it for 48 hours ➤ Ensure that the patient has complied
after the test. Failure to do so may with dietary and medication restric-
result in lactic acidosis. tions and pretesting preparations;
assure that food and medications
➤ Review the procedure with the
have been restricted for at least 8
patient. Address concerns about pain
hours prior to the procedure. Ensure
related to the procedure. Explain to
that the patient has removed jew-
the patient that some pain may be
elry, dentures, all external metallic
experienced during the test, or there
objects, and the like prior to the pro-
may be moments of discomfort.
cedure.
Inform the patient that the procedure
is performed in a special department, ➤ Have emergency equipment readily
usually in a radiology or vascular available.
suite, by a health care practitioner ➤ If the patient has a history of severe
and support staff and takes approxi- allergic reactions to any substance or
mately 30 to 60 minutes. drug, administer ordered prophylac-
➤ Sensitivity to social and cultural tic steroids or antihistamines before
issues, as well as concern for mod- the procedure. Use nonionic contrast
esty, is important in providing psy- medium for the procedure.
chological support before, during, ➤ Patients are given a gown, robe, and
and after the procedure. foot coverings to wear and ins-
➤ Explain that an intravenous (IV) line tructed to void prior to the proce-
may be inserted to allow infusion of dure.
IV fluids, contrast medium, dye, or ➤ Observe standard precautions, and
sedatives. Usually normal saline is follow the general guidelines in
infused. Appendix A.
➤ Inform the patient that a burning ➤ Record baseline vital signs, and
and flushing sensation may be felt assess neurologic status. Protocols
throughout the body during injection may vary from facility to facility.
of the contrast medium. After injec-
tion of the contrast medium, the ➤ Instruct the patient to cooperate fully
patient may experience an urge to and to follow directions. Instruct the
cough, flushing, nausea, or a salty or patient to remain still throughout the
metallic taste. procedure because movement pro-
duces unreliable results.
➤ The patient should fast and restrict
fluids for 8 hours prior to the proce- ➤ Establish an IV fluid line for the injec-
dure. Instruct the patient to avoid tion of emergency drugs and of
taking anticoagulant medication or to sedatives.
reduce dosage as ordered prior to ➤ Administer an antianxiety agent, as
the procedure. ordered, if the patient has claustro-
➤ Instruct the patient to remove den- phobia. Administer a sedative to a
tures, jewelry (including watches), child or to an uncooperative adult, as
hairpins, credit cards, and other ordered.
metallic objects in the area to be ➤ Place electrocardiographic elec-
examined. trodes on the patient for cardiac
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Angiography, Abdomen 73

monitoring. Establish a baseline every 4 hours for 24 hours. Compare


rhythm; determine if the patient has with baseline values. Protocols may
ventricular arrhythmias. vary from facility to facility.
➤ Using a pen, mark the site of the ➤ Observe for delayed allergic reac-
patient’s peripheral pulses before tions, such as rash, urticaria, tachy-
angiography; this allows for quicker cardia, hyperpnea, hypertension,
and more consistent assessment of palpitations, nausea, or vomiting.
the pulses after the procedure. ➤ Instruct the patient to immediately
➤ Place the patient in the supine posi- report symptoms such as fast heart
tion on an exam table. Cleanse the rate, difficulty breathing, skin rash,
selected area, and cover with a ster- itching, or decreased urinary output.
ile drape. ➤ Assess extremities for signs of
➤ A local anesthetic is injected at the ischemia or absence of distal pulse
site, and a small incision is made or caused by a catheter-induced throm-
a needle inserted under fluoroscopy. bus.
➤ The contrast medium is injected, and ➤ Observe the needle/catheter inser-
a rapid series of images is taken dur- tion site for bleeding, inflammation,
ing and after the filling of the vessels or hematoma formation.
to be examined. Delayed images ➤ Instruct the patient to apply cold
may be taken to examine the vessels compresses to the puncture site, as
after a time and to monitor the needed, to reduce discomfort or
venous phase of the procedure. edema.
➤ Instruct the patient to inhale deeply ➤ Instruct the patient to maintain bed
and hold his or her breath while the rest for 4 to 6 hours after the proce-
x-ray images are taken, and then to dure or as ordered.
exhale after the images are taken.
➤ Instruct the patient in the care and
➤ Instruct the patient to take slow,
assessment of the site and to
deep breaths if nausea occurs during
observe for bleeding, hematoma for-
the procedure.
mation, bile leakage, and inflamma-
➤ Monitor the patient for complications tion. Note any pleuritic pain,
related to the procedure (e.g., aller- persistent right shoulder pain, or
gic reaction, anaphylaxis, bron- abdominal pain.
chospasm).
➤ Nutritional considerations: A low-fat,
➤ The needle or catheter is removed, low-cholesterol, and low-sodium diet
and a pressure dressing is applied should be consumed to reduce
over the puncture site. current disease processes and/or
➤ The results are recorded on x-ray film decrease risk of hypertension and
or electronically in a computerized coronary artery disease.
system for recall and postprocedure ➤ No other radionuclide tests should
interpretation by the appropriate be scheduled for 24 to 48 hours after
health care practitioner. this procedure.
Post-test: ➤ A written report of the examination
will be completed by a health care
➤ Instruct the patient to resume usual practitioner specializing in this
diet, fluids, medications, or activity, branch of medicine. The report will
as directed by the health care practi- be sent to the requesting health care
tioner. Renal function should be practitioner, who will discuss the
assessed before metformin is results with the patient.
resumed. ➤ Recognize anxiety related to test
➤ Monitor vital signs and neurologic results, and be supportive of per-
status every 15 minutes for 1 hour, ceived loss of independent function.
then every 2 hours for 4 hours, and Discuss the implications of abnormal
as ordered. Take the temperature test results on the patient’s lifestyle.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 74

74 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Provide teaching and information responding literature provided by a


regarding the clinical implications of pharmacist.
the test results, as appropriate. ➤ Depending on the results of this
➤ Reinforce information given by procedure, additional testing may
the patient’s health care provider be performed to evaluate or monitor
regarding further testing, treatment, progression of the disease process
or referral to another health care and determine the need for a change
provider. Answer any questions or in therapy. Evaluate test results in
address any concerns voiced by the relation to the patient’s symptoms
patient or family. and other tests performed.
➤ Instruct the patient in the use of any Related diagnostic tests:
ordered medications. Explain the
importance of adhering to the ther- ➤ Related diagnostic tests include
apy regimen. As appropriate, instruct computed tomography of the
the patient in significant side effects abdomen; kidney, ureter, and bladder
and systemic reactions associated study; magnetic resonance imaging
with the prescribed medication. of the abdomen, and magnetic reso-
Encourage him or her to review cor- nance angiography.

ANGIOGRAPHY, ADRENAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Adrenal angiogram, adrenal arteriography.


AREA OF APPLICATION: Adrenal gland.
CONTRAST: Intravenous iodine based.

DESCRIPTION & RATIONALE: Adrenal may be taken from the vein of each
angiography evaluates adrenal dys- gland to assess cortisol levels in deter-
function by allowing x-ray visualiza- mining a diagnosis of Cushing’s
tion of the large and small arteries of syndrome or the presence of pheo-
the adrenal gland vasculature and chromocytoma. After injection of the
parenchyma. This visualization is contrast medium through the
accomplished by the injection of con- catheter, images of the adrenal glands
trast medium through a catheter that and associated vessels surrounding the
has been inserted into the femoral adrenal tissue are displayed on a mon-
artery for viewing the artery (arterio- itor and are recorded on film or elec-
graphy) or into the femoral vein for tronically. Patterns of circulation,
viewing the veins (venography). After adrenal function, and changes in ves-
the catheter is in place, a blood sample sel wall appearance can be viewed to
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 75

Angiography, Adrenal 75

help diagnose the presence of vascular • No evidence of obstruction, variations


abnormalities, trauma, or lesions. This in number and size of vessels and
organs, malformations, cysts, or tumors
definitive test for adrenal disease may
be used to evaluate chronic adrenal Abnormal Findings:
disease, evaluate arterial or venous • Adrenal adenoma
stenosis, differentiate an adrenal cyst
from adrenal tumors, and evaluate • Adrenal carcinoma
medical therapy or surgery of the • Bilateral adrenal hyperplasia
adrenal glands. ■
• Pheochromocytoma
INDICATIONS: INTERFERING FACTORS
• Assist in the infusion of thrombolytic
drugs into an occluded artery
This procedure is
• Assist with the collection of blood contraindicated for:
samples from the vein for laboratory
analysis • Patients with allergies to shellfish
or iodinated dye. The contrast
• Detect adrenal hyperplasia medium used may cause a life-threat-
• Detect and determine the location of ening allergic reaction. Patients with a
adrenal tumors evidenced by arterial known hypersensitivity to contrast
supply, extent of venous invasion, and medium may benefit from premedica-
tumor vascularity tion with corticosteroids or the use of
nonionic contrast medium.
• Detect arterial occlusion, evidenced by
a transection of the artery caused by • Patients with bleeding disorders.
trauma or a penetrating injury
• Patients who are pregnant or suspected
• Detect arterial stenosis, evidenced by of being pregnant, unless the potential
vessel dilation, collateral vessels, or benefits of the procedure far outweigh
increased vascular pressure the risks to the fetus and mother.
• Detect nonmalignant tumors before • Elderly and other patients who
surgical resection are chronically dehydrated before
• Detect thrombosis, arteriovenous fis- the test, because of their risk of con-
tula, aneurysms, or emboli in vessels trast-induced renal failure.
• Differentiate between adrenal tumors • Patients who are in renal failure.
and adrenal cysts
Factors that may
• Evaluate tumor vascularity before sur- impair clear imaging:
gery or embolization
• Gas or feces in the gastrointestinal tract
• Perform angioplasty, perform atherec- resulting from inadequate cleansing or
tomy, or place a stent failure to restrict food intake before the
study
RESULT
• Retained barium from a previous radi-
Normal Findings: ologic procedure
• Normal structure, function, and • Metallic objects within the examina-
patency of adrenal vessels tion field (e.g., jewelry, body rings,
• Contrast medium circulating through- dental amalgams), which may inhibit
out the adrenal gland symmetrically organ visualization and can produce
and without interruption unclear images
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 76

76 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Improper adjustment of the radi- allergens (especially allergies or


ographic equipment to accommodate sensitivities to latex, iodine, seafood,
obese or thin patients, which can cause contrast medium, anesthetics, or
overexposure or underexposure and a dyes), and inform the appropriate
health care practitioner accordingly.
poor-quality study
➤ Obtain a history of results of previ-
• Patients who are very obese, who may ously performed diagnostic proce-
exceed the weight limit for the equip- dures, surgical procedures, and
ment laboratory tests. Ensure that the
results of blood tests are obtained
• Incorrect positioning of the patient, and recorded before the procedure,
which may produce poor visualization especially coagulation tests, blood
of the area to be examined urea nitrogen, and creatinine, if con-
trast medium is to be used. For
• Inability of the patient to cooperate related diagnostic tests, refer to
or remain still during the procedure the Cardiovascular and Endocrine
because of age, significant pain, or System tables.
mental status ➤ Note any recent procedures that can
interfere with test results, including
Other considerations: examinations using iodine-based
• Consultation with a health care practi- contrast medium.
tioner should occur before the proce- ➤ Record the date of the last menstrual
dure for radiation safety concerns period and determine the possibil-
regarding younger patients or patients ity of pregnancy in perimenopausal
who are lactating. women.
➤ Obtain a list of the medications the
• Risks associated with radiographic patient is taking, especially medica-
overexposure can result from frequent tions known to affect bleeding,
x-ray procedures. Personnel in the including anticoagulant therapy,
room with the patient should wear a aspirin and other salicylates, herbs,
protective lead apron, stand behind a nutritional supplements, and nutra-
shield, or leave the area while the exam- ceuticals (see Appendix F: Effects of
ination is being done. Personnel work- Natural Products on Laboratory
ing in the area where the examination Values). It is recommended that use
of such products be discontinued 14
is being done should wear badges
days before surgical procedures. The
that reveal their level of exposure to requesting health care practitioner
radiation. and laboratory should be advised if
• Failure to follow dietary restrictions the patient regularly uses these prod-
ucts so that their effects can be taken
and other pretesting preparations may
into consideration when reviewing
cause the procedure to be canceled or results.
repeated.
➤ Patients receiving metformin (glu-
cophage) for non–insulin-dependent
(type 2) diabetes should discontinue
Nursing Implications and the drug on the day of the test and
Procedure ● ● ● ● ● ● ● ● ● ● ● continue to withhold it for 48 hours
after the test. Failure to do so may
Pretest: result in lactic acidosis.
➤ Review the procedure with the
➤ Inform the patient that the procedure patient. Address concerns about pain
assesses cardiovascular function. related to the procedure. Explain to
➤ Obtain a history of the patient’s com- the patient that some pain may be
plaints, including a list of known experienced during the test, or there
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Angiography, Adrenal 77

may be moments of discomfort. elry, dentures, all external metallic


Inform the patient that the procedure objects, and the like prior to the pro-
is performed in a special department, cedure.
usually in a radiology or vascular ➤ Have emergency equipment readily
suite, by a health care practitioner available.
and support staff and takes approxi-
mately 30 to 60 minutes. ➤ If the patient has a history of severe
allergic reactions to any substance or
➤ Sensitivity to social and cultural
drug, administer ordered prophylac-
issues, as well as concern for mod-
tic steroids or antihistamines before
esty, is important in providing psy-
the procedure. Use nonionic contrast
chological support before, during,
medium for the procedure.
and after the procedure.
➤ Patients are given a gown, robe,
➤ Explain that an intravenous (IV) line
and foot coverings to wear and
may be inserted to allow infusion of
instructed to void prior to the proce-
IV fluids, contrast medium, dye, or
dure.
sedatives. Usually normal saline is
infused. ➤ Observe standard precautions, and
➤ Inform the patient that a burning and follow the general guidelines in
flushing sensation may be felt Appendix A.
throughout the body during injection ➤ Record baseline vital signs, and
of the contrast medium. After injec- assess neurologic status. Protocols
tion of the contrast medium, the may vary from facility to facility.
patient may experience an urge to
➤ Instruct the patient to cooperate fully
cough, flushing, nausea, or a salty or
and to follow directions. Instruct the
metallic taste.
patient to remain still throughout the
➤ The patient should fast and restrict procedure because movement pro-
fluids for 8 hours prior to the pro- duces unreliable results.
cedure. Instruct the patient to avoid
➤ Establish an IV fluid line for the injec-
taking anticoagulant medication or to
tion of emergency drugs and of
reduce dosage as ordered prior to
sedatives.
the procedure.
➤ Instruct the patient to remove den- ➤ Administer an antianxiety agent, as
tures, jewelry (including watches), ordered, if the patient has claustro-
hairpins, credit cards, and other phobia. Administer a sedative to a
metallic objects in the area to be child or to an uncooperative adult, as
examined. ordered.
➤ Make sure a written and informed ➤ Place electrocardiographic elec-
consent has been signed prior to the trodes on the patient for cardiac
procedure and before administering monitoring. Establish a baseline
any medications. rhythm; determine if the patient has
ventricular arrhythmias.
➤ This procedure may be terminated
if chest pain, severe cardiac arrhy- ➤ Using a pen, mark the site of the
thmias, or signs of a cerebrovascular patient’s peripheral pulses before
accident occur. angiography; this allows for quicker
and more consistent assessment of
Intratest: the pulses after the procedure.
➤ Place the patient in the supine posi-
➤ Ensure that the patient has complied
tion on an exam table. Cleanse the
with dietary and medication restric-
selected area, and cover with a
tions and pretesting preparations;
sterile drape.
assure that food and medications
have been restricted for at least 8 ➤ A local anesthetic is injected at the
hours prior to the procedure. Ensure site, and a small incision is made or
that the patient has removed jew- a needle inserted under fluoroscopy.
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78 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ The contrast medium is injected, ➤ Observe the needle/catheter inser-


and a rapid series of images is taken tion site for bleeding, inflammation,
during and after the filling of the or hematoma formation.
vessels to be examined. Delayed ➤ Instruct the patient to apply cold
images may be taken to examine the compresses to the puncture site, as
vessels after a time and to monitor needed, to reduce discomfort or
the venous phase of the procedure. edema.
➤ Ask the patient to inhale deeply and ➤ Instruct the patient to maintain bed
hold his or her breath while the x-ray rest for 4 to 6 hours after the proce-
images are taken, and then to exhale dure or as ordered.
after the images are taken.
➤ Instruct the patient in the care and
➤ Instruct the patient to take slow, assessment of the site and to ob-
deep breaths if nausea occurs during serve for bleeding, hematoma forma-
the procedure. tion, bile leakage, and inflammation.
➤ Monitor the patient for complications Note any pleuritic pain, persistent
related to the procedure (e.g., right shoulder pain, or abdominal
allergic reaction, anaphylaxis, bron- pain.
chospasm).
➤ Nutritional considerations: A low-
➤ The needle or catheter is removed, fat, low-cholesterol, and low-sodium
and a pressure dressing is applied diet should be consumed to reduce
over the puncture site. current disease processes and/or
➤ The results are recorded on x-ray film decrease risk of hypertension and
or electronically in a computerized coronary artery disease.
system for recall and postprocedure ➤ No other radionuclide tests should
interpretation by the appropriate be scheduled for 24 to 48 hours after
health care practitioner. this procedure.
Post-test: ➤ A written report of the examina-
tion will be completed by a health
➤ Instruct the patient to resume usual care practitioner specializing in this
diet, fluids, medications, or activity, branch of medicine. The report will
as directed by the health care be sent to the requesting health care
practitioner. Renal function should practitioner, who will discuss the
be assessed before metformin is results with the patient.
resumed. ➤ Recognize anxiety related to test
➤ Monitor vital signs and neurologic results, and be supportive of per-
status every 15 minutes for 1 hour, ceived loss of independent function.
then every 2 hours for 4 hours, and Discuss the implications of abnormal
as ordered. Take the temperature test results on the patient’s lifestyle.
every 4 hours for 24 hours. Compare Provide teaching and information
with baseline values. Protocols may regarding the clinical implications of
vary from facility to facility. the test results, as appropriate.
➤ Observe for delayed allergic reac- ➤ Reinforce information given by the
tions, such as rash, urticaria, tachy- patient’s health care provider regard-
cardia, hyperpnea, hypertension, ing further testing, treatment, or
palpitations, nausea, or vomiting. referral to another health care
➤ Advise the patient to immediately provider. Answer any questions or
report symptoms such as fast heart address any concerns voiced by the
rate, difficulty breathing, skin rash, patient or family.
itching, or decreased urinary output. ➤ Instruct the patient in the use of
➤ Assess extremities for signs of any ordered medications. Explain the
ischemia or absence of distal importance of adhering to the ther-
pulse caused by a catheter-induced apy regimen. As appropriate, instruct
thrombus. the patient in significant side effects
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Angiography, Carotid 79

and systemic reactions associated in therapy. Evaluate test results in


with the prescribed medication. relation to the patient’s symptoms
Encourage him or her to review cor- and other tests performed.
responding literature provided by a
pharmacist. Related diagnostic tests:
➤ Depending on the results of this pro- ➤ Related diagnostic tests include adre-
cedure, additional testing may be nal gland scan; computed tomogra-
performed to evaluate or monitor phy of the abdomen; kidney, ureter,
progression of the disease process and bladder study; and magnetic res-
and determine the need for a change onance imaging of the abdomen.

ANGIOGRAPHY, CAROTID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Carotid angiogram, carotid arteriography.


AREA OF APPLICATION: Neck/cervical spine area.
CONTRAST: Intravenous iodine based.

DESCRIPTION & RATIONALE: The beneath the table on which the patient
test evaluates blood vessels in the neck lies. Over the patient is an image
carrying arterial blood. This visualiza- intensifier that receives the x-rays after
tion is accomplished by the injection they pass through the patient. Patterns
of contrast material through a catheter of circulation or changes in vessel
that has been inserted into the femoral wall appearance can be viewed to help
artery for viewing the artery (arteriog- diagnose the presence of vascular
raphy). The angiographic catheter is a abnormalities, disease, narrowing,
long tube about the size of a strand of enlargement, blockage, trauma, or
spaghetti. After the injection of con- lesions. This definitive test for arterial
trast media through the catheter, x-ray disease may be used to evaluate
images of the carotid artery and asso- chronic vascular disease, arterial or
ciated vessels in surrounding tissue are venous stenosis, and medical therapy
displayed on a monitor and are or surgery of the vasculature. Catheter
recorded on film or electronically. The angiography still is used in patients
x-ray equipment is mounted on a C- who may undergo surgery, angio-
shaped bed with the x-ray device plasty, or stent placement. ■
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80 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

INDICATIONS: • Congenital anomalies


• Aid in angioplasty, atherectomy, or • Cysts or tumors
stent placement
• Trauma causing tears or other disrup-
• Allow infusion of thrombolytic drugs tion
into an occluded artery
• Vascular blockage or other disruption
• Detect arterial occlusion, which may be
evidenced by a transection of the artery INTERFERING FACTORS
caused by trauma or penetrating injury
This procedure is
• Detect artery stenosis, evidenced by contraindicated for:
vessel dilation, collateral vessels, or
increased vascular pressure • Patients with allergies to shellfish
or iodinated dye. The contrast
• Detect nonmalignant tumors before
medium used may cause a life-threaten-
surgical resection
ing allergic reaction. Patients with a
• Detect tumors and arterial supply, known hypersensitivity to contrast
extent of venous invasion, and tumor medium may benefit from premedica-
vascularity tion with corticosteroids or the use of
• Detect thrombosis, arteriovenous fis- nonionic contrast medium.
tula, aneurysms, or emboli in vessels • Patients with bleeding disorders.
• Differentiate between tumors and cysts • Patients who are pregnant or suspected
of being pregnant, unless the potential
• Evaluate placement of a stent
benefits of the procedure far outweigh
• Evaluate tumor vascularity before sur- the risks to the fetus and mother.
gery or embolization • Elderly and other patients who
• Evaluate the vascular system of prospec- are chronically dehydrated before
tive organ donors before surgery the test, because of their risk of con-
trast-induced renal failure.
RESULT • Patients who are in renal failure.
Factors that may
Normal Findings:
impair clear imaging:
• Normal structure, function, and
• Gas or feces in the gastrointestinal tract
patency of carotid vessels
resulting from inadequate cleansing or
• Contrast medium normally circulates failure to restrict food intake before the
throughout neck symmetrically and study
without interruption • Retained barium from a previous radi-
• No evidence of obstruction, variations ologic procedure
in number and size of vessels, malfor- • Metallic objects within the examina-
mations, cysts, or tumors tion field (e.g., jewelry, body rings,
dental amalgams), which may inhibit
Abnormal Findings: organ visualization and can produce
• Abscess or inflammation unclear images
• Arterial aneurysm • Improper adjustment of the radi-
ographic equipment to accommodate
• Arterial stenosis or dysplasia
obese or thin patients, which can cause
• Arteriovenous fistula or other abnor- overexposure or underexposure and a
malities poor-quality study
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Angiography, Carotid 81

• Patients who are very obese, who may ously performed diagnostic proce-
exceed the weight limit for the equip- dures, surgical procedures, and
ment laboratory tests. Ensure that the
results of blood tests are obtained
• Incorrect positioning of the patient, and recorded before the procedure,
which may produce poor visualization especially coagulation tests, blood
of the area to be examined urea nitrogen, and creatinine, if con-
trast medium is to be used. For
• Inability of the patient to cooperate or related diagnostic tests, refer to the
remain still during the procedure Cardiovascular System table.
because of age, significant pain, or ➤ Note any recent procedures that can
mental status interfere with test results, including
examinations using iodine-based
Other considerations: contrast medium.
• Consultation with a health care practi- ➤ Record the date of the last menstrual
tioner should occur before the proce- period and determine the possibility
dure for radiation safety concerns of pregnancy in perimenopausal
regarding younger patients or patients women.
who are lactating. ➤ Obtain a list of the medications the
patient is taking, especially medica-
• Risks associated with radiographic tions known to affect bleeding,
overexposure can result from frequent including anticoagulant therapy,
x-ray procedures. Personnel in the aspirin and other salicylates, herbs,
room with the patient should wear a nutritional supplements, and nutra-
protective lead apron, stand behind a ceuticals (see Appendix F: Effects of
shield, or leave the area while the exam- Natural Products on Laboratory
ination is being done. Personnel work- Values). It is recommended that use
ing in the area where the examination is of such products be discontinued 14
being done should wear badges that days before surgical procedures. The
requesting health care practitioner
reveal their level of exposure to radia- and laboratory should be advised if
tion. the patient regularly uses these prod-
• Failure to follow dietary restrictions ucts so that their effects can be taken
into consideration when reviewing
and other pretesting preparations may results.
cause the procedure to be canceled or
repeated. ➤ Patients receiving metformin (glu-
cophage) for non–insulin-dependent
(type 2) diabetes should discontinue
the drug on the day of the test and
Nursing Implications and continue to withhold it for 48 hours
Procedure ● ● ● ● ● ● ● ● ● ● ● after the test. Failure to do so may
result in lactic acidosis.
Pretest: ➤ Review the procedure with the
➤ Inform the patient that the procedure patient. Address concerns about pain
assesses cardiovascular function. related to the procedure. Explain to
the patient that some pain may be
➤ Obtain a history of the patient’s com- experienced during the test, or there
plaints, including a list of known may be moments of discomfort.
allergens (especially allergies or sen- Inform the patient that the procedure
sitivities to latex, iodine, seafood, is performed in a special department,
contrast medium, anesthetics, or usually in a radiology or vascular
dyes), and inform the appropriate suite, by a health care practitioner
health care practitioner accordingly. and support staff and takes approxi-
➤ Obtain a history of results of previ- mately 30 to 60 minutes.
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82 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Sensitivity to social and cultural drug, administer ordered prophylac-


issues, as well as concern for mod- tic steroids or antihistamines before
esty, is important in providing psy- the procedure. Use nonionic contrast
chological support before, during, medium for the procedure.
and after the procedure. ➤ Patients are given a gown, robe, and
➤ Explain that an intravenous (IV) line foot coverings to wear and instructed
may be inserted to allow infusion of to void prior to the procedure.
IV fluids, contrast medium, dye, or
➤ Observe standard precautions, and
sedatives. Usually normal saline is
follow the general guidelines in
infused.
Appendix A.
➤ Inform the patient that a burning and
➤ Record baseline vital signs, and
flushing sensation may be felt
assess neurologic status. Protocols
throughout the body during injection
may vary from facility to facility.
of the contrast medium. After injec-
tion of the contrast medium, the ➤ Instruct the patient to cooperate fully
patient may experience an urge to and to follow directions. Instruct the
cough, flushing, nausea, or a salty or patient to remain still throughout the
metallic taste. procedure because movement pro-
➤ The patient should fast and restrict duces unreliable results.
fluids for 8 hours prior to the proce- ➤ Establish an IV fluid line for the injec-
dure. Instruct the patient to avoid tion of emergency drugs and of
taking anticoagulant medication or to sedatives.
reduce dosage as ordered prior to ➤ Administer an antianxiety agent, as
the procedure. ordered, if the patient has claustro-
➤ Instruct the patient to remove den- phobia. Administer a sedative to a
tures, jewelry (including watches), child or to an uncooperative adult, as
hairpins, credit cards, and other ordered.
metallic objects in the area to be ➤ Place electrocardiographic electrodes
examined. on the patient for cardiac monitoring.
➤ Make sure a written and informed Establish a baseline rhythm; deter-
consent has been signed prior to the mine if the patient has ventricular
procedure and before administering arrhythmias.
any medications. ➤ Using a pen, mark the site of the
➤ This procedure may be terminated if patient’s peripheral pulses before
chest pain, severe cardiac arrhyth- angiography; this allows for quicker
mias, or signs of a cerebrovascular and more consistent assessment of
accident occur. the pulses after the procedure.
➤ Place the patient in the supine posi-
Intratest: tion on an exam table. Cleanse the
➤ Ensure that the patient has complied selected area, and cover with a ster-
with dietary, medication, or activity ile drape.
restrictions and pretesting prepara- ➤ A local anesthetic is injected at the
tions; assure that food and medica- site, and a small incision is made or
tions have been restricted for at least a needle inserted under fluoroscopy.
8 hours prior to the procedure. ➤ The contrast medium is injected, and
Ensure that the patient has removed a rapid series of images is taken dur-
jewelry, dentures, all external metal- ing and after the filling of the vessels
lic objects, and the like prior to the to be examined. Delayed images
procedure. may be taken to examine the vessels
➤ Have emergency equipment readily after a time and to monitor the
available. venous phase of the procedure.
➤ If the patient has a history of severe ➤ Ask the patient to inhale deeply and
allergic reactions to any substance or hold his or her breath while the x-ray
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Angiography, Carotid 83

images are taken, and then to exhale ➤ Instruct the patient to maintain bed
after the images are taken. rest for 4 to 6 hours after the proce-
dure or as ordered.
➤ Instruct the patient to take slow,
deep breaths if nausea occurs during ➤ Instruct the patient in the care and
the procedure. assessment of the site and to
observe for bleeding, hematoma for-
➤ Monitor the patient for complications
mation, bile leakage, and inflamma-
related to the procedure (e.g., aller-
tion. Note any pleuritic pain,
gic reaction, anaphylaxis, bron-
persistent right shoulder pain, or
chospasm).
abdominal pain.
➤ The needle or catheter is removed,
➤ Nutritional considerations: A low-fat,
and a pressure dressing is applied
low-cholesterol, and low-sodium diet
over the puncture site.
should be consumed to reduce cur-
➤ The results are recorded on x-ray film rent disease processes and/or
or electronically in a computerized decrease risk of hypertension and
system for recall and postprocedure coronary artery disease.
interpretation by the appropriate
➤ No other radionuclide tests should
health care practitioner.
be scheduled for 24 to 48 hours after
this procedure.
Post-test: ➤ A written report of the examination
➤ Instruct the patient to resume usual will be completed by a health care
diet, fluids, medications, or activity, practitioner specializing in this
as directed by the health care practi- branch of medicine. The report will
tioner. Renal function should be be sent to the requesting health care
assessed before metformin is practitioner, who will discuss the
resumed. results with the patient.
➤ Monitor vital signs and neurologic ➤ Recognize anxiety related to test
status every 15 minutes for 1 hour, results, and be supportive of per-
then every 2 hours for 4 hours, and ceived loss of independent func-
as ordered. Take the temperature tion. Discuss the implications of
every 4 hours for 24 hours. Compare abnormal test results on the
with baseline values. Protocols may patient’s lifestyle. Provide teaching
vary from facility to facility. and information regarding the clinical
implications of the test results, as
➤ Observe for delayed allergic reac- appropriate.
tions, such as rash, urticaria, tachy-
cardia, hyperpnea, hypertension, ➤ Reinforce information given by the
palpitations, nausea, or vomiting. patient’s health care provider regard-
ing further testing, treatment, or
➤ Instruct the patient to immediately referral to another health care
report symptoms such as fast heart provider. Answer any questions or
rate, difficulty breathing, skin rash, address any concerns voiced by the
itching, or decreased urinary output. patient or family.
➤ Assess extremities for signs of ➤ Instruct the patient in the use of any
ischemia or absence of distal ordered medications. Explain the
pulse caused by a catheter-induced importance of adhering to the ther-
thrombus. apy regimen. As appropriate, instruct
➤ Observe the needle/catheter inser- the patient in significant side effects
tion site for bleeding, inflammation, and systemic reactions associated
or hematoma formation. with the prescribed medication.
Encourage him or her to review cor-
➤ Instruct the patient to apply cold
responding literature provided by a
compresses to the puncture site, as
pharmacist.
needed, to reduce discomfort or
edema. ➤ Depending on the results of this pro-
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84 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

cedure, additional testing may be Related diagnostic tests:


performed to evaluate or monitor
progression of the disease process ➤ Related diagnostic tests include com-
and determine the need for a change puted tomography angiography, mag-
in therapy. Evaluate test results in netic resonance angiography, and
relation to the patient’s symptoms ultrasound, arterial Doppler carotid
and other tests performed. studies.

ANGIOGRAPHY, CORONARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Angiocardiography, cardiac angiography, cardiac


catheterization, cineangiocardiography, coronary arteriography.

AREA OF APPLICATION: Heart.


CONTRAST: Intravenous iodine based.

DESCRIPTION & RATIONALE: Angio- abnormalities are seen with left heart
graphy allows x-ray visualization of the views. Coronary angiography is a
heart, aorta, inferior vena cava, pul- definitive test for coronary artery dis-
monary artery and vein, and coronary ease, and it is useful for evaluating
arteries after injection of contrast other types of cardiac abnormalities. ■
medium. Contrast medium is injected
through a catheter, which has been INDICATIONS:
inserted into a peripheral vein for a • Allow infusion of thrombolytic drugs
right heart catheterization or an artery into an occluded coronary artery
for a left heart catheterization; through • Detect narrowing of coronary vessels or
the same catheter, cardiac pressures abnormalities of the great vessels in
are recorded. Images of the heart and patients with angina, syncope, abnor-
mal electrocardiogram, hypercholes-
associated vessels are displayed on a
teremia with chest pain, and persistent
monitor and are recorded on film or chest pain after revascularization
electronically. Patterns of circulation,
cardiac output, cardiac functions, and • Evaluate cardiac muscle function
changes in vessel wall appearance can • Evaluate cardiac valvular and septal
be viewed to help diagnose the pres- defects
ence of vascular abnormalities or • Evaluate disease associated with the
lesions. Pulmonary artery abnormali- aortic arch
ties are seen with right heart views, • Evaluate previous cardiac surgery or
and coronary artery and thoracic aorta other interventional procedures
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 85

Angiography, Coronary 85

• Evaluate ventricular aneurysms • Patients who are pregnant or suspected


• Monitor pulmonary pressures and car- of being pregnant, unless the potential
diac output benefits of the procedure far outweigh
the risk of radiation exposure to the
• Perform angioplasty, perform atherec- fetus.
tomy, or place a stent
• Quantify the severity of atherosclerotic, • Elderly and compromised pa-
occlusive coronary artery disease tients who are chronically dehy-
drated before the test, because of their
RESULT risk of contrast-induced renal failure.
• Patients who are in renal failure.
Normal Findings:
• Normal great vessels and coronary Factors that may
arteries impair clear imaging:
• Gas or feces in the gastrointestinal tract
Abnormal Findings: resulting from inadequate cleansing or
• Aortic atherosclerosis failure to restrict food intake before the
study
• Aortic dissection
• Retained barium from a previous radi-
• Aortitis ologic procedure
• Aneurysms • Metallic objects within the examina-
• Cardiomyopathy tion field (e.g., jewelry, body rings),
which may inhibit organ visualization
• Congenital anomalies and can produce unclear images
• Coronary artery atherosclerosis and • Improper adjustment of the radi-
degree of obstruction ographic equipment to accommodate
• Graft occlusion obese or thin patients, which can cause
overexposure or underexposure and a
• Pulmonary artery abnormalities poor-quality study
• Septal defects • Patients who are very obese, who may
exceed the weight limit for the equip-
• Trauma causing tears or other dis-
ment
ruption
• Incorrect positioning of the patient,
• Tumors which may produce poor visualization
• Valvular disease of the area to be examined
• Inability of the patient to cooperate or
INTERFERING FACTORS remain still during the procedure
because of age, significant pain, or
This procedure is
mental status
contraindicated for:

• Patients with allergies to shellfish Other considerations:


or iodinated dye. The contrast • Consultation with a physician should
medium used may cause a life-threat- occur before the procedure for radia-
ening allergic reaction. Patients with a tion safety concerns regarding younger
known hypersensitivity to contrast patients or patients who are lactating.
medium may benefit from premedica- • Risks associated with radiographic over-
tion with corticosteroids or the use of exposure can result from frequent x-ray
nonionic contrast medium. procedures. Personnel in the room with
• Patients with bleeding disorders. the patient should wear a protective
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 86

86 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

lead apron, stand behind a shield, or Natural Products on Laboratory


leave the area while the examination is Values). It is recommended that use
being done. Personnel working in the of such products be discontinued 14
area where the examination is being days before surgical procedures. The
requesting health care practitioner
done should wear badges that reveal and laboratory should be advised if
their level of exposure to radiation. the patient regularly uses these prod-
• Failure to follow dietary restrictions ucts so that their effects can be taken
and other pretesting preparations may into consideration when reviewing
cause the procedure to be canceled or results.
repeated. ➤ Patients receiving metformin (glu-
cophage) for non–insulin-dependent
(type 2) diabetes should discontinue
the drug on the day of the test and
Nursing Implications and continue to withhold it for 48 hours
Procedure ● ● ● ● ● ● ● ● ● ● ●
after the test. Failure to do so may
result in lactic acidosis.
Pretest: ➤ Review the procedure with the
patient. Address concerns about
➤ Inform the patient that the procedure pain related to the procedure.
assesses cardiovascular function. Explain to the patient that some pain
may be experienced during the test,
➤ Obtain a history of the patient’s com-
or there may be moments of dis-
plaints, including a list of known
comfort. Inform the patient that the
allergens (especially allergies or sen-
procedure is performed in a special
sitivities to latex, iodine, seafood,
department, usually in a radiology
contrast medium, anesthetics, or
or vascular suite, by a physician and
dyes), and inform the appropriate
support staff and takes approxi-
health care practitioner accordingly.
mately 30 to 60 minutes.
➤ Obtain a history of results of previ- ➤ Sensitivity to cultural and social
ously performed diagnostic proce- issues, as well as concern for mod-
dures, surgical procedures, and esty, is important in providing psy-
laboratory tests. Ensure that the chological support before, during,
results of blood tests are obtained and after the procedure.
and recorded before the procedure,
➤ Explain that an intravenous (IV) line
especially coagulation tests, blood
may be inserted to allow infusion
urea nitrogen, and creatinine, if con-
of IV fluids, contrast medium, dye, or
trast medium is to be used. For
sedatives. Usually normal saline is
related diagnostic tests, refer to
infused.
the Cardiovascular and Respiratory
System tables. ➤ Inform the patient that a burning and
flushing sensation may be felt
➤ Note any recent procedures that can throughout the body during injection
interfere with test results, including of the contrast medium. After injec-
examinations using iodine-based tion of the contrast medium, the
contrast medium. patient may experience an urge to
➤ Record the date of the last menstrual cough, flushing, nausea, or a salty or
period and determine the possibility metallic taste.
of pregnancy in perimenopausal ➤ The patient should fast and restrict
women. fluids for 8 hours prior to the proce-
➤ Obtain a list of the medications the dure. Instruct the patient to avoid
patient is taking, especially medica- taking anticoagulant medication or to
tions known to affect bleeding, reduce dosage as ordered prior to
including anticoagulant therapy, the procedure.
aspirin and other salicylates, herbs, ➤ Instruct the patient to remove den-
nutritional supplements, and nutra- tures, jewelry (including watches),
ceuticals (see Appendix F: Effects of hairpins, credit cards, and other
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 87

Angiography, Coronary 87

metallic objects in the area to be rhythm; determine if the patient has


examined. ventricular arrhythmias.
➤ Make sure a written and informed ➤ Using a pen, mark the site of the
consent has been signed prior to the patient’s peripheral pulses before
procedure and before administering angiography; this allows for quicker
any medications. and more consistent assessment of
➤ This procedure may be terminated if the pulses after the procedure.
chest pain, severe cardiac arrhyth- ➤ Place the patient in the supine posi-
mias, or signs of a cerebrovascular tion on an exam table. Cleanse the
accident occur. selected area, and cover with a ster-
ile drape.
Intratest: ➤ A local anesthetic is injected at the
➤ Ensure that the patient has complied site, and a small incision is made or
with dietary and medication restric- a needle inserted under fluoroscopy.
tions and pretesting preparations; ➤ The contrast medium is injected, and
assure that food and medications a rapid series of images is taken dur-
have been restricted for at least 8 ing and after the filling of the vessels
hours prior to the procedure. Ensure to be examined. Delayed images
that the patient has removed jew- may be taken to examine the vessels
elry, dentures, all external metallic after a time and to monitor the
objects, and the like prior to the pro- venous phase of the procedure.
cedure. ➤ Ask the patient to inhale deeply and
➤ Have emergency equipment readily hold his or her breath while the x-ray
available. images are taken, and then to exhale
➤ If the patient has a history of severe after the images are taken.
allergic reactions to any substance or ➤ Instruct the patient to take slow,
drug, administer ordered prophylac- deep breaths if nausea occurs during
tic steroids or antihistamines before the procedure.
the procedure. Use nonionic contrast ➤ Monitor the patient for complica-
medium for the procedure. tions related to the procedure (e.g.,
➤ Patients are given a gown, robe, and allergic reaction, anaphylaxis, bron-
foot coverings to wear and instructed chospasm).
to void prior to the procedure. ➤ The needle or catheter is removed,
➤ Observe standard precautions, and and a pressure dressing is applied
follow the general guidelines in over the puncture site.
Appendix A. ➤ The results are recorded on x-ray film
➤ Record baseline vital signs, and or electronically in a computerized
assess neurologic status. Protocols system for recall and postprocedure
may vary from facility to facility. interpretation by the appropriate
➤ Instruct the patient to cooperate fully health care practitioner.
and to follow directions. Instruct the
patient to remain still throughout Post-test:
the procedure because movement
➤ Instruct the patient to resume usual
produces unreliable results.
diet, fluids, medications, or activity,
➤ Establish an IV fluid line for the injec- as directed by the health care practi-
tion of emergency drugs and of tioner. Renal function should be
sedatives. assessed before metformin is
➤ Administer an antianxiety agent, as resumed.
ordered, if the patient has claustro- ➤ Monitor vital signs and neurologic
phobia. Administer a sedative to a status every 15 minutes for 1 hour,
child or to an uncooperative adult, as then every 2 hours for 4 hours, and
ordered. as ordered. Take the temperature
➤ Place electrocardiographic elec- every 4 hours for 24 hours. Compare
trodes on the patient for cardiac with baseline values. Protocols may
monitoring. Establish a baseline vary from facility to facility.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 88

88 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Observe for delayed allergic reac- Discuss the implications of abnormal


tions, such as rash, urticaria, tachy- test results on the patient’s lifestyle.
cardia, hyperpnea, hypertension, Provide teaching and information
palpitations, nausea, or vomiting. regarding the clinical implications of
➤ Advise the patient to immediately the test results, as appropriate.
report symptoms such as fast heart ➤ Reinforce information given by the
rate, difficulty breathing, skin rash, patient’s health care provider regard-
itching, or decreased urinary output. ing further testing, treatment, or
referral to another health care
➤ Assess extremities for signs of
provider. Answer any questions or
ischemia or absence of distal pulse
address any concerns voiced by the
caused by a catheter-induced throm-
patient or family.
bus.
➤ Instruct the patient in the use of any
➤ Observe the needle/catheter inser-
ordered medications. Explain the
tion site for bleeding, inflammation,
importance of adhering to the ther-
or hematoma formation.
apy regimen. As appropriate, instruct
➤ Instruct the patient to apply cold the patient in significant side effects
compresses to the puncture site, as and systemic reactions associated
needed, to reduce discomfort or with the prescribed medication.
edema. Encourage him or her to review cor-
➤ Instruct the patient to maintain bed responding literature provided by a
rest for 4 to 6 hours after the proce- pharmacist.
dure or as ordered. ➤ Depending on the results of this pro-
➤ Instruct the patient in the care and as- cedure, additional testing may be
sessment of the site and to observe performed to evaluate or monitor
for bleeding, hematoma formation, progression of the disease process
bile leakage, and inflammation. Note and determine the need for a change
any pleuritic pain, persistent right in therapy. Evaluate test results in
shoulder pain, or abdominal pain. relation to the patient’s symptoms
and other tests performed.
➤ A written report of the examination
will be completed by a health care
practitioner specializing in this Related diagnostic tests:
branch of medicine. The report will ➤ Related diagnostic tests include
be sent to the requesting health care chest x-ray, computed tomography
practitioner, who will discuss the angiography, computed tomogra-
results with the patient. phy cardiac scoring, electrocardio-
➤ Recognize anxiety related to test gram, magnetic resonance angiogra-
results, and be supportive of per- phy, and myocardial perfusion heart
ceived loss of independent function. scan.

ANGIOGRAPHY, PULMONARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Pulmonary angiography, pulmonary arteriography.


AREA OF APPLICATION: Pulmonary vasculature.
CONTRAST: Intravenous iodine based.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 89

Angiography, Pulmonary 89

• Bleeding caused by tuberculosis, bron-


DESCRIPTION & RATIONALE: Pul- chiectasis, sarcoidosis, or aspergilloma
monary angiography allows x-ray visu- • Inflammatory diseases
alization of the pulmonary vasculature
• Pulmonary embolism (acute or chronic)
after injection of an iodinated contrast
medium into the pulmonary artery or • Pulmonary sequestration
a branch of this great vessel. Contrast • Tumors
medium is injected through a catheter
that has been inserted into the vascu- CRITICAL VALUES: N/A
lar system, usually through the
femoral vein. It is one of the definitive INTERFERING FACTORS:
tests for pulmonary embolism, but it
This procedure is
is also useful for evaluating other types
contraindicated for:
of pulmonary vascular abnormalities.
It is definitive for peripheral pul- • Patients with allergies to shellfish
monary artery stenosis, anomalous or iodinated dye. The contrast
pulmonary venous drainage, and medium used may cause a life-threat-
ening allergic reaction. Patients with a
pulmonary fistulae. Hemodynamic
known hypersensitivity to contrast
measurements during pulmonary medium may benefit from premedica-
angiography can assist in the diagnosis tion with corticosteroids or the use of
of pulmonary hypertension and cor nonionic contrast medium.
pulmonale. ■ • Patients with bleeding disorders.
INDICATIONS: • Patients who are pregnant or suspected
• Detect acute pulmonary embolism of being pregnant, unless the potential
benefits of the procedure far outweigh
• Detect arteriovenous malformations or the risks to the fetus and mother.
aneurysms
• Elderly and other patients who
• Detect tumors; aneurysms; congenital are chronically dehydrated before
defects; vascular changes associated the test, because of their risk of con-
with emphysema, blebs, and bullae; trast-induced renal failure.
and heart abnormalities
• Patients who are in renal failure.
• Determine the cause of recurrent or
severe hemoptysis Factors that may impair
• Evaluate pulmonary circulation clear imaging:
• Retained barium from a previous radi-
RESULT ologic procedure
• Metallic objects within the examina-
Normal Findings: tion field (e.g., jewelry, body rings),
• Normal pulmonary vasculature; radio- which may inhibit organ visualization
paque iodine contrast medium should and can produce unclear images
circulate symmetrically and without • Improper adjustment of the radi-
interruption through the pulmonary ographic equipment to accommodate
circulatory system. obese or thin patients, which can cause
overexposure or underexposure and a
Abnormal Findings:
poor-quality study
• Aneurysms
• Patients who are very obese, who may
• Arterial hypoplasia or stenosis exceed the weight limit for the equip-
• Arteriovenous malformations ment
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 90

90 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Incorrect positioning of the patient, trast medium is to be used. For


which may produce poor visualization related diagnostic tests, refer to the
of the area to be examined Cardiovascular and Respiratory
System tables.
• Inability of the patient to cooperate or
remain still during the procedure ➤ Note any recent procedures that
can interfere with test results,
because of age, significant pain, or
including examinations using iodine-
mental status based contrast medium.

Other considerations: ➤ Record the date of the last menstrual


period and determine the possibility
• Consultation with a physician should
of pregnancy in perimenopausal
occur before the procedure for radia- women.
tion safety concerns regarding younger
patients or patients who are lactating. ➤ Obtain a list of the medications the
patient is taking, especially medica-
• Risks associated with radiographic over- tions known to affect bleeding,
exposure can result from frequent x-ray including anticoagulant therapy,
procedures. Personnel in the room with aspirin and other salicylates, herbs,
the patient should wear a protective nutritional supplements, and nutra-
lead apron, stand behind a shield, or ceuticals (see Appendix F: Effects of
Natural Products on Laboratory
leave the area while the examination is Values). It is recommended that use
being done. Personnel working in the of such products be discontinued 14
area where the examination is being days before surgical procedures. The
done should wear badges that reveal requesting health care practitioner
their level of exposure to radiation. and laboratory should be advised if
the patient regularly uses these prod-
• Failure to follow dietary restrictions ucts so that their effects can be taken
and other pretesting preparations may into consideration when reviewing
cause the procedure to be canceled or results.
repeated.
➤ Patients receiving metformin (glu-
cophage) for non–insulin-dependent
(type 2) diabetes should discontinue
Nursing Implications and the drug on the day of the test and
Procedure ● ● ● ● ● ● ● ● ● ● ● continue to withhold it for 48 hours
after the test. Failure to do so may
Pretest: result in lactic acidosis.
➤ Inform the patient that the procedure ➤ Review the procedure with the
assesses cardiovascular function. patient. Address concerns about pain
➤ Obtain a history of the patient’s com- related to the procedure. Explain to
plaints, including a list of known the patient that some pain may be
allergens (especially allergies or experienced during the test, or there
sensitivities to latex, iodine, sea- may be moments of discomfort.
food, contrast medium, anesthetics, Inform the patient that the procedure
or dyes), and inform the appropriate is performed in a special depart-
health care practitioner accordingly. ment, usually in a radiology or vascu-
lar suite, by a physician and support
➤ Obtain a history of results of previ- staff and takes approximately 30 to
ously performed diagnostic proce- 60 minutes.
dures, surgical procedures, and
laboratory tests. Ensure that the ➤ Sensitivity to cultural and social
results of blood tests are obtained issues, as well as concern for mod-
and recorded before the procedure, esty, is important in providing psy-
especially coagulation tests, blood chological support before, during,
urea nitrogen, and creatinine, if con- and after the procedure.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 91

Angiography, Pulmonary 91

➤ Explain that an intravenous (IV) line ➤ Patients are given a gown, robe, and
may be inserted to allow infusion of foot coverings to wear and instruc-
IV fluids, contrast medium, dye, or ted to void prior to the procedure.
sedatives. Usually normal saline is ➤ Observe standard precautions, and
infused. follow the general guidelines in
➤ Inform the patient that a burning and Appendix A.
flushing sensation may be felt ➤ Record baseline vital signs, and
throughout the body during injection assess neurologic status. Protocols
of the contrast medium. After injec- may vary from facility to facility.
tion of the contrast medium, the ➤ Instruct the patient to cooperate fully
patient may experience an urge to and to follow directions. Instruct the
cough, flushing, nausea, or a salty or patient to remain still throughout the
metallic taste. procedure because movement pro-
➤ The patient should fast and restrict duces unreliable results.
fluids for 8 hours prior to the proce- ➤ Establish an IV fluid line for the injec-
dure. Instruct the patient to avoid tion of emergency drugs and of
taking anticoagulant medication or to sedatives.
reduce dosage as ordered prior to ➤ Administer an antianxiety agent, as
the procedure. ordered, if the patient has claustro-
➤ Instruct the patient to remove den- phobia. Administer a sedative to a
tures, jewelry (including watches), child or to an uncooperative adult, as
hairpins, credit cards, and other ordered.
metallic objects in the area to be ➤ Place electrocardiographic elec-
examined. trodes on the patient for cardiac
➤ Make sure a written and informed monitoring. Establish a baseline
consent has been signed prior to the rhythm; determine if the patient has
procedure and before administering ventricular arrhythmias.
any medications. ➤ Using a pen, mark the site of the
patient’s peripheral pulses before
➤ This procedure may be terminated if
angiography; this allows for quicker
chest pain, severe cardiac arrhyth-
and more consistent assessment of
mias, or signs of a cerebrovascular
the pulses after the procedure.
accident occur.
➤ Place the patient in the supine posi-
tion on an exam table. Cleanse the
Intratest: selected area, and cover with a ster-
➤ Ensure that the patient has complied ile drape.
with dietary and medication restric- ➤ A local anesthetic is injected at the
tions and pretesting preparations; site, and a small incision is made or
assure that food and medications a needle inserted under fluoroscopy.
have been restricted for at least 8 ➤ The contrast medium is injected, and
hours prior to the procedure. Ensure a rapid series of images is taken dur-
that the patient has removed jew- ing and after the filling of the vessels
elry, dentures, all external metallic to be examined. Delayed images
objects, and the like prior to the pro- may be taken to examine the vessels
cedure. after a time and to monitor the
➤ Have emergency equipment readily venous phase of the procedure.
available. ➤ Ask the patient to inhale deeply and
➤ If the patient has a history of severe hold his or her breath while the x-ray
allergic reactions to any substance or images are taken, and then to exhale
drug, administer ordered prophylac- after the images are taken.
tic steroids or antihistamines before ➤ Instruct the patient to take slow,
the procedure. Use nonionic contrast deep breaths if nausea occurs during
medium for the procedure. the procedure.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 92

92 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Monitor the patient for complications any pleuritic pain, persistent right
related to the procedure (e.g., aller- shoulder pain, or abdominal pain.
gic reaction, anaphylaxis, bron-
➤ A written report of the examination
chospasm).
will be completed by a health care
➤ The needle or catheter is removed, practitioner specializing in this
and a pressure dressing is applied branch of medicine. The report will
over the puncture site. be sent to the requesting health care
➤ The results are recorded on x-ray film practitioner, who will discuss the
or electronically in a computerized results with the patient.
system for recall and postprocedure ➤ Recognize anxiety related to test
interpretation by the appropriate results, and be supportive of per-
health care practitioner. ceived loss of independent func-
tion. Discuss the implications of
Post-test: abnormal test results on the pa-
➤ Instruct the patient to resume usual tient’s lifestyle. Provide teaching and
diet, fluids, medications, or activity, information regarding the clinical
as directed by the health care practi- implications of the test results, as
tioner. Renal function should be appropriate.
assessed before metformin is ➤ Reinforce information given by the
resumed. patient’s health care provider regard-
➤ Monitor vital signs and neurologic ing further testing, treatment, or
status every 15 minutes for 1 hour, referral to another health care
then every 2 hours for 4 hours, and provider. Answer any questions or
as ordered. Take the temperature address any concerns voiced by the
every 4 hours for 24 hours. Compare patient or family.
with baseline values. Protocols may ➤ Instruct the patient in the use of any
vary from facility to facility. ordered medications. Explain the
➤ Observe for delayed allergic reac- importance of adhering to the ther-
tions, such as rash, urticaria, tachy- apy regimen. As appropriate, instruct
cardia, hyperpnea, hypertension, the patient in significant side effects
palpitations, nausea, or vomiting. and systemic reactions associated
with the prescribed medication.
➤ Advise the patient to immediately Encourage him or her to review cor-
report symptoms such as fast heart responding literature provided by a
rate, difficulty breathing, skin rash, pharmacist.
itching, or decreased urinary output.
➤ Depending on the results of this pro-
➤ Assess extremities for signs of
cedure, additional testing may be
ischemia or absence of distal
performed to evaluate or monitor
pulse caused by a catheter-induced
progression of the disease process
thrombus.
and determine the need for a change
➤ Observe the needle/catheter inser- in therapy. Evaluate test results in
tion site for bleeding, inflammation, relation to the patient’s symptoms
or hematoma formation. and other tests performed.
➤ Instruct the patient to apply cold
compresses to the puncture site, as
needed, to reduce discomfort or Related diagnostic tests
edema.
➤ Related diagnostic tests include
➤ Instruct the patient to maintain bed chest x-ray, computed tomography
rest for 4 to 6 hours after the proce- angiography, electrocardiogram, lung
dure or as ordered. perfusion and lung ventilation scans,
➤ Instruct the patient in the care and as- magnetic resonance angiography,
sessment of the site and to observe magnetic resonance imaging of the
for bleeding, hematoma formation, chest, and thoracic computed tomo-
bile leakage, and inflammation. Note graphy.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 93

Angiography, Renal 93

ANGIOGRAPHY, RENAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Renal angiogram, renal arteriography.


AREA OF APPLICATION: Kidney.
CONTRAST: Intravenous iodine based.

caused by trauma or a penetrating


DESCRIPTION & RATIONALE: Renal injury
angiography allows x-ray visualization • Detect nonmalignant tumors before
of the large and small arteries of the surgical resection
renal vasculature and parenchyma or • Detect renal artery stenosis as evi-
the renal veins and their branches. denced by vessel dilation, collateral ves-
Contrast medium is injected through sels, or increased renovascular pressure
a catheter that has been inserted into • Detect renal tumors as evidenced by
the femoral artery or vein and arterial supply, extent of venous inva-
advanced through the iliac artery and sion, and tumor vascularity
aorta into the renal artery or the infe- • Detect small kidney or absence of a
rior vena cava into the renal vein. kidney
Images of the kidneys and associated • Detect thrombosis, arteriovenous fistu-
vessels are displayed on a monitor and lae, aneurysms, or emboli in renal ves-
recorded on film or electronically. sels
Patterns of circulation, renal function, • Differentiate between renal tumors and
or changes in vessel wall appearance renal cysts
can be viewed to help diagnose the • Evaluate postoperative renal transplan-
presence of vascular abnormalities, tation for function or organ rejection
trauma, or lesions. This definitive test • Evaluate renal function in chronic renal
for renal disease may be used to evalu- failure or end-stage renal disease or
ate chronic renal disease, renal failure, hydronephrosis
and renal artery stenosis; differentiate • Evaluate the renal vascular system of
a vascular renal cyst from hypervascu- prospective kidney donors before sur-
lar renal cancers; and evaluate renal gery
transplant donors, recipients, and the • Evaluate tumor vascularity before sur-
kidney after transplantation. ■ gery or embolization
INDICATIONS: • Perform angioplasty, perform atherec-
• Allow infusion of thrombolytic drugs tomy, or place a stent
into an occluded artery
RESULT
• Assist with the collection of blood sam-
ples from renal vein for renin analysis Normal Findings:
• Detect arterial occlusion as evidenced • Normal structure, function, and
by a transection of the renal artery patency of renal vessels
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 94

94 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Contrast medium circulating through- • Retained barium from a previous radi-


out the kidneys symmetrically and ologic procedure
without interruption • Metallic objects within the examina-
• No evidence of obstruction, variations tion field (e.g., jewelry, body rings,
in number and size of vessels and dental amalgams), which may inhibit
organs, malformations, cysts, or tumors organ visualization and can produce
Abnormal Findings:
unclear images
• Abscess or inflammation • Improper adjustment of the radi-
ographic equipment to accommodate
• Arterial stenosis, dysplasia, or infarction
obese or thin patients, which can cause
• Arteriovenous fistula or other abnor- overexposure or underexposure and a
malities poor-quality study
• Congenital anomalies • Patients who are very obese, who may
• Intrarenal hematoma exceed the weight limit for the equip-
• Renal artery aneurysm ment
• Renal cysts or tumors • Incorrect positioning of the patient,
• Trauma causing tears or other disrup- which may produce poor visualization
tion of the area to be examined
• Inability of the patient to cooperate or
CRITICAL VALUES: N/A remain still during the procedure
INTERFERING FACTORS because of age, significant pain, or
mental status
This procedure is
contraindicated for: Other considerations:
• Consultation with a physician should
• Patients with allergies to shellfish occur before the procedure for radia-
or iodinated dye. The contrast tion safety concerns regarding younger
medium used may cause a life-threat- patients or patients who are lactating.
ening allergic reaction. Patients with a • Risks associated with radiographic over-
known hypersensitivity to contrast exposure can result from frequent x-ray
medium may benefit from premedica- procedures. Personnel in the room with
tion with corticosteroids or the use of the patient should wear a protective
nonionic contrast medium. lead apron, stand behind a shield, or
• Patients with bleeding disorders. leave the area while the examination is
• Patients who are pregnant or suspected being done. Personnel working in the
of being pregnant, unless the potential area where the examination is being
benefits of the procedure far outweigh done should wear badges that reveal
the risks to the fetus and mother. their level of exposure to radiation.
• Elderly and other patients who • Failure to follow dietary restrictions
are chronically dehydrated before and other pretesting preparations may
the test, because of their risk of con- cause the procedure to be canceled or
trast-induced renal failure. repeated.
• Patients who are in renal failure.

Factors that may Nursing Implications and


impair clear imaging: Procedure ● ● ● ● ● ● ● ● ● ● ●

• Gas or feces in the gastrointestinal tract


resulting from inadequate cleansing or Pretest:
failure to restrict food intake before the ➤ Inform the patient that the procedure
study assesses cardiovascular function.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 95

➤ Obtain a history of the patient’s com- the procedure is performed in a spe-


plaints, including a list of known cial department, usually in a radiol-
allergens (especially allergies or sen- ogy or vascular suite, by a physician
sitivities to latex, iodine, seafood, and support staff and takes approxi-
contrast medium, anesthetics, or mately 30 to 60 minutes.
dyes), and inform the appropriate ➤ Sensitivity to cultural and social
health care practitioner accordingly. issues, as well as concern for mod-
➤ Obtain a history of results of previ- esty, is important in providing psy-
ously performed diagnostic proce- chological support before, during,
dures, surgical procedures, and and after the procedure.
laboratory tests. Ensure that the ➤ Explain that an intravenous (IV) line
results of blood tests are obtained may be inserted to allow infusion of
and recorded before the procedure, IV fluids, contrast medium, dye, or
especially coagulation tests, blood sedatives. Usually normal saline is
urea nitrogen, and creatinine, if con- infused.
trast medium is to be used. For
related diagnostic tests, refer to the ➤ Inform the patient that a burning and
Cardiovascular and Genitourinary flushing sensation may be felt
System tables. throughout the body during injection
of the contrast medium. After injec-
➤ Note any recent procedures that can
tion of the contrast medium, the
interfere with test results, including
patient may experience an urge to
examinations using iodine-based
cough, flushing, nausea, or a salty or
contrast medium.
metallic taste.
➤ Record the date of the last menstrual
period and determine the possibility ➤ The patient should fast and restrict
of pregnancy in perimenopausal fluids for 8 hours prior to the proce-
women. dure. Instruct the patient to avoid
taking anticoagulant medication or to
➤ Obtain a list of the medications the
reduce dosage as ordered prior to
patient is taking, especially medica-
the procedure.
tions known to affect bleeding,
including anticoagulant therapy, as- ➤ Instruct the patient to remove den-
pirin and other salicylates, herbs, tures, jewelry (including watches),
nutritional supplements, and nutra- hairpins, credit cards, and other
ceuticals (see Appendix F: Effects of metallic objects in the area to be
Natural Products on Laboratory examined.
Values). It is recommended that use ➤ Make sure a written and informed
of such products be discontinued 14 consent has been signed prior to the
days before surgical procedures. The procedure and before administering
requesting health care practitioner any medications.
and laboratory should be advised if
the patient regularly uses these prod- ➤ This procedure may be terminated if
ucts so that their effects can be taken chest pain, severe cardiac arrhyth-
into consideration when reviewing mias, or signs of a cerebrovascular
results. accident occur.
➤ Patients receiving metformin (glu- Intratest:
cophage) for non–insulin-dependent
(type 2) diabetes should discontinue ➤ Ensure that the patient has complied
the drug on the day of the test and with dietary and medication restric-
continue to withhold it for 48 hours tions and pretesting preparations;
after the test. Failure to do so may assure that food and medications
result in lactic acidosis. have been restricted for at least 8
➤ Review the procedure with the hours prior to the procedure. Ensure
patient. Address concerns about that the patient has removed jew-
pain related to the procedure. elry, dentures, all external metallic
Explain to the patient that some objects, and the like prior to the pro-
pain may be experienced during the cedure.
test, or there may be moments of ➤ Have emergency equipment readily
discomfort. Inform the patient that available.
95
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 96

96 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ If the patient has a history of severe images are taken, and then to exhale
allergic reactions to any substance or after the images are taken.
drug, administer ordered prophylac- ➤ Instruct the patient to take slow,
tic steroids or antihistamines before deep breaths if nausea occurs during
the procedure. Use nonionic contrast the procedure.
medium for the procedure. ➤ Monitor the patient for complications
➤ Patients are given a gown, robe, and related to the procedure (e.g.,
foot coverings to wear and instructed allergic reaction, anaphylaxis, bron-
to void prior to the procedure. chospasm).
➤ Observe standard precautions, and ➤ The needle or catheter is removed,
follow the general guidelines in and a pressure dressing is applied
Appendix A. over the puncture site.
➤ Record baseline vital signs, and ➤ The results are recorded on x-ray film
assess neurologic status. Protocols or electronically in a computerized
may vary from facility to facility. system for recall and postprocedure
interpretation by the appropriate
➤ Instruct the patient to cooperate fully
health care practitioner.
and to follow directions. Instruct the
patient to remain still throughout the
Post-test:
procedure because movement pro-
duces unreliable results. ➤ Instruct the patient to resume usual
➤ Establish an IV fluid line for the injec- diet, fluids, medications, or activity,
tion of emergency drugs and of as directed by the health care
sedatives. practitioner. Renal function should
be assessed before metformin is
➤ Administer an antianxiety agent, as
resumed.
ordered, if the patient has claustro-
phobia. Administer a sedative to a ➤ Monitor vital signs and neurologic
child or to an uncooperative adult, as status every 15 minutes for 1 hour,
ordered. then every 2 hours for 4 hours, and
as ordered. Take the temperature
➤ Place electrocardiographic elec- every 4 hours for 24 hours. Compare
trodes on the patient for cardiac with baseline values. Protocols may
monitoring. Establish a baseline vary from facility to facility.
rhythm; determine if the patient has
➤ Observe for delayed allergic reac-
ventricular arrhythmias.
tions, such as rash, urticaria, tachy-
➤ Using a pen, mark the site of the cardia, hyperpnea, hypertension,
patient’s peripheral pulses before palpitations, nausea, or vomiting.
angiography; this allows for quicker ➤ Advise the patient to immediately
and more consistent assessment of report symptoms such as fast heart
the pulses after the procedure. rate, difficulty breathing, skin rash,
➤ Place the patient in the supine posi- itching, or decreased urinary output.
tion on an exam table. Cleanse the ➤ Assess extremities for signs of
selected area, and cover with a ster- ischemia or absence of distal pulse
ile drape. caused by a catheter-induced throm-
➤ A local anesthetic is injected at the bus.
site, and a small incision is made or ➤ Observe the needle/catheter inser-
a needle inserted under fluoroscopy. tion site for bleeding, inflammation,
➤ The contrast medium is injected, and or hematoma formation.
a rapid series of images is taken dur- ➤ Instruct the patient to apply cold
ing and after the filling of the vessels compresses to the puncture site, as
to be examined. Delayed images needed, to reduce discomfort or
may be taken to examine the vessels edema.
after a time and to monitor the ➤ Instruct the patient to maintain bed
venous phase of the procedure. rest for 4 to 6 hours after the proce-
➤ Ask the patient to inhale deeply and dure or as ordered.
hold his or her breath while the x-ray ➤ Instruct the patient in the care and
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 97

Angiotensin-Converting Enzyme 97

assessment of the site and to ➤ Instruct the patient in the use of any
observe for bleeding, hematoma for- ordered medications. Explain the
mation, bile leakage, and inflamma- importance of adhering to the ther-
tion. Note any pleuritic pain, apy regimen. As appropriate, instruct
persistent right shoulder pain, or the patient in significant side effects
abdominal pain. and systemic reactions associated
➤ A written report of the examina- with the prescribed medication.
tion will be completed by a health Encourage him or her to review cor-
care practitioner specializing in this responding literature provided by a
branch of medicine. The report will pharmacist.
be sent to the requesting health care ➤ Depending on the results of this pro-
practitioner, who will discuss the cedure, additional testing may be
results with the patient. performed to evaluate or monitor
➤ Recognize anxiety related to test progression of the disease process
results, and be supportive of per- and determine the need for a change
ceived loss of independent function. in therapy. Evaluate test results in
Discuss the implications of abnormal relation to the patient’s symptoms
test results on the patient’s lifestyle. and other tests performed.
Provide teaching and information
regarding the clinical implications of
the test results, as appropriate. Related diagnostic tests
➤ Reinforce information given by the ➤ Related diagnostic tests include
patient’s health care provider regard- computed tomography of the abdo-
ing further testing, treatment, or men; computed tomography angiog-
referral to another health care pro- raphy; kidney, ureter, and bladder
vider. Answer any questions or study; magnetic resonance angiogra-
address any concerns voiced by the phy and magnetic resonance imag-
patient or family. ing of the abdomen.

ANGIOTENSIN-CONVERTING ENZYME
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: Angiotensin I–converting enzyme (ACE).


SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Spectrophotometry)

SI Units (Conventional
Age Conventional Units Units  0.017)
0–2 y 5–83 U/L 0.09–1.41 Kat/L
3–7 y 8–76 U/L 0.14–1.29 Kat/L
8–14 y 6–89 U/L 0.10–1.51 Kat/L
Greater than 14 y 8–52 U/L 0.14–0.88 Kat/L
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98 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

DESCRIPTION & RATIONALE: useful marker in the evaluation of dis-


Angiotensin-converting enzyme ease for patients less than 20 years of
(ACE) production occurs mainly in age. ■
the epithelial cells of the pulmonary
bed. Smaller amounts are found in INDICATIONS:
blood vessels and renal tissue, where • Assist in establishing a diagnosis of sar-
coidosis
ACE converts angiotensin I to
angiotensin II; this conversion helps • Assist in the evaluation of Gaucher’s
regulate arterial blood pressure. disease
Angiotensin II stimulates the adrenal • Assist in the treatment of sarcoidosis
cortex to produce aldosterone. • Evaluate hypertension
Aldosterone is a hormone that helps • Evaluate the severity and activity of sar-
the kidneys maintain water balance by coidosis
retaining sodium and promoting the
excretion of potassium. RESULT
ACE levels are used primarily in the
Increased in:
evaluation of hypertension and active
• Bronchitis (acute and chronic)
sarcoidosis, a granulomatous disease
that can affect many organs, including • Connective tissue disease
the lungs. Serial levels are useful in • Gaucher’s disease
correlating the therapeutic response to • Hansen’s disease (leprosy)
corticosteroid treatment. Increasing
• Histoplasmosis and other fungal dis-
ACE levels with positive gallium eases
scans in sarcoidosis patients receiving
steroids indicate a poor response to • Hyperthyroidism (untreated)
therapy. Monitoring ACE levels may • Pulmonary fibrosis
also have some utility in assessing the • Rheumatoid arthritis
risk of pulmonary damage in affected • Sarcoidosis
patients receiving antineoplastic
agents. Thyroid hormones may play a Decreased in:
role in regulating ACE levels: • Advanced pulmonary carcinoma
Decreased levels have been noted in • The period following corticosteroid
patients with clinical hypothyroidism therapy for sarcoidosis
and anorexia nervosa, whereas
increased levels have been noted in CRITICAL VALUES: N/A
patients with hyperthyroidism. INTERFERING FACTORS:
Elevations of serum ACE have been • Drugs that may increase serum ACE
reported in 20% to 30% of patients levels include triiodothyronine.
with abnormal 1-antitrypsin vari- • Drugs that may decrease serum ACE
ants. ACE levels are sometimes levels include captopril, cilazapril, enal-
ordered on cerebrospinal fluid to eval- april, fosinopril, lisinopril, nicardipine,
uate patients with neurosarcoidosis. pentopril, perindopril, propranolol,
Results must be interpreted with care quinapril, ramipril, and trandolapril.
because of the nonspecificity of • Prompt and proper specimen process-
increased and decreased ACE levels. ing, storage, and analysis are important
ACE is normally elevated in pediatric to achieve accurate results. Failure to
patients and therefore is not a freeze sample if not tested immediately
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 99

Angiotensin-Converting Enzyme 99

may cause falsely decreased values ➤ Instruct the patient to cooperate


because ACE degrades rapidly. fully and to follow directions. Dir-
ect the patient to breathe normally
and to avoid unnecessary move-
Nursing Implications and ment.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Observe standard precautions, and
follow the general guidelines in
Pretest: Appendix A. Positively identify the
patient, and label the appropriate
➤ Inform the patient that the test is pri- tubes with the corresponding patient
marily used to diagnose and monitor demographics, date, and time of col-
treatment of sarcoidosis. lection. Perform a venipuncture; col-
➤ Obtain a history of the patient’s com- lect the specimen in a 5-mL red- or
plaints, including a list of known tiger-top tube.
allergens (especially allergies or sen- ➤ Remove the needle, place a gauze
sitivities to latex), and inform the over the puncture site and apply gen-
appropriate health care practitioner tle pressure to stop bleeding.
accordingly. Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
endocrine, immune, musculoskele- paper tape over gauze or replace
tal, and respiratory systems, as well with adhesive bandage.
as results of previously performed ➤ Promptly transport the specimen to
laboratory tests, surgical proce- the laboratory for processing and
dures, and other diagnostic proce- analysis.
dures. For related laboratory tests,
refer to the Endocrine, Immune, ➤ The results are recorded manually or
Musculoskeletal, and Respiratory in a computerized system for recall
System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and
nutraceuticals. The requesting health Post-test:
care practitioner and laboratory
should be advised if the patient reg- ➤ Nutritional considerations: ACE levels
ularly uses these products so that affect the regulation of fluid balance
their effects can be taken into con- and electrolytes. Dietary adjustment
sideration when reviewing results. may be considered if sodium
allowances need to be regulated.
➤ Review the procedure with the
Educate patients with low sodium
patient. Note the patient’s age. This
levels that the major source of
test is rarely ordered on patients
dietary sodium is found in table salt.
less than 20 years old. Inform the
Many foods such as milk and other
patient that specimen collection
dairy products are also good sources
takes approximately 5 to 10 minutes.
of dietary sodium. Most other
Address concerns about pain related
dietary sodium is available through
to the procedure. Explain to the
consumption of processed foods.
patient that there may be some dis-
Patients who need to follow low-
comfort during the venipuncture.
sodium diets should be advised to
➤ There are no food, fluid, or medica- avoid beverages such as colas, gin-
tion restrictions unless by medical ger ale, Gatorade, lemon-lime sodas,
direction. and root beer. Many over-the-counter
medications, including antacids, lax-
Intratest: atives, analgesics, sedatives, and
➤ If the patient has a history of severe antitussives, contain significant
allergic reaction to latex, care should amounts of sodium. The best advice
be taken to avoid the use of equip- is to emphasize the importance
ment containing latex. of reading all food, beverage, and
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100 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

medicine labels. In 1989, the Sub- address any concerns voiced by the
committee on the 10th Edition of the patient or family.
Recommended Dietary Allowances
➤ Depending on the results of this pro-
(RDAs) established 500 mg as the
cedure, additional testing may be
recommended minimum limit for
performed to evaluate or monitor
dietary intake of sodium. There are
progression of the disease process
no RDAs established for potassium,
and determine the need for a change
but the estimated minimum intake
in therapy. Evaluate test results in
for adults is 200 mEq/d. Potassium is
relation to the patient’s symptoms
present in all plant and animal cells,
and other tests performed.
making dietary replacement fairly
simple. A health care practitioner or Related laboratory tests:
nutritionist should be consulted
before considering the use of salt ➤ Related laboratory tests include
substitutes. aldosterone, alkaline phosphatase,
anion gap, 1-antitrypsin, 1-antit-
➤ A written report of the examination
rypsin phenotyping, arterial/alveolar
will be sent to the requesting health
oxygen ratio, blood gases, serum
care practitioner, who will discuss
and urine calcium, electrolytes, ery-
the results with the patient.
throcyte sedimentation rate, liver
➤ Reinforce information given by the biopsy, lymph node biopsy, phospho-
patient’s health care provider regard- rus, potassium, protein electrophore-
ing further testing, treatment, or sis, renin, rheumatoid factor, skin
referral to another health care pro- biopsy, sodium, thyroid hormone lev-
vider. Answer any questions or els, and urine protein.

ANION GAP
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: Agap.

SPECIMEN: Serum (1 mL) for electrolytes collected in a red- or tiger-top


tube. Plasma (1 mL) collected in a green-top (heparin) tube is also acceptable.

REFERENCE VALUE: (Method: Anion gap is derived mathematically from the


direct measurement of sodium, chloride, and total carbon dioxide.) There are
differences between serum and plasma values for some electrolytes. The refer-
ence ranges listed are based on serum values.

SI Units (Conventional
Age Conventional Units Units  1)
Child 8–16 mEq/L 8–16 mmol/L
Adult 8–16 mEq/L 8–16 mmol/L
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 101

Anion Gap 101

high-protein/low-carbohydrate diet,
DESCRIPTION & RATIONALE: The diabetes, and alcoholism
anion gap is used most frequently as a
• Lactic acidosis
clinical indicator of metabolic acido-
sis. It does not include measurement • Poisoning (salicylate, methanol, ethyl-
of important cations, such as calcium, ene glycol, or paraldehyde)
potassium (usually), and magnesium; • Renal failure
or anions, such as proteins, forms
of phosphorus, sulfur, and organic • Uremia
acids. The anion gap is calculated as
Decreased in:
follows:
• Hyperchloremia
(sodium – [chloride HCO3–])
• Hypergammaglobulinemia (multiple
Because bicarbonate (HCO3–) is myeloma)
not directly measured on most chem-
istry analyzers, it is estimated by sub- • Hypoalbuminemia
stitution of the total carbon dioxide • Hyponatremia (hyperviscosity syn-
(TCO2) value in the calculation. Some dromes)
laboratories may include potassium in
TCO2 is commonly substituted for
the calculation of the anion gap. HCO3– in anion gap calculations. It is
Calculations including potassium can important to note the clinical significance
be invalidated because minor amounts of excessive HCO3–, which occurs in
of hemolysis can contribute signifi- renal alkalosis, gastrointestinal alkalosis,
cant levels of potassium leaked into and excessive ingestion of exogenous
the serum as a result of cell rupture. sources of alkali, the effects of which may
The anion gap is also widely used as a not be accurately reflected by the calcu-
laboratory quality control measure lated anion gap.
because low gaps usually indicate a
reagent, calibration, or instrument CRITICAL VALUES: N/A
error. ■
INTERFERING FACTORS:
• Drugs that can increase or decrease the
INDICATIONS: anion gap include those listed in the
• Evaluate metabolic acidosis individual electrolyte (i.e., sodium,
• Indicate the need for laboratory instru- chloride, calcium, magnesium, and
ment recalibration or review of elec- total carbon dioxide), total protein,
trolyte reagent preparation and stability lactic acid, and phosphorus mono-
graphs.
• Indicate the presence of a disturbance
• Specimens should never be collected
in electrolyte balance
above an intravenous line because of
the potential for dilution when the
RESULT specimen and the intravenous solution
combine in the collection container,
Increased in: falsely decreasing the result. There is
• Dehydration (severe) also the potential of contaminating the
• Excessive exercise sample with the substance of interest, if
it is present in the intravenous solution,
• Ketoacidosis caused by starvation, falsely increasing the result.
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102 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Instruct the patient to cooperate fully


Nursing Implications and and to follow directions. Direct the
Procedure ● ● ● ● ● ● ● ● ● ● ● patient to breathe normally and to
avoid unnecessary movement.
Pretest: ➤ Observe standard precautions, and
➤ Inform the patient that the test is follow the general guidelines in
used to assist in the evaluation of Appendix A. Positively identify the
electrolyte balance. patient, and label the appropriate
tubes with the corresponding patient
➤ Obtain a history of the patient’s demographics, date, and time of
complaints, including a list of known collection. Perform a venipuncture;
allergens (especially allergies or sen- collect the specimen in a 5-mL red-
sitivities to latex), and inform the or tiger-top tube.
appropriate health care practitioner
accordingly. ➤ Remove the needle, place a gauze
over the puncture site and apply gen-
➤ Obtain a history of the patient’s car- tle pressure to stop bleeding.
diovascular, endocrine, gastrointesti- Observe venipuncture site for bleed-
nal, genitourinary, hematopoietic, ing and hematoma formation. Apply
immune, and respiratory systems, paper tape over gauze or replace
as well as results of previously per- with adhesive bandage.
formed laboratory tests, surgical
procedures, and other diagnostic ➤ Promptly transport the specimen to
procedures. For related laboratory the laboratory for processing and
tests, refer to the Cardiovascular, analysis.
Endocrine, Gastrointestinal, Geni- ➤ The results are recorded manually or
tourinary, Hematopoietic, Immune, in a computerized system for recall
and Respiratory System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and nutra-
ceuticals. The requesting health care Post-test:
practitioner and laboratory should be
advised if the patient regularly uses ➤ Nutritional considerations: Specific
these products so that their effects dietary considerations are listed in
can be taken into consideration the monographs on individual elec-
when reviewing results. trolytes (i.e., sodium, chloride, cal-
➤ Review the procedure with the cium, and magnesium), total protein,
patient. Inform the patient that spec- and phosphorus.
imen collection takes approximately ➤ Nutritional considerations: The anion
5 to 10 minutes. Address concerns gap can be used to indicate the pres-
about pain related to the procedure. ence of dehydration. Evaluate the
Explain to the patient that there may patient for signs and symptoms of
be some discomfort during the dehydration. Dehydration is a signifi-
venipuncture. cant and common finding in geriatric
➤ There are no food, fluid, or medica- patients and patients with decreased
tion restrictions unless by medical renal function.
direction. ➤ A written report of the examination
will be sent to the requesting health
Intratest: care practitioner, who will discuss
the results with the patient.
➤ If the patient has a history of severe
allergic reaction to latex, care should ➤ Reinforce information given by the
be taken to avoid the use of equip- patient’s health care provider regard-
ment containing latex. ing further testing, treatment, or re-
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Anion Gap 103

ferral to another health care provider. relation to the patient’s symptoms


Answer any questions or address and other tests performed.
any concerns voiced by the patient
or family. Related laboratory tests:
➤ Depending on the results of this pro- ➤ Related laboratory tests include albu-
cedure, additional testing may be min, blood gases, blood urea nitro-
performed to evaluate or monitor gen, creatinine, electrolytes, ethanol,
progression of the disease process glucose, ketones, lactic acid, osmo-
and determine the need for a change lality, protein, protein electrophore-
in therapy. Evaluate test results in sis, salicylate, and urinalysis.
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104 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ANTIARRHYTHMIC DRUGS:
DIGOXIN, DISOPYRAMIDE,
FLECAINIDE, LIDOCAINE,
PROCAINAMIDE, QUINIDINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYMS: Digoxin (Digitek, Lanoxicaps, Lanoxin); disopyra-


mide (Norpace, Norpace CR); flecainide (flecainide acetate, Tambocor);
lidocaine (Xylocaine); procainamide (Procanbid, Pronestyl, Pronestyl SR);
quinidine (Quinidex Extentabs, quinidine sulface SR, quinidine gluconate
SR).

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Route of Recommended
Drug Administration Collection Time
Digoxin Oral Trough: 12–24 h after dose
Never draw peak samples
Disopyramide Oral Trough: immediately before
next dose
Peak: 2–5 h after dose
Flecainide Oral Trough: immediately before
next dose
Peak: 3 h after dose
Lidocaine IV 15 min, 1 h, then every 24 h
Procainamide IV 15 min; 2, 6, 12 hours; then
every 24 h
Procainamide Oral Trough: immediately before
next dose
Peak: 75 min after dose
Quinidine sulfate Oral Trough: immediately before
next dose
Peak: 1 h after dose
Quinidine gluconate Oral Trough: immediately before
next dose
Peak: 5 h after dose
Quinidine polygalac- Oral Trough: immediately before
turonate next dose
Peak: 2 h after dose

IV  intravenous.
Drug Therapeutic Volume of Protein
(Indication) Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion
(SI  Conventional Units  1.28)
Digoxin 0.5–2.0 ng/mL 0.6–2.6 nmol/L 20–60 7 20–30 1o renal
(SI  Conventional Units  2.95)
Disopyramide 2.8–3.2 g/mL 8.3–9.4 mol/L 4–10 0.7–0.9 20–60 1o renal
(atrial
01Van Leewan(F) (1-188)

arrhythmias)
Disopyramide 3.3–5.0 g/mL 9.7–15.0 mol/L 1o renal
(ventricular
arrhythmias)
12/15/05

(SI  Conventional Units  2.41)

Flecainide 0.2–1.0 g/mL 0.5–2.4 mol/L 7–19 5–13 40–50 1o renal


REFERENCE VALUE: (Method: Immunoassay)

(SI  Conventional Units  4.27)


8:34 PM

Lidocaine 1.5–5.0 g/mL 6.4–21.4 mol/L 1.5–2 1–1.5 60–80 1o hepatic

(SI  Conventional Units  4.23)


Procainamide 4–10 g/mL 17–42 mol/L 2–6 2–4 10–20 1o renal
Page 105

(SI  Conventional Units  3.61)


+
Procainamide 10–30 g/mL 36–108 mol/L 8 1o renal
N-acetyl
procainamide
(SI  Conventional Units  3.08)
Quinidine 2–5 g/mL 6–15 mol/L 6–8 2–3 70–90 Renal and
hepatic

105
* Conventional units.
CHF  congestive heart failure.
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106 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

DESCRIPTION & RATIONALE: Cardiac tion. Peak and trough collection times
glycosides are used in the prophylactic should be documented carefully in
management and treatment of heart relation to the time of medication
failure and ventricular and atrial administration. ■
arrhythmias. Because these drugs have
IMPORTANT NOTE: This information
narrow therapeutic windows, they must be communicated clearly and accu-
must be monitored closely. The signs rately to avoid misunderstanding of the
and symptoms of toxicity are often dose time in relation to the collection
difficult to distinguish from those of time. Miscommunication between the
cardiac disease. Patients with toxic lev- individual administering the medication
els may show gastrointestinal, ocular, and the individual collecting the speci-
and central nervous system effects and men is the most frequent cause of sub-
disturbances in potassium balance. therapeutic levels, toxic levels, and
Many factors must be considered in misleading information used in the calcu-
lation of future doses.
effective dosing and monitoring of
therapeutic drugs, including patient INDICATIONS:
age, patient weight, interacting med- • Assist in the diagnosis and prevention
ications, electrolyte balance, protein of toxicity
levels, water balance, conditions that • Monitor compliance with therapeutic
affect absorption and excretion, and regimen
the ingestion of substances (e.g., • Monitor patients who have a pace-
foods, herbals, vitamins, and miner- maker, who have impaired renal or
als) that can either potentiate or hepatic function, or who are taking
inhibit the intended target concentra- interacting drugs

RESULT

Level Result
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Digoxin Renal impairment, CHF, elderly patients
Disopyramide Renal impairment
Flecainide Renal impairment, CHF
Lidocaine Hepatic impairment, CHF
Procainamide Renal impairment
Quinidine Renal and hepatic impairment, CHF,
elderly patients

CHF  congestive heart failure.

CRITICAL VALUES: Adverse effects much medication. Note and immediately


of subtherapeutic levels are important. report to the health care practitioner any
Care should be taken to investigate the critically increased values and related
signs and symptoms of too little and too symptoms.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 107

Antiarrhythmic Drugs 107

Digoxin: Greater Than 2.5 ng/mL respiratory, and blood pressure moni-
toring.
Signs and symptoms of digoxin toxicity
include arrhythmias, anorexia, hyper- Lidocaine: Greater Than 6 g/mL
kalemia, nausea, vomiting, diarrhea,
changes in mental status, and visual dis- Signs and symptoms of lidocaine toxicity
turbances (objects appear yellow or have include slurred speech, central nervous
halos around them). Possible interven- system depression, cardiovascular depres-
tions include discontinuing the medica- sion, convulsions, muscle twitches, and
tion, continuous electrocardiographic possible coma. Possible interventions
(ECG) monitoring (prolonged P-R inter- include continuous ECG monitoring,
val, widening QRS interval, lengthening airway support, seizure precautions, and
Q-Tc interval, and atrioventricular hourly monitoring of temperature for
block), transcutaneous pacing, adminis- hyperthermia.
tration of activated charcoal (if the
patient has a gag reflex and central nerv- Procainamide: Greater Than
ous system function), support and treat- 12 g/mL; Procainamide
ment of electrolyte disturbance, and N-acetyl Procainamide:
administration of Digibind (digoxin Greater Than 30 g/mL
immune Fab). The amount of Digibind The active metabolite of procainamide is
given depends on the level of digoxin to N-acetyl procainamide (NAPA). Signs
be neutralized. Digoxin levels must be and symptoms of procainamide toxicity
measured before the administration of include torsades de pointes (ventricular
Digibind. Digoxin levels should not be tachycardia), nausea, vomiting, agranulo-
measured for several days after adminis- cytosis, and hepatic disturbances. Possible
tration of Digibind in patients with nor- interventions include airway protection,
mal renal function (1 week or longer in emesis, gastric lavage, and administration
patients with decreased renal function). of sodium lactate.
Digibind cross-reacts in the digoxin assay
and may provide misleading elevations or Quinidine: Greater Than 8 g/mL
decreases in values depending on the par-
ticular assay in use by the laboratory. Signs and symptoms of quinidine toxicity
include ataxia, nausea, vomiting, diar-
rhea, respiratory system depression, hypo-
Disopyramide: Greater
tension, syncope, anuria, arrhythmias
Than 7 g/mL (heart block, widening of QRS and Q-T
Signs and symptoms of disopyramide intervals), asystole, hallucinations, pares-
toxicity include prolonged Q-T interval, thesia, and irritability. Possible interven-
ventricular tachycardia, hypotension, and tions include airway support, emesis,
heart failure. Possible interventions gastric lavage, administration of activated
include discontinuing the medication, charcoal, administration of sodium lac-
airway support, and ECG and blood tate, and temporary transcutaneous or
pressure monitoring. transvenous pacemaker.

INTERFERING FACTORS:
Flecainide: Greater Than 1 g/mL
• Blood drawn in serum separator tubes
Signs and symptoms of flecainide toxi- (gel tubes).
city include exaggerated pharmacologic
effects resulting in arrhythmia. Possible • Contraindicated in patients with liver
interventions include discontinuing the disease, and caution advised in patients
medication as well as continuous ECG, with renal impairment.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 108

108 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Drugs that may increase digoxin levels immunoreactive substances usually


or increase risk of toxicity include have a condition related to salt and
amiodarone, amphotericin B, fluid retention, such as renal failure,
diclofenac, diltiazem, erythromycin, hepatic failure, low-renin hypertension,
propantheline, quinidine, spironolac- and pregnancy.
tone, tetracycline, and verapamil. • Unexpectedly low digoxin levels may
• Drugs that may decrease digoxin be found in patients with thyroid dis-
levels include aluminum hydroxide ease.
(antacids), cholestyramine, colestipol, • Disopyramide may cause a decrease in
kaolin-pectin, metoclopramide, neo- glucose levels. It may also potentiate
mycin, phenytoin, and sulfasalazine. the anticoagulating effects of warfarin.
• Drugs that may increase disopyramide • Long-term administration of pro-
levels or increase risk of toxicity include cainamide can cause false-positive
amiodarone and troleandomycin. antinuclear antibody results and devel-
opment of a lupus-like syndrome in
• Drugs that may decrease disopyramide some patients.
levels include rifampin.
• Quinidine may potentiate the effects of
• Drugs that may increase flecainide lev- neuromuscular blocking medications
els or increase risk of toxicity include and warfarin anticoagulants.
amiodarone and cimetidine.
• Concomitant administration of quini-
• Drugs that may increase lidocaine lev- dine and digoxin can rapidly raise
els or increase risk of toxicity include digoxin to toxic levels. If both drugs are
anticonvulsants, -blockers, cimeti- to be given together, the digoxin level
dine, metoprolol, nadolol, and propra- should be measured before the first
nolol. dose of quinidine and again in 4 to 6
days.
• Drugs that may increase procainamide
levels or increase risk of toxicity include
amiodarone, cimetidine, other antiar-
rhythmics, ranitidine, and trimetho- Nursing Implications and
prim. Procedure ● ● ● ● ● ● ● ● ● ● ●

• Drugs that may increase quinidine lev- Pretest:


els or increase risk of toxicity include
amiodarone, cimetidine, thiazide ➤ Inform the patient that the test is
diuretics, and verapamil. used to monitor for therapeutic and
toxic drug levels.
• Drugs that may decrease quinidine ➤ Obtain a history of the patient’s
levels include disopyramide, nifedip- complaints, including a list of known
ine, phenobarbital, phenytoin, and allergens (especially allergies or sen-
rifampin. sitivities to latex), and inform the
appropriate health care practitioner
• Digitoxin cross-reacts with digoxin; accordingly.
results are falsely elevated if digoxin is ➤ Obtain a history of the patient’s gen-
measured when the patient is taking itourinary and hepatobiliary systems
digitoxin. as well as results of previously per-
formed laboratory tests, surgical
• Digitalis-like immunoreactive sub- procedures, and other diagnostic
stances are found in the serum of some procedures. For related laboratory
patients who are not taking digoxin, tests, refer to the Genitourinary and
causing false-positive results. Patients Hepatobiliary Systems and Thera-
whose serum contain digitalis-like peutic/ Toxicology tables.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 109

Antiarrhythmic Drugs 109

➤ Obtain a list of the medications the ing or hematoma formation. Apply


patient is taking, including herbs, paper tape over gauze or replace
nutritional supplements, and nutra- with adhesive bandage.
ceuticals. Note the last time and ➤ Promptly transport the specimen to
dose of medication taken. The the laboratory for processing and
requesting health care practitioner analysis.
and laboratory should be advised if
the patient regularly uses these ➤ The results are recorded manually or
products so that their effects can be in a computerized system for recall
taken into consideration when and postprocedure interpretation by
reviewing results. the appropriate health care practi-
tioner.
➤ Review the procedure with the
patient. Inform the patient that spec-
imen collection takes approximately Post-test:
5 to 10 minutes. Address concerns
➤ Nutritional considerations include
about pain related to the procedure.
the avoidance of alcohol consump-
Explain to the patient that there may
tion.
be some discomfort during the
venipuncture. ➤ A written report of the examination
will be sent to the requesting health
➤ Sensitivity to cultural and social
care practitioner, who will discuss
issues, as well as concern for mod-
the results with the patient.
esty, is important in providing psy-
chological support before, during, ➤ Reinforce information given by the
and after the procedure. patient’s health care provider regard-
ing further testing, treatment, or
➤ There are no food, fluid, or medica-
referral to another health care
tion restrictions unless by medical
provider. Explain to the patient the
direction.
importance of following the medica-
tion regimen and instructions regard-
Intratest: ing drug interactions. Instruct the
patient to immediately report any
➤ If the patient has a history of severe unusual sensations (e.g., dizziness,
allergic reaction to latex, care should changes in vision, loss of appetite,
be taken to avoid the use of equip- nausea, vomiting, diarrhea, weak-
ment containing latex. ness, or irregular heartbeat) to his or
➤ Instruct the patient to cooperate fully her health care practitioner. Instruct
and to follow directions. Direct the the patient not to take medicine
patient to breathe normally and to within 1 hour of food high in fiber.
avoid unnecessary movement. Answer any questions or address
any concerns voiced by the patient
➤ Observe standard precautions, and
or family.
follow the general guidelines in
Appendix A. Consider recommended ➤ Instruct the patient to be prepared to
collection time in relation to the dos- provide the pharmacist with a list of
ing schedule. Positively identify the other medications he or she is
patient, and label the appropriate already taking in the event that the
tubes with the corresponding patient requesting health care practitioner
demographics, date, and time of prescribes a medication.
collection, noting the last dose of ➤ Depending on the results of this pro-
medication taken. Perform a veni- cedure, additional testing may be
puncture; collect the specimen in a performed to evaluate or monitor
5-mL red top tube. progression of the disease process
➤ Remove the needle, place a gauze and determine the need for a change
over the puncture site and apply gen- in therapy. Evaluate test results in
tle pressure to stop bleeding. relation to the patient’s symptoms
Observe venipuncture site for bleed- and other tests performed.
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110 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

cholesterol (total, HDL, and LDL),


Related laboratory tests:
creatine kinase and isoenzymes,
➤ Related laboratory tests include ala- creatinine, glucose, glycated hemo-
nine aminotransferase, albumin, globin, homocysteine, ionized
alkaline phosphatase, apolipoprotein calcium, ketones, lactate dehydroge-
A, apolipoprotein B, aspartate amino- nase and isoenzymes, magnesium,
transferase, atrial natriuretic peptide, myoglobin, platelet count, potas-
B-type natriuretic peptide, blood sium, triglycerides, troponin, and
gases, C-reactive protein, calcium, urea nitrogen.

ANTIBIOTIC DRUGS—
AMINOGLYCOSIDES:
AMIKACIN, GENTAMICIN,
TOBRAMYCIN; TRICYCLIC
GLYCOPEPTIDE: VANCOMYCIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS: Amikacin (Amikin); gentamicin (Garamycin, Genoptic,


Gentacidin, Gentafair, Gentak, Gentamar, Gentrasul, G-myticin, Oco-
Mycin, Spectro-Genta); tobramycin (Nebcin, Tobrex); vancomycin (Lyphocin,
Vancocin, Vancoled).

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Route of Recommended
Antibiotic Type Administration Collection Time*
Aminoglycosides
Amikacin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-
min IV infusion
Gentamicin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-
min IV infusion
Tobramycin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-
min IV infusion
Tricyclic glycopeptide
Vancomycin IV, PO Trough: immediately before next dose
Peak: 30-60 min after the end of a 60-
min IV infusion

* Usually after fifth dose if given every 8 hours or third dose if given every 12 hours.
IV  intravenous; IM  intramuscular; PO  by mouth.
Therapeutic Half- Distribution Volume of Protein
Drug Dose* SI Units Life (h) (L/kg) Binding (%) Excretion
(SI  Conventional Units  1.71)
Amikacin
Peak 20–30 g/mL 34–51 mol/L 4–8 0.4–1.3 50 1 renal
Trough 1–8 g/mL 2–14 mol/L
01Van Leewan(F) (1-188)

(SI  Conventional Units  2.09)


Gentamicin
(Standard
Dosing)
12/15/05

Peak 6–10 g/mL 12–21 mol/L 4–8 0.4–1.3 50 1 renal


Trough 0.5–1.5 g/mL 1–3 mol/L
(SI  Conventional Units  2.14)
Tobramycin
REFERENCE VALUE: (Method: Immunoassay)
8:34 PM

Peak 6–10 g/mL 13–21 mol/L 4–8 0.4–1.3 50 1 renal


Trough 0.5–1.5 g/mL 1–3 mol/L
(SI  Conventional Units  0.69)
Vancomycin
Peak 30–40 g/mL 21–28 mol/L 4–8 0.4–1.3 50 1 renal
Page 111

Trough 5–10 g/mL 3–7 mol/L


* Conventional units.

111
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112 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

DESCRIPTION & RATIONALE: The herbals, vitamins, and minerals) that


aminoglycoside antibiotics amikacin, can either potentiate or inhibit the
gentamicin, and tobramycin are used intended target concentration. The
against many gram-negative (Acineto- most serious side effects of the amino-
bacter, Citrobacter, Enterobacter, glycosides and vancomycin are
Escherichia coli, Klebsiella, Proteus, nephrotoxicity and irreversible oto-
Providencia, Pseudomonas, Salmonella, toxicity (uncommon). Peak and
Serratia, and Shigella) and some trough collection times should be
gram-positive (Staphylococcus aureus) documented carefully in relation to
pathogenic microorganisms. Amino- the time of medication administra-
glycosides are poorly absorbed tion. Creatinine levels should be mon-
through the gastrointestinal tract and itored every 2 to 3 days to detect renal
are most frequently administered impairment due to toxic drug levels. ■
intravenously.
Vancomycin is a tricyclic glycopep- IMPORTANT NOTE: This information
tide antibiotic used against many gram- must be clearly and accurately communi-
cated to avoid misunderstanding of the
positive microorganisms, such as
dose time in relation to the collection
staphylococci, Streptococcus pneumo- time. Miscommunication between the
niae, group A -hemolytic strepto- individual administering the medication
cocci, enterococci, Corynebacterium, and the individual collecting the specimen
and Clostridium. Vancomycin has also is the most frequent cause of subtherapeu-
been used in an oral form for the treat- tic levels, toxic levels, and misleading
ment of pseudomembranous colitis information used in the calculation of
resulting from Clostridium difficile in- future doses. Some pharmacies use a com-
fection. This approach is less frequently puterized pharmacokinetics approach to
used because of the emergence of van- dosing that eliminates the need to be con-
cerned about peak and trough collections;
comycin-resistant enterococci (VRE).
random specimens are adequate.
Many factors must be considered in
effective dosing and monitoring of INDICATIONS:
therapeutic drugs, including patient • Assist in the diagnosis and prevention
age, patient weight, interacting med- of toxicity
ications, electrolyte balance, protein • Monitor renal dialysis patients or
levels, water balance, conditions that patients with rapidly changing renal
affect absorption and excretion, and function
ingestion of substances (e.g., foods, • Monitor therapeutic regimen

RESULT
Level Result
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Amikacin Renal, hearing impairment
Gentamicin Renal, hearing impairment
Tobramycin Renal, hearing impairment
Vancomycin Renal, hearing impairment
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 113

Antibiotic Drugs 113

CRITICAL VALUES: The adverse Signs and symptoms of toxic levels of


effects of subtherapeutic levels are impor- these antibiotics are similar and include
tant. Care should be taken to investigate loss of hearing and decreased renal
signs and symptoms of too little and too function. The most important interven-
much medication. Note and immediately tion is accurate therapeutic drug moni-
report to the health care practitioner any toring so the medication can be discon-
critically increased or subtherapeutic val- tinued before irreversible damage is
ues and related symptoms. done.

Drug Name Toxic Levels


Amikacin Peak greater than 30 g/mL, trough greater than 8 g/mL
Gentamicin Peak greater than 12 g/mL, trough greater than 2 g/mL
Tobramycin Peak greater than 12 g/mL, trough greater than 2 g/mL
Vancomycin Peak greater than 80 g/mL, trough greater than 20 g/mL

INTERFERING FACTORS: of previously performed laboratory


• Blood drawn in serum separator tubes tests, surgical procedures, and other
diagnostic procedures. For related
(gel tubes).
laboratory tests, refer to the Genito-
• Contraindicated in patients with liver urinary System and Therapeutic/
disease, and caution advised in patients Toxicology tables.
with renal impairment. ➤ Obtain a list of the medications the
patient is taking, including herbs,
• Drugs that may decrease aminoglyco- nutritional supplements, and nutra-
side efficacy include bleomycin, ceuticals. Note the last time and
daunorubicin, doxorubicin, and peni- dose of medication taken. The re-
cillins (e.g., carbenicillin, piperacillin). questing health care practitioner and
laboratory should be advised if the
• Obtain a culture before and after the patient regularly uses such products
first dose of aminoglycosides. so that their effects can be taken into
• The risks of ototoxicity and nephrotox- consideration when reviewing results.
icity are increased by the concomitant ➤ Review the procedure with the
administration of aminoglycosides. patient. Inform the patient that spec-
imen collection takes approximately
5 to 10 minutes. Address concerns
about pain related to the procedure.
Nursing Implications and Explain to the patient that there may
Procedure ● ● ● ● ● ● ● ● ● ● ● be some discomfort during the
venipuncture.
Pretest: ➤ Sensitivity to cultural and social
➤ Inform the patient that the test is issues, as well as concern for mod-
used to monitor for therapeutic and esty, is important in providing psy-
toxic drug levels. chological support before, during,
and after the procedure.
➤ Obtain a history of the patient’s com-
plaints, including a list of known ➤ There are no food, fluid, or medica-
allergens (especially allergies or sen- tion restrictions unless by medical
sitivities to latex), and inform the direction.
appropriate health care practitioner
accordingly. Intratest:
➤ Obtain a history of the patient’s gen- ➤ If the patient has a history of severe
itourinary system as well as results allergic reaction to latex, care should
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 114

114 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

be taken to avoid the use of equip- the avoidance of alcohol consump-


ment containing latex. tion.
➤ Instruct the patient to cooperate fully ➤ Administer antibiotic therapy if
and to follow directions. Direct the ordered. Remind the patient of the
patient to breathe normally and to importance of completing the entire
avoid unnecessary movement. course of antibiotic therapy, even if
signs and symptoms disappear
➤ Observe standard precautions, and before completion of therapy.
follow the general guidelines in
Appendix A. Consider recommended ➤ A written report of the examination
collection time in relation to the dos- will be sent to the requesting health
ing schedule. Positively identify the care practitioner, who will discuss
patient and label the appropriate the results with the patient.
tubes with the corresponding patient ➤ Reinforce information given by the
demographics, date, and time of patient’s health care provider regard-
collection, noting the last dose of ing further testing, treatment, or
medication taken. Perform a veni- referral to another health care
puncture; collect the specimen in a provider. Explain to the patient the
5-mL red- or tiger-top tube. importance of following the medica-
➤ Remove the needle, place a gauze tion regimen and instructions regard-
over the puncture site and apply gen- ing food and drug interactions.
tle pressure to stop bleeding. Answer any questions or address
Observe venipuncture site for bleed- any concerns voiced by the patient
ing or hematoma formation. Apply or family.
paper tape over gauze or replace ➤ Instruct the patient to be prepared to
with adhesive bandage. provide the pharmacist with a list of
other medications he or she is
➤ Promptly transport the specimen to
already taking in the event that the
the laboratory for processing and
requesting health care practitioner
analysis.
prescribes a medication.
➤ The results are recorded manually or ➤ Depending on the results of this pro-
in a computerized system for recall cedure, additional testing may be
and postprocedure interpretation by performed to evaluate or monitor
the appropriate health care practi- progression of the disease process
tioner. and determine the need for a change
in therapy. Evaluate test results in
relation to the patient’s symptoms
Post-test:
and other tests performed.
➤ Instruct the patient receiving amino-
glycosides to immediately report any Related laboratory tests:
unusual symptoms (e.g., hearing ➤ Related laboratory tests include albu-
loss, decreased urinary output) to his min, blood urea nitrogen, creatinine,
or her health care practitioner. creatinine clearance, potassium, and
➤ Nutritional considerations include urinalysis.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 115

Antibodies, Anticytoplasmic Neutrophilic 115

ANTIBODIES, ANTICYTOPLASMIC
NEUTROPHILIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYMS: Cytoplasmic antineutrophil cytoplasmic antibody


(c-ANCA), perinuclear antineutrophil cytoplasmic antibody (p-ANCA).

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative.

• Distinguish between vasculitic disease


DESCRIPTION & RATIONALE: There and the effects of therapy
are two types of cytoplasmic neu-
trophil antibodies (ANCA), identified RESULT
by their cellular staining characteris-
tics. c-ANCA (cytoplasmic) is specific Increased in:
for proteinase 3 in neutrophils and • c-ANCA
monocytes and is found in the sera Wegener’s granulomatosis and its
of patients with Wegener’s granulo- variants
matosis. Wegener’s syndrome includes
• p-ANCA
granulomatous inflammation of the
Alveolar hemorrhage
upper and lower respiratory tract and
Angiitis and polyangiitis
vasculitis. p-ANCA (perinuclear) is
Autoimmune liver disease
specific for myeloperoxidase, elastase,
Capillaritis
and lactoferrin, as well as other
enzymes in neutrophils. p-ANCA is Churg-Strauss syndrome
present in the sera of patients with Felty’s syndrome
pauci-immune necrotizing glomeru- Inflammatory bowel disease
lonephritis. ■ Leukocytoclastic skin vasculitis
Necrotizing-crescentic
glomerulonephritis
INDICATIONS:
Rheumatoid arthritis
• Assist in the diagnosis of Wegener’s
granulomatosis and its variants Vasculitis

• Differential diagnosis of ulcerative colitis Decreased in: N/A


• Distinguish between biliary cirrhosis
and sclerosing cholangitis CRITICAL VALUES: N/A
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 116

116 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

INTERFERING FACTORS: N/A be taken to avoid the use of equip-


ment containing latex.
➤ Instruct the patient to cooperate
Nursing Implications and fully and to follow directions.
Direct the patient to breathe nor-
Procedure ● ● ● ● ● ● ● ● ● ● ●
mally and to avoid unnecessary
movement.
Pretest:
➤ Observe standard precautions, and
➤ Inform the patient that the test is follow the general guidelines in
used to assist in the diagnosis and Appendix A. Positively identify the
monitoring of inflammatory activity patient, and label the appropriate
in primary systemic small vessel vas- tubes with the corresponding patient
culitides. demographics, date, and time of col-
➤ Obtain a history of the patient’s com- lection. Perform a venipuncture; col-
plaints, including a list of known lect the specimen in a 5-mL red-top
allergens (especially allergies or sen- tube.
sitivities to latex), and inform the ➤ Remove the needle, place a gauze
appropriate health care practitioner over the puncture site and apply gen-
accordingly. tle pressure to stop bleeding.
➤ Obtain a history of the patient’s gas- Observe venipuncture site for bleed-
trointestinal, genitourinary, hepato- ing or hematoma formation. Apply
biliary, immune, and musculoskeletal paper tape over gauze or replace
systems and results of previously with adhesive bandage.
performed laboratory tests, surgical ➤ Promptly transport the specimen to
procedures, and other diagnostic the laboratory for processing and
procedures. For related laboratory analysis.
tests, refer to the Gastrointestinal,
Genitourinary, Hepatobiliary, Immune, ➤ The results are recorded manually or
and Musculoskeletal System tables. in a computerized system for recall
and postprocedure interpretation by
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and nutra-
ceuticals. The requesting health care
practitioner and laboratory should be Post-test:
advised if the patient regularly uses
these products so that their effects ➤ A written report of the examination
can be taken into consideration will be sent to the requesting health
when reviewing results. care practitioner, who will discuss
the results with the patient.
➤ Review the procedure with the
patient. Inform the patient that spec- ➤ Recognize anxiety related to test
imen collection takes approximately results, and be supportive of per-
5 to 10 minutes. Address concerns ceived loss of independence and
about pain related to the procedure. fear of shortened life expectancy.
Explain to the patient that there may Discuss the implications of abnormal
be some discomfort during the test results on the patient’s lifestyle.
venipuncture. Provide teaching and information
regarding the clinical implications of
➤ There are no food, fluid, or medica-
the test results, as appropriate.
tion restrictions unless by medical
Educate the patient regarding access
direction.
to counseling services.

Intratest: ➤ Reinforce information given by the


patient’s health care provider regard-
➤ If the patient has a history of severe ing further testing, treatment, or re-
allergic reaction to latex, care should ferral to another health care provider.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 117

Antibodies, Anti–Glomerular Basement Membrane 117

Answer any questions or address relation to the patient’s symptoms


any concerns voiced by the patient and other tests performed.
or family.
Related laboratory tests:
➤ Depending on the results of this pro-
cedure, additional testing may be ➤ Related laboratory tests include anti–
performed to evaluate or monitor glomerular basement membrane
progression of the disease process antibody, antimitochondrial antibody,
and determine the need for a change eosinophil count, kidney biopsy,
in therapy. Evaluate test results in rheumatoid factor, and urinalysis.

ANTIBODIES, ANTI–GLOMERULAR
BASEMENT MEMBRANE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Goodpasture’s antibody, anti-GBM.


SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Lung or kid-
ney tissue also may be submitted for testing. Refer to related biopsy mono-
graphs for specimen collection instructions.

REFERENCE VALUE: (Method: Direct or indirect immunofluorescence)


Negative.

INDICATIONS:
DESCRIPTION & RATIONALE: Good-
pasture syndrome is a rare hypersensi- • Differentiate glomerulonephritis caus-
tivity condition characterized by the ed by anti-GBM from glomeru-
lonephritis from other causes
presence of circulating anti–glomeru-
lar basement membrane antibodies in
the blood and the deposition of RESULT
immunoglobulin and complement
in renal basement membrane tissue.
Increased in:
Severe and progressive glomeru-
• Glomerulonephritis
lonephritis can result from the
presence of antibodies to renal • Goodpasture’s syndrome
glomerular basement membrane
(GBM). Autoantibodies may also be • Idiopathic pulmonary hemosiderosis
directed to act against lung tissue in
Goodpasture’s syndrome. ■ Decreased in: N/A
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 118

118 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

CRITICAL VALUES: N/A be taken to avoid the use of equip-


ment containing latex.
INTERFERING FACTORS: N/A ➤ Instruct the patient to cooperate
fully and to follow directions.
Direct the patient to breathe nor-
mally and to avoid unnecessary
Nursing Implications and movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Observe standard precautions, and
follow the general guidelines in
Pretest:
Appendix A. Positively identify the
➤ Inform the patient that the test is patient, and label the appropriate
used to assist in detection and tubes with the corresponding patient
monitoring of glomerular basement demographics, date, and time of
membrane antibodies present in collection. Perform a venipuncture;
Goodpasture’s syndrome. collect the specimen in a 5-mL red-
top tube.
➤ Obtain a history of the patient’s com-
plaints, including a list of known ➤ Remove the needle, place a gauze
allergens (especially allergies or sen- over the puncture site and apply gen-
sitivities to latex), and inform the tle pressure to stop bleeding.
appropriate health care practitioner Observe venipuncture site for bleed-
accordingly. ing or hematoma formation. Apply
➤ Obtain a history of the patient’s geni- paper tape over gauze or replace
tourinary, immune, and respiratory with adhesive bandage.
systems and results of previously ➤ Promptly transport the specimen to
performed laboratory tests, surgical the laboratory for processing and
procedures, and other diagnostic pro- analysis.
cedures. For related laboratory tests,
➤ The results are recorded manually or
refer to the Genitourinary, Immune,
in a computerized system for recall
and Respiratory System tables.
and postprocedure interpretation by
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and nutra-
ceuticals. The requesting health care Post-test:
practitioner and laboratory should be
advised if the patient regularly uses ➤ A written report of the examination
such products so that their effects will be sent to the requesting health
can be taken into consideration care practitioner, who will discuss
when reviewing results. the results with the patient.
➤ Review the procedure with the ➤ Recognize anxiety related to test
patient. Inform the patient that spec- results, and be supportive of per-
imen collection takes approximately ceived loss of independence and
5 to 10 minutes. Address concerns fear of shortened life expectancy.
about pain related to the procedure. Discuss the implications of abnormal
Explain to the patient that there may test results on the patient’s lifestyle.
be some discomfort during the Provide teaching and information
venipuncture. regarding the clinical implications of
the test results, as appropriate.
➤ There are no food, fluid, or medica- Educate the patient regarding access
tion restrictions unless by medical to counseling services.
direction.
➤ Reinforce information given by the
Intratest: patient’s health care provider regard-
ing further testing, treatment, or re-
➤ If the patient has a history of severe ferral to another health care provider.
allergic reaction to latex, care should Answer any questions or address
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 119

Antibodies, Antinuclear, Anti-DNA, and Anticentromere 119

any concerns voiced by the patient relation to the patient’s symptoms


or family. and other tests performed.
➤ Depending on the results of this pro- Related laboratory tests:
cedure, additional testing may be
performed to evaluate or monitor ➤ Related laboratory tests include anti-
progression of the disease process neutrophilic anti-cytoplasmic anti-
and determine the need for a change body, kidney biopsy, lung biopsy, and
in therapy. Evaluate test results in urinalysis.

ANTIBODIES, ANTINUCLEAR,
ANTI-DNA, AND ANTICENTROMERE
SYNONYMS/ACRONYMS: Antinuclear antibodies (ANA), anti-DNA
(anti-ds DNA).

SPECIMEN: Serum (2 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Indirect fluorescent antibody for ANA
and anticentromere; enzyme-linked immunosorbent assay [ELISA] for
anti-DNA)
ANA and anticentromere: titer of 1:40 or less

ANTI-DNA:

Negative Less than 24 IU eases. Antibodies against cellular DNA


Borderline 25–30 IU are strongly associated with SLE.
Positive 31–200 IU Anticentromere antibodies are a subset
Strong Greater than of ANA. Their presence is strongly
positive 200 IU associated with CREST syndrome
(calcinosis, Raynaud’s phenomenon,
esophageal dysfunction, sclerodactyly,
and telangiectasia). ANA and anticen-
DESCRIPTION & RATIONALE: Antinu- tromere antibodies are detected using
clear antibodies (ANA) are autoanti- Hep-2 cells (human epithelial cul-
bodies mainly located in the nucleus tured cells). Anti-DNA antibodies can
of affected cells. The presence of ANA be detected using a Crithidia luciliae
indicates systemic lupus erythemato- substrate. Women are much more
sus (SLE), related collagen vascular likely than men to be diagnosed
diseases, and immune complex dis- with SLE. ■
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120 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

INDICATIONS: • Evaluate suspected immune disorders,


such as rheumatoid arthritis, systemic
• Assist in the diagnosis and evaluation sclerosis, polymyositis, Sjögren’s syn-
of SLE drome, and mixed connective tissue dis-
ease

RESULT

ANA Pattern* Associated Antibody


Rim and/or homogeneous Double-stranded DNA
Single- or double-stranded DNA
Homogeneous Histones
Speckled Sm (Smith) antibody
RNP
SS-B/La, SS-A/Ro
Diffuse speckled with positive Centromere
mitotic figures
Nucleolar Nucleolar, RNP
*ANA patterns are helpful in that certain conditions are frequently associated with
specific patterns, but the patterns are not diagnostic for a particular disease.
RNP  ribonucleoprotein.

Increased in: • Inability of the patient to cooperate or


• Drug-induced lupus erythematosus remain still during the procedure
because of age, significant pain, or
• Lupoid hepatitis mental status may interfere with the
• Mixed connective tissue disease test results.

• Polymyositis
Nursing Implications and
• Progressive systemic sclerosis
Procedure ● ● ● ● ● ● ● ● ● ● ●

• Rheumatoid arthritis
Pretest:
• Sjögren’s syndrome
➤ Inform the patient that the test is
• SLE used to detect the presence of anti-
nuclear antibodies associated with a
Decreased in: N/A variety of musculoskeletal and con-
nective tissue diseases.
CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s com-
plaints, including a list of known
INTERFERING FACTORS: allergens (especially allergies or sen-
• Drugs that may cause positive sitivities to latex), and inform the
results include carbamazepine, chlor- appropriate health care practitioner
promazine, ethosuximide, hydralazine, accordingly.
isoniazid, mephenytoin, methyldopa, ➤ Obtain a history of the patient’s
penicillins, phenytoin, primidone, pro- immune and musculoskeletal sys-
cainamide, and quinidine. tems and results of previously per-
formed laboratory tests, surgical
• A patient can have lupus and test ANA procedures, and other diagnostic
negative. procedures. For related laboratory
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 121

Antibodies, Antinuclear, Anti-DNA, and Anticentromere 121

tests, refer to the Immune and in a computerized system for recall


Musculoskeletal System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the appropriate health care practi-
the patient is taking, including tioner.
herbs, nutritional supplements, and
nutraceuticals. The requesting health Post-test:
care practitioner and laboratory ➤ A written report of the examination
should be advised if the patient reg- will be sent to the requesting health
ularly uses these products so that care practitioner, who will discuss
their effects can be taken into con- the results with the patient.
sideration when reviewing results.
➤ Recognize anxiety related to test
➤ Review the procedure with the results, and be supportive of per-
patient. Inform the patient that spec- ceived loss of independence and fear
imen collection takes approximately of shortened life expectancy. Col-
5 to 10 minutes. Address concerns lagen and connective tissue diseases
about pain related to the procedure. are chronic and, as such, they must
Explain to the patient that there may be addressed on a continuous basis.
be some discomfort during the Discuss the implications of abnormal
venipuncture. test results on the patient’s lifestyle.
➤ There are no food, fluid, or medica- Provide teaching and information
tion restrictions unless by medical regarding the clinical implications of
direction. the test results, as appropriate.
Educate the patient regarding access
to counseling services.
Intratest: ➤ Educate the patient, as appropriate,
➤ If the patient has a history of severe regarding the importance of prevent-
allergic reaction to latex, care should ing infection, which is a significant
be taken to avoid the use of equip- cause of death in immunosup-
ment containing latex. pressed individuals.
➤ Reinforce information given by the
➤ Instruct the patient to cooperate fully patient’s health care provider regard-
and to follow directions. Direct the ing further testing, treatment, or
patient to breathe normally and to referral to another health care
avoid unnecessary movement. provider. Answer any questions or
➤ Observe standard precautions, and address any concerns voiced by the
follow the general guidelines in patient or family.
Appendix A. Positively identify the ➤ Depending on the results of this pro-
patient, and label the appropriate cedure, additional testing may be
tubes with the corresponding patient performed to evaluate or monitor
demographics, date, and time of col- progression of the disease process
lection. Perform a venipuncture; col- and determine the need for a change
lect the specimen in a 5-mL red-top in therapy. Evaluate test results in
tube. relation to the patient’s symptoms
➤ Remove the needle, place a gauze and other tests performed.
over the puncture site and apply gen-
tle pressure to stop bleeding. Related laboratory tests:
Observe venipuncture site for bleed-
ing or hematoma formation. Apply ➤ Related laboratory tests include anti-
paper tape over gauze or replace cardiolipin antibody, antisclerodermal
with adhesive bandage. antibodies, C3, C4, erythrocyte sedi-
mentation rate, extractable nuclear
➤ Promptly transport the specimen to
antibodies, Jo-1 antibody, kidney
the laboratory for processing and
biopsy, procainamide, rheumatoid
analysis.
factor, skin biopsy, and total com-
➤ The results are recorded manually or plement.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 122

122 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ANTIBODIES, ANTISCLERODERMA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Progressive systemic sclerosis antibody, Scl-70 anti-


body.

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative.

DESCRIPTION & RATIONALE: Antis- Nursing Implications and


cleroderma antibodies are associated Procedure ● ● ● ● ● ● ● ● ● ● ●

with progressive systemic sclerosis,


Pretest:
a condition that affects multiple
systems, including the skin, gastroin- ➤ Inform the patient that the test is
used in the differential diagnosis of
testinal tract, lungs, blood vessels,
scleroderma and other autoimmune
heart, and kidneys. These antibodies diseases of the musculoskeletal sys-
are present in the sera of patients tem.
with CREST syndrome (calcinosis, ➤ Obtain a history of the patient’s com-
Raynaud’s phenomenon, esophageal plaints, including a list of known
dysfunction, sclerodactyly, and telang- allergens (especially allergies or sen-
iectasia). ■ sitivities to latex), and inform the
appropriate health care practitioner
accordingly.
INDICATIONS: ➤ Obtain a history of the patient’s
immune and musculoskeletal sys-
• Assist in the diagnosis of scleroderma tems and results of previously per-
formed laboratory tests, surgical
RESULT procedures, and other diagnostic
procedures. For related laboratory
tests, refer to the Immune and
Increased in: Musculoskeletal System tables.
• CREST syndrome
➤ Obtain a list of the medications
• Progressive diffuse scleroderma the patient is taking, including
herbs, nutritional supplements, and
nutraceuticals. The requesting health
Decreased in: N/A care practitioner and laboratory
should be advised if the patient reg-
ularly uses these products so that
CRITICAL VALUES: N/A their effects can be taken into con-
sideration when reviewing results.
INTERFERING FACTORS: N/A ➤ Review the procedure with the
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Antibodies, Antiscleroderma 123

patient. Inform the patient that spec- care practitioner, who will discuss
imen collection takes approximately the results with the patient.
5 to 10 minutes. Address concerns
about pain related to the procedure. ➤ Recognize anxiety related to test
Explain to the patient that there may results, and be supportive of per-
be some discomfort during the ceived loss of independence and
venipuncture. fear of shortened life expectancy.
Collagen and connective tissue
➤ There are no food, fluid, or medica- diseases are chronic and, as such,
tion restrictions unless by medical they must be addressed on a con-
direction. tinuous basis. Discuss the impli-
cations of abnormal test results
Intratest: on the patient’s lifestyle. Provide
➤ If the patient has a history of severe teaching and information regarding
allergic reaction to latex, care should the clinical implications of the test
be taken to avoid the use of equip- results, as appropriate. Educate the
ment containing latex. patient regarding access to counsel-
➤ Instruct the patient to cooperate fully ing services.
and to follow directions. Direct the ➤ Educate the patient, as appropriate,
patient to breathe normally and to regarding the importance of prevent-
avoid unnecessary movement. ing infection, which is a significant
➤ Observe standard precautions, and cause of death in immunosup-
follow the general guidelines in pressed individuals.
Appendix A. Positively identify the
patient, and label the appropriate ➤ Reinforce information given by the
tubes with the corresponding patient patient’s health care provider regard-
demographics, date, and time of ing further testing, treatment, or
collection. Perform a venipuncture; referral to another health care pro-
collect the specimen in a 5-mL red- vider. Answer any questions or
top tube. address any concerns voiced by the
patient or family.
➤ Remove the needle, place a gauze
over the puncture site and apply gen- ➤ Depending on the results of this
tle pressure to stop bleeding. procedure, additional testing may
Observe venipuncture site for bleed- be performed to evaluate or moni-
ing or hematoma formation. Apply tor progression of the disease
paper tape over gauze or replace process and determine the need for
with adhesive bandage. a change in therapy. Evaluate test
➤ Promptly transport the specimen to results in relation to the patient’s
the laboratory for processing and symptoms and other tests per-
analysis. formed.
➤ The results are recorded manually or
in a computerized system for recall
and postprocedure interpretation by Related laboratory tests:
the appropriate health care practi-
➤ Related laboratory tests include anti-
tioner.
centromere antibodies, anti-DNA
antibodies, antinuclear antibodies,
Post-test: extractable nuclear antibodies, Jo-1
➤ A written report of the examination antibody, kidney biopsy, rheumatoid
will be sent to the requesting health factor, and skin biopsy.
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124 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ANTIBODIES, ANTISPERM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Immunoassay)

Sperm Bound by CRITICAL VALUES: N/A


Result Immunobead (%)
INTERFERING FACTORS:
Negative 0–15 • The patient should not ejaculate for 3
Weak 16–30 to 4 days before specimen collection if
positive semen will be evaluated.
Moderate 31–50
positive • Sperm antibodies have been detected in
Strong positive 51–100 pregnant women and in women with
primary infertility.

Nursing Implications and


DESCRIPTION & RATIONALE: A major
Procedure ● ● ● ● ● ● ● ● ● ● ●
cause of infertility in men is blocked
efferent testicular ducts. As a result of Pretest:
the reabsorption of sperm from the
blocked ducts, antibodies against the ➤ Inform the patient that the test is
used in the evaluation of infertility
sperm may be produced over time and and guidance through assisted repro-
thereby may lower the patient’s fertil- ductive techniques.
ity. Semen and cervical mucus can also ➤ Obtain a history of the patient’s com-
be tested for antisperm antibodies. ■ plaints, including a list of known
allergens (especially allergies or sen-
sitivities to latex), and inform the
INDICATIONS: appropriate health care practitioner
• Evaluation of infertility accordingly.
➤ Obtain a history of the patient’s
RESULT immune and reproductive systems
and results of previously performed
Increased in: laboratory tests, surgical procedures,
• Blocked testicular efferent duct and other diagnostic procedures. For
related laboratory tests, refer to the
• Postvasectomy Immune and Reproductive System
tables.
Decreased in: N/A ➤ Obtain a list of the medications the
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Antibodies, Antisperm 125

patient is taking, including herbs, paper tape over gauze or replace


nutritional supplements, and nutra- with adhesive bandage.
ceuticals. The requesting health care ➤ Promptly transport the specimen to
practitioner and laboratory should be the laboratory for processing and
advised if the patient regularly uses analysis.
these products so that their effects
can be taken into consideration ➤ The results are recorded manually or
when reviewing results. in a computerized system for recall
and postprocedure interpretation by
➤ Review the procedure with the the appropriate health care practi-
patient. Inform the patient that tioner.
specimen collection takes approxi-
mately 5 to 10 minutes and that addi-
Post-test:
tional specimens may be required.
Address concerns about pain rela- ➤ A written report of the examination
ted to the procedure. Explain to will be sent to the requesting health
the patient that there may be some care practitioner, who will discuss
discomfort during the venipuncture. the results with the patient.
➤ Sensitivity to social and cultural ➤ Recognize anxiety related to test
issues, as well as concern for mod- results. Discuss the implications of
esty, is important in providing psy- abnormal test results on the patient’s
chological support before, during, lifestyle. Educate the patient regard-
and after the procedure. ing access to counseling services.
➤ There are no food, fluid, or medica- Provide a supportive, nonjudgmen-
tion restrictions unless by medical tal environment when assisting a
direction. patient through the process of fertil-
ity testing. Educate the patient
Intratest: regarding access to counseling serv-
ices, as appropriate.
➤ If the patient has a history of severe ➤ Reinforce information given by the
allergic reaction to latex, care should patient’s health care provider regard-
be taken to avoid the use of equip- ing further testing, treatment, or re-
ment containing latex. ferral to another health care provider.
➤ Instruct the patient to cooperate fully Answer any questions or address
and to follow directions. Direct the any concerns voiced by the patient
patient to breathe normally and to or family.
avoid unnecessary movement. ➤ Depending on the results of this pro-
➤ Observe standard precautions, and cedure, additional testing may be
follow the general guidelines in performed to evaluate or monitor
Appendix A. Positively identify the progression of the disease process
patient, and label the appropriate and determine the need for a change
tubes with the corresponding patient in therapy. Evaluate test results in
demographics, date, and time of col- relation to the patient’s symptoms
lection. Perform a venipuncture; and other tests performed.
collect the specimen in a 5-mL red-
top tube.
Related laboratory tests:
➤ Remove the needle, place a gauze
over the puncture site and apply gen- ➤ Related laboratory tests include
tle pressure to stop bleeding. human chorionic gonadotropin,
Observe venipuncture site for bleed- luteinizing hormone, progesterone,
ing or hematoma formation. Apply semen analysis, and testosterone.
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126 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ANTIBODIES, ANTISTREPTOLYSIN O
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: Streptozyme, ASO.


SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Nephelometry) Less than 200 IU/mL.

DESCRIPTION & RATIONALE: Group Decreased in: N/A


A -hemolytic streptococci secrete the
enzyme streptolysin O, which can CRITICAL VALUES: N/A
destroy red blood cells. The enzyme
acts as an antigen and stimulates the INTERFERING FACTORS:
immune system to develop strep- • Drugs that may decrease ASO titers
tolysin O antibodies. These antistrep- include antibiotics and corticosteroids,
because therapy suppresses antibody
tolysin O (ASO) antibodies occur
response.
within 1 month after the onset of a
streptococcal infection. Detection of
the antibody over several weeks Nursing Implications and
strongly suggests exposure to group A Procedure ● ● ● ● ● ● ● ● ● ● ●

-hemolytic streptococci. ■
Pretest:
INDICATIONS: ➤ Inform the patient that the test is
• Assist in establishing a diagnosis of used to document exposure to group
streptococcal infection A streptococci bacteria.
• Evaluate patients with streptococcal ➤ Obtain a history of the patient’s com-
infections for the development of acute plaints, including a list of known
rheumatic fever or nephritis allergens (especially allergies or sen-
sitivities to latex), and inform the
• Monitor response to therapy in strepto- appropriate health care practitioner
coccal illnesses accordingly.
➤ Obtain a history of the patient’s
RESULT immune system and results of previ-
ously performed laboratory tests,
Increased in: surgical procedures, and other diag-
• Endocarditis nostic procedures. For related labo-
ratory tests, refer to the Immune
• Glomerulonephritis System table.
• Rheumatic fever ➤ Obtain a list of the medications
the patient is taking, including
• Scarlet fever herbs, nutritional supplements, and
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Antibodies, Antistreptolysin O 127

nutraceuticals. The requesting health ➤ Promptly transport the specimen to


care practitioner and laboratory the laboratory for processing and
should be advised if the patient reg- analysis.
ularly uses these products so that ➤ The results are recorded manually or
their effects can be taken into con- in a computerized system for recall
sideration when reviewing results. and postprocedure interpretation by
➤ Review the procedure with the the appropriate health care practi-
patient. Inform the patient that spec- tioner.
imen collection takes approximately
5 to 10 minutes. Address concerns Post-test:
about pain related to the procedure.
Explain to the patient that there may ➤ Administer antibiotics as ordered.
be some discomfort during the Remind the patient of the impor-
venipuncture. tance of completing the entire
➤ There are no food, fluid, or medica- course of antibiotic therapy even if
tion restrictions unless by medical signs and symptoms disappear
direction. before completion of therapy.
➤ A written report of the examination
Intratest: will be sent to the requesting health
care practitioner, who will discuss
➤ If the patient has a history of severe
the results with the patient.
allergic reaction to latex, care should
be taken to avoid the use of equip- ➤ Reinforce information given by the
ment containing latex. patient’s health care provider regard-
➤ Instruct the patient to cooperate fully ing further testing, treatment, or
and to follow directions. Direct the referral to another health care
patient to breathe normally and to provider. Answer any questions or
avoid unnecessary movement. address any concerns voiced by the
patient or family.
➤ Observe standard precautions, and
follow the general guidelines in ➤ Depending on the results of this
Appendix A. Positively identify the procedure, additional testing may be
patient, and label the appropriate performed to evaluate or monitor
tubes with the corresponding patient progression of the disease process
demographics, date, and time of and determine the need for a change
collection. Perform a venipuncture; in therapy. Evaluate test results in
collect the specimen in a 5-mL red- relation to the patient’s symptoms
top tube. and other tests performed.
➤ Remove the needle, place a gauze
over the puncture site and apply gen- Related laboratory tests:
tle pressure to stop bleeding.
Observe venipuncture site for bleed- ➤ Related laboratory tests include
ing or hematoma formation. Apply group A streptococcal screen, strep-
paper tape over gauze or replace tococcal anti-DNAse B, and throat
with adhesive bandage. culture.
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128 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ANTIBODIES, ANTITHYROGLOBULIN
AND ANTITHYROID PEROXIDASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Thyroid antibodies, antithyroid peroxidase antibod-


ies (thyroid peroxidase [TPO] antibodies were previously called thyroid
antimicrosomal antibodies).

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Radioimmunoassay)

Conventional SI Units (Conversion


Antibody Units Factor  1)
Antithyroglobulin Less than 0.3 U/mL Less than 0.3 kU/L
antibody
Antiperoxidase Less than 0.3 U/mL Less than 0.3 kU/L
antibody

• Assist in the diagnosis of suspected


DESCRIPTION & RATIONALE: Thyroid hypothyroidism caused by thyroid tis-
antibodies are mainly immunoglobu- sue destruction
lin G–type antibodies. Antithyroid • Assist in the diagnosis of suspected thy-
peroxidase antibodies bind with roid autoimmunity in patients with
microsomal antigens on cells lining other autoimmune disorders
the microsomal membrane. They are
thought to destroy thyroid tissue as a
result of stimulation by lymphocytic RESULT
killer cells. These antibodies are pres- Increased in:
ent in hypothyroid and hyperthyroid
• Autoimmune disorders
conditions. Antithyroglobulin anti-
bodies are autoantibodies directed • Graves’ disease
against thyroglobulin. The function of • Goiter
these antibodies is unclear. Both tests
• Hashimoto’s thyroiditis
are normally requested together. ■
• Idiopathic myxedema
INDICATIONS: • Pernicious anemia
• Assist in confirming suspected inflam-
mation of thyroid gland • Thyroid carcinoma
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Antibodies, Antithyroglobulin and Antithyroid Peroxidase 129

Decreased in: N/A Explain to the patient that there may


be some discomfort during the
venipuncture.
CRITICAL VALUES: N/A
➤ There are no food, fluid, or medica-
INTERFERING FACTORS: tion restrictions unless by medical
direction.
• Lithium may increase thyroid antibody
levels.
Intratest:
• Recent radioactive scans or radiation
within 1 week before the test can inter- ➤ If the patient has a history of severe
fere with test results when radioim- allergic reaction to latex, care should
be taken to avoid the use of equip-
munoassay is the test method. ment containing latex.
➤ Instruct the patient to cooperate fully
and to follow directions. Direct the
Nursing Implications and patient to breathe normally and to
Procedure ● ● ● ● ● ● ● ● ● ● ● avoid unnecessary movement.
➤ Observe standard precautions, and
Pretest: follow the general guidelines in
➤ Inform the patient that the test is used Appendix A. Positively identify the
to assess thyroid gland function. patient, and label the appropriate
tubes with the corresponding patient
➤ Obtain a history of the patient’s demographics, date, and time of
complaints, including a list of known collection. Perform a venipuncture;
allergens (especially allergies or sen- collect the specimen in a 5-mL red-
sitivities to latex), and inform the top tube.
appropriate health care practitioner
accordingly. ➤ Remove the needle, place a gauze
over the puncture site and apply gen-
➤ Obtain a history of the patient’s
tle pressure to stop bleeding.
endocrine and immune system and
Observe venipuncture site for bleed-
results of previously performed labo-
ing or hematoma formation. Apply
ratory tests, surgical procedures, and
paper tape over gauze or replace
other diagnostic procedures. For
with adhesive bandage.
related laboratory tests, refer to the
Endocrine and Immune System ➤ Promptly transport the specimen to
tables. the laboratory for processing and
analysis.
➤ Obtain a list of the medications
the patient is taking, including ➤ The results are recorded manually or
herbs, nutritional supplements, and in a computerized system for recall
nutraceuticals. The requesting health and postprocedure interpretation by
care practitioner and laboratory the appropriate health care practi-
should be advised if the patient tioner.
regularly uses these products so
that their effects can be taken into
consideration when reviewing
Post-test:
results. ➤ A written report of the examination
➤ Note any recent procedures that can will be sent to the requesting health
interfere with test results. care practitioner, who will discuss
the results with the patient.
➤ Review the procedure with the
patient. Inform the patient that spec- ➤ Reinforce information given by the
imen collection takes approximately patient’s health care provider regard-
5 to 10 minutes. Address concerns ing further testing, treatment, or re-
about pain related to the procedure. ferral to another health care provider.
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130 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Answer any questions or address relation to the patient’s symptoms


any concerns voiced by the patient and other tests performed.
or family.
Related laboratory tests:
➤ Depending on the results of this pro-
cedure, additional testing may be ➤ Related laboratory tests include com-
performed to evaluate or monitor plete blood count, thyroid biopsy,
progression of the disease process thyroid-stimulating hormone, free
and determine the need for a change thyroxine, thyroxine, and triiodothyro-
in therapy. Evaluate test results in nine.

ANTIBODIES, CARDIOLIPIN,
IMMUNOGLOBULIN G, AND
IMMUNOGLOBULIN M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYMS: Antiphospholipid antibody, lupus anticoagulant,


LA, ACA.

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Immunoassay, enzyme-linked immunosorbent
assay [ELISA]) Negative.

DESCRIPTION & RATIONALE: Cardi- Cardiolipin antibodies are often


olipin antibody is one of several iden- found in association with lupus anti-
tified antiphospholipid antibodies. coagulant. Increased antiphospholipid
These antibodies react with proteins antibody levels have been found in
in the blood that are bound to phos- pregnant women with lupus who
pholipid and interfere with normal have had miscarriages. The com-
blood vessel function. The two pri- bination of noninflammatory throm-
mary types of problems they cause are bosis of blood vessels, low platelet
narrowing and irregularity of the count, and history of miscarriage is
blood vessels and blood clots in the termed antiphospholipid antibody syn-
blood vessels. Cardiolipin antibodies drome. ■
are found in individuals with lupus
erythematosus, lupus-related condi- INDICATIONS:
tions, infectious diseases, drug reac- • Assist in the diagnosis of antiphospho-
tions, and sometimes fetal loss. lipid antibody syndrome
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 131

Antibodies, Cardiolipin, Immunoglobulin G, and Immunoglobulin M 131

RESULT ➤ Obtain a history of the patient’s


hematopoietic, immune, and repro-
ductive systems and results of pre-
Increased in:
viously performed laboratory tests,
• Antiphospholipid antibody syndrome surgical procedures, and other diag-
nostic procedures. For related labora-
• Chorea
tory tests, refer to the Hematopoietic,
• Drug reactions Immune, and Reproductive System
tables.
• Epilepsy
➤ Obtain a list of the medications
• Infectious diseases the patient is taking, including
herbs, nutritional supplements, and
• Mitral valve endocarditis nutraceuticals. The requesting health
care practitioner and laboratory
• Patients with lupus-like symptoms
should be advised if the patient
(often antinuclear antibody negative) regularly uses these products so
• Placental infarction that their effects can be taken
into consideration when reviewing
• Recurrent fetal loss (strong association results.
with two or more occurrences) ➤ Review the procedure with the
• Recurrent venous and arterial throm- patient. Inform the patient that spec-
boses imen collection takes approximately
5 to 10 minutes. Address concerns
about pain related to the procedure.
Decreased in: N/A Explain to the patient that there
may be some discomfort during the
CRITICAL VALUES: N/A venipuncture.
➤ There are no food, fluid, or medica-
INTERFERING FACTORS: Cardiolipin tion restrictions unless by medical
antibody is partially cross-reactive with direction.
syphilis reagin antibody and lupus anti-
coagulant. False-positive rapid plasma Intratest:
reagin results may occur.
➤ If the patient has a history of severe
allergic reaction to latex, care should
be taken to avoid the use of equip-
Nursing Implications and ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Instruct the patient to cooperate fully
and to follow directions. Direct the
Pretest: patient to breathe normally and to
➤ Inform the patient that the test is avoid unnecessary movement.
used to detect the presence of ➤ Observe standard precautions, and
antiphospholipid antibodies, which follow the general guidelines in
can lead to the development of blood Appendix A. Positively identify the
vessel problems, complications of patient, and label the appropriate
which include stroke, heart attack, tubes with the corresponding patient
and miscarriage. demographics, date, and time of col-
➤ Obtain a history of the patient’s com- lection. Perform a venipuncture;
plaints, including a list of known collect the specimen in a 5-mL red-
allergens (especially allergies or sen- top tube.
sitivities to latex), and inform the ➤ Remove the needle, place a gauze
appropriate health care practitioner over the puncture site and apply gen-
accordingly. tle pressure to stop bleeding.
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132 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Observe venipuncture site for bleed- Educate the patient regarding access
ing or hematoma formation. Apply to counseling services. Provide con-
paper tape over gauze or replace tact information, if desired, for the
with adhesive bandage. Lupus Foundation of America (http://
➤ Promptly transport the specimen to www.lupus.org).
the laboratory for processing and ➤ Reinforce information given by
analysis. the patient’s health care provider
➤ The results are recorded manually regarding further testing, treatment,
or in a computerized system for or referral to another health care
recall and postprocedure interpreta- provider. Answer any questions or
tion by the appropriate health care address any concerns voiced by the
practitioner. patient or family.
➤ Depending on the results of this pro-
cedure, additional testing may be
Post-test: performed to evaluate or monitor
➤ A written report of the examination progression of the disease process
will be sent to the requesting health and determine the need for a change
care practitioner, who will discuss in therapy. Evaluate test results in
the results with the patient. relation to the patient’s symptoms
and other tests performed.
➤ Recognize anxiety related to test
results, and be supportive of fear of Related laboratory tests:
shortened life expectancy. Discuss
the implications of abnormal test ➤ Related laboratory tests include anti-
results on the patient’s lifestyle. nuclear antibodies, complete blood
Provide teaching and information count, fibrinogen, lupus anticoagul-
regarding the clinical implications of ant antibodies, platelet count, protein
the test results, as appropriate. C, protein S, and syphilis serology.

ANTIBODIES, GLIADIN
(IMMUNOGLOBULIN G AND
IMMUNOGLOBULIN A)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYMS: Endomysial antibodies, gliadin (IgG and IgA)


antibodies, EMA.

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Immunoassay)
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 133

Antibodies, Gliadin (Immunoglobulin G, and Immunoglobulin A) 133

Gliadin Conventional INTERFERING FACTORS:


Antibody Units • Conditions other than gluten-sensitive
enteropathy can result in elevated anti-
IgA Less than 5 U body levels without corresponding his-
IgG Less than 57 U tologic evidence. These conditions
include Crohn’s disease, postinfection
malabsorption, and food protein intol-
erance.
DESCRIPTION & RATIONALE: Gliadin • A negative IgA gliadin result, especially
is a water-soluble protein found in the with a positive IgG gliadin result in an
gluten of wheat, rye, oats, and barley. untreated patient, does not rule out
The intestinal mucosa of certain indi- active gluten-sensitive enteropathy.
viduals does not digest gluten, allow-
ing a toxic buildup of gliadin. Nursing Implications and
Antibodies to gliadin form and result Procedure ● ● ● ● ● ● ● ● ● ● ●

in damage to the intestinal mucosa. In


severe cases, intestinal mucosa can be Pretest:
lost. Immunoglobulin G (IgG) and ➤ Inform the patient that the test is
immunoglobulin A (IgA) gliadin anti- used to assist in the diagnosis
bodies are detectable in the serum of and monitoring of gluten-sensitive
patients with gluten-sensitive enter- enteropathies.
opathy. ■ ➤ Obtain a history of the patient’s com-
plaints, including a list of known
allergens (especially allergies or sen-
INDICATIONS: sitivities to latex), and inform the
• Assist in the diagnosis of asymptomatic appropriate health care practitioner
gluten-sensitive enteropathy in some accordingly.
patients with dermatitis herpetiformis ➤ Obtain a history of the patient’s gas-
• Assist in the diagnosis of gluten- trointestinal and immune systems as
well as results of previously per-
sensitive enteropathies formed laboratory tests, surgical
• Assist in the diagnosis of nontropical procedures, and other diagnostic
sprue procedures. For related laboratory
tests, refer to the Gastrointestinal
• Monitor dietary compliance of patients and Immune System tables.
with gluten-sensitive enteropathies ➤ Obtain a list of foods and medica-
tions the patient is taking, including
RESULT herbs, nutritional supplements, and
nutraceuticals. The requesting health
care practitioner and laboratory
Increased in:
should be advised if the patient reg-
• Asymptomatic gluten-sensitive entero- ularly uses these products so that
pathy their effects can be taken into con-
sideration when reviewing results.
• Celiac disease
➤ Review the procedure with the
• Dermatitis herpetiformis patient. Inform the patient that spec-
imen collection takes approximately
• Nontropical sprue 5 to 10 minutes. Address concerns
about pain related to the procedure.
Decreased in: N/A Explain to the patient that there may
be some discomfort during the
CRITICAL VALUES: N/A venipuncture.
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134 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ There are no food, fluid, or medica- ings to consult with a qualified nutri-
tion restrictions unless by medical tionist to plan a gluten-free diet. This
direction. dietary planning is complex because
patients are often malnourished and
Intratest: have other related nutritional prob-
lems.
➤ If the patient has a history of severe
➤ A written report of the examination
allergic reaction to latex, care should
will be sent to the requesting health
be taken to avoid the use of equip-
care practitioner, who will discuss
ment containing latex.
the results with the patient.
➤ Instruct the patient to cooperate fully
and to follow directions. Direct the ➤ Recognize anxiety related to test
patient to breathe normally and to results, and offer support. Discuss
avoid unnecessary movement. the implications of abnormal test
results on the patient’s lifestyle.
➤ Observe standard precautions, and Provide teaching and information
follow the general guidelines in regarding the clinical implications of
Appendix A. Positively identify the the test results, as appropriate.
patient, and label the appropriate Educate the patient regarding access
tubes with the corresponding patient to appropriate counseling services.
demographics, date, and time of col-
lection. Perform a venipuncture; col- ➤ Reinforce information given by the
lect the specimen in a 5-mL red-top patient’s health care provider regard-
tube. ing further testing, treatment, or
➤ Remove the needle, place a gauze referral to another health care
over the puncture site and apply gen- provider. Answer any questions or
tle pressure to stop bleeding. address any concerns voiced by the
Observe venipuncture site for bleed- patient or family.
ing or hematoma formation. Apply ➤ Depending on the results of this
paper tape over gauze or replace procedure, additional testing may be
with adhesive bandage. performed to evaluate or monitor
➤ Promptly transport the specimen to progression of the disease process
the laboratory for processing and and determine the need for a change
analysis. in therapy. Evaluate test results in
relation to the patient’s symptoms
➤ The results are recorded manually or
and other tests performed.
in a computerized system for recall
and postprocedure interpretation by
the appropriate health care practi- Related laboratory tests:
tioner.
➤ Related laboratory tests include albu-
Post-test: min, calcium, D-xylose tolerance
test, electrolytes, fecal analysis,
➤ Nutritional considerations: Encour- fecal fat, folic acid, iron, lactose tol-
age the patient with abnormal find- erance test, and skin biopsy.

ANTIBODY, ANTIMITOCHONDRIAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: AMA.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 135

Antibody, Antimitochondrial 135

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative or titer
less than 1:20.

allergens (especially allergies or sen-


DESCRIPTION & RATIONALE: Anti- sitivities to latex), and inform the
appropriate health care practitioner
mitochondrial antibodies are found in accordingly.
90% of patients with primary biliary
➤ Obtain a history of the patient’s
cirrhosis (PBC). PBC is identified hepatobiliary and immune systems,
most frequently in women ages 35 to as well as results of previously
60 years. Testing is useful in the dif- performed laboratory tests, surgical
ferential diagnosis of chronic liver dis- procedures, and other diagnostic
ease as antimitochondrial antibodies procedures. For related laboratory
tests, refer to the Hepatobiliary and
are rarely detected in extrahepatic bil- Immune System tables.
iary obstruction, various forms of
➤ Obtain a list of the medications the
hepatitis, and cirrhosis. ■ patient is taking, including herbs,
nutritional supplements, and nutra-
INDICATIONS: ceuticals. The requesting health care
• Assist in the diagnosis of PBC practitioner and laboratory should be
advised if the patient regularly uses
• Assist in the differential diagnosis of these products so that their effects
chronic liver disease can be taken into consideration
when reviewing results.
RESULT ➤ Review the procedure with the
patient. Inform the patient that spec-
Increased in:
imen collection takes approximately
• Hepatitis (alcoholic, viral) 5 to 10 minutes. Address concerns
• PBC about pain related to the procedure.
Explain to the patient that there may
• Rheumatoid arthritis (occasionally) be some discomfort during the
• Systemic lupus erythematosus (occa- venipuncture.
sionally) ➤ There are no food, fluid, or medica-
• Thyroid disease (occasionally) tion restrictions unless by medical
direction.
Decreased in: N/A
Intratest:
CRITICAL VALUES: N/A ➤ If the patient has a history of severe
allergic reaction to latex, care should
INTERFERING FACTORS: N/A be taken to avoid the use of equip-
ment containing latex.
Nursing Implications and ➤ Instruct the patient to cooperate fully
Procedure ● ● ● ● ● ● ● ● ● ● ●
and to follow directions. Direct the
patient to breathe normally and to
avoid unnecessary movement.
Pretest:
➤ Observe standard precautions, and
➤ Inform the patient that the test is follow the general guidelines in
used in the differential diagnosis of Appendix A. Positively identify the
chronic liver disease. patient, and label the appropriate
➤ Obtain a history of the patient’s com- tubes with the corresponding patient
plaints, including a list of known demographics, date, and time of col-
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136 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

lection. Perform a venipuncture; plex carbohydrates (e.g., starch,


collect the specimen in a 5-mL red- fiber, and glycogen [animal carbohy-
top tube. drates]) and complex fats, which
➤ Remove the needle, place a gauze would require additional bile to emul-
over the puncture site and apply gen- sify them so that they could be used.
tle pressure to stop bleeding. Observe the cirrhotic patient care-
Observe venipuncture site for bleed- fully for the development of ascites;
ing or hematoma formation. Apply if ascites develops, pay strict atten-
paper tape over gauze or replace tion to fluid and electrolyte balance.
with adhesive bandage. ➤ A written report of the examination
➤ Promptly transport the specimen to will be sent to the requesting health
the laboratory for processing and care practitioner, who will discuss
analysis. the results with the patient.
➤ The results are recorded manually or ➤ Reinforce information given by the
in a computerized system for recall patient’s health care provider regard-
and postprocedure interpretation by ing further testing, treatment, or
the appropriate health care practi- referral to another health care pro-
tioner. vider. Answer any questions or
address any concerns voiced by the
Post-test: patient or family.
➤ Depending on the results of this pro-
➤ Nutritional considerations: The pres-
cedure, additional testing may be
ence of antimitochondrial antibodies
performed to evaluate or monitor
may be associated with liver dis-
progression of the disease process
ease. Dietary recommendations may
and determine the need for a change
be indicated and vary depending on
in therapy. Evaluate test results in
the severity of the condition. A low-
relation to the patient’s symptoms
protein diet may be in order if the
and other tests performed.
liver cannot process the end prod-
ucts of protein metabolism. A diet of
soft foods may be required if Related laboratory tests:
esophageal varices have developed.
Ammonia levels may be used to ➤ Related laboratory tests include albu-
determine whether protein should min, alkaline phosphatase, ammo-
be added to or reduced from the nia, anticytoplasmic neutrophilic
diet. Patients should be encouraged antibodies, antinuclear antibodies,
to eat simple carbohydrates and anti–smooth muscle antibodies,
emulsified fats (as in homogenized bilirubin, electrolytes, -glutamyl
milk or eggs), as opposed to com- transpeptidase, and liver biopsy.

ANTIBODY, ANTI–SMOOTH MUSCLE


● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: ASMA.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 137

Antibody, Anti–Smooth Muscle 137

herbs, nutritional supplements, and


DESCRIPTION & RATIONALE: Anti– nutraceuticals. The requesting health
smooth muscle antibodies are autoan- care practitioner and laboratory
should be advised if the patient reg-
tibodies found in high titers in the ularly uses these products so that
sera of patients with autoimmune their effects can be taken into con-
diseases of the liver and bile duct. sideration when reviewing results.
Simultaneous testing for antimito- ➤ Review the procedure with the
chondrial antibodies can be useful in patient. Inform the patient that spec-
the differential diagnosis of chronic imen collection takes approximately
5 to 10 minutes. Address concerns
liver diesease. ■
about pain related to the procedure.
Explain to the patient that there
INDICATIONS: may be some discomfort during the
• Differential diagnosis of liver disease venipuncture.
➤ There are no food, fluid, or medica-
RESULT tion restrictions unless by medical
direction.
Increased in:
• Autoimmune hepatitis
Intratest:
• Chronic active viral hepatitis
➤ If the patient has a history of severe
• Infectious mononucleosis allergic reaction to latex, care should
be taken to avoid the use of equip-
Decreased in: N/A ment containing latex.

CRITICAL VALUES: N/A ➤ Instruct the patient to cooperate fully


and to follow directions. Direct the
INTERFERING FACTORS: N/A patient to breathe normally and to
avoid unnecessary movement.
➤ Observe standard precautions, and
Nursing Implications and follow the general guidelines in
Procedure ● ● ● ● ● ● ● ● ● ● ● Appendix A. Positively identify the
patient, and label the appropriate
Pretest: tubes with the corresponding patient
demographics, date, and time of col-
➤ Inform the patient that the test is lection. Perform a venipuncture;
used in the differential diagnosis of collect the specimen in a 5-mL red-
chronic liver disease. top tube.
➤ Obtain a history of the patient’s com-
➤ Remove the needle, place a gauze
plaints, including a list of known
over the puncture site and apply gen-
allergens (especially allergies or sen-
tle pressure to stop bleeding.
sitivities to latex), and inform the
Observe venipuncture site for bleed-
appropriate health care practitioner
ing or hematoma formation. Apply
accordingly.
paper tape over gauze or replace
➤ Obtain a history of the patient’s with adhesive bandage.
hepatobiliary and immune systems,
as well as results of previously per- ➤ Promptly transport the specimen to
formed laboratory tests, surgical pro- the laboratory for processing and
cedures, and other diagnostic analysis.
procedures. For related laboratory ➤ The results are recorded manually or
tests, refer to the Hepatobiliary and in a computerized system for recall
Immune System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the appropriate health care practi-
the patient is taking, including tioner.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 138

138 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

Post-test: ➤ A written report of the examination


will be sent to the requesting health
➤ Nutritional considerations: The pres- care practitioner, who will discuss
ence of anti–smooth muscle anti- the results with the patient.
bodies may be associated with liver ➤ Reinforce information given by the
disease. Dietary recommendations patient’s health care provider regard-
may be indicated and vary depend- ing further testing, treatment, or
ing on the severity of the condition. referral to another health care pro-
A low-protein diet may be in order if vider. Answer any questions or
the liver cannot process the end address any concerns voiced by the
products of protein metabolism. A patient or family.
diet of soft foods may be required if
esophageal varices have developed. ➤ Depending on the results of this
Ammonia levels may be used to procedure, additional testing may be
determine whether protein should performed to evaluate or monitor
be added to or reduced from the progression of the disease process
diet. Patients should be encouraged and determine the need for a change
to eat simple carbohydrates and in therapy. Evaluate test results in
emulsified fats (as in homogenized relation to the patient’s symptoms
milk or eggs), as opposed to com- and other tests performed.
plex carbohydrates (e.g., starch,
fiber, and glycogen [animal carbohy- Related laboratory tests:
drates]) and complex fats, which
would require additional bile to emul- ➤ Related laboratory tests include
sify them so that they could be alkaline phosphatase, ammonia,
used. Observe the cirrhotic patient antimitochondrial antibody, antinu-
carefully for the development of clear antibody, aspartate aminotrans-
ascites; if ascites develops, pay strict ferase, bilirubin, hepatitis serology,
attention to fluid and electrolyte liver biopsy, prothrombin time, and
balance. serum protein electrophoresis.

ANTIBODY, Jo-1
SYNONYM/ACRONYM: Antihistidyl transfer RNA (tRNA) synthase.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Immunoassay) Negative.

DESCRIPTION & RATIONALE: Jo-1 is ease course and a higher risk of mor-
an autoantibody found in the serum tality. The clinical effects of this
of some antinuclear antibody–positive autoantibody include acute onset,
patients. Compared to the presence fever, dry and cracked skin on the
of other autoantibodies, the presence hands, Raynaud’s phenomenon, and
of Jo-1 suggests a more aggressive dis- arthritis.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 139

Antibody, Jo-1 139

INDICATIONS: 5 to 10 minutes. Address concerns


• Test for idiopathic inflammatory myo- about pain related to the procedure.
Explain to the patient that there may
pathies
be some discomfort during the
venipuncture.
RESULT
➤ There are no food, fluid, or medica-
Increased in: tion restrictions unless by medical
• Dermatomyositis direction.

• Polymyositis
Intratest:
Decreased in: N/A ➤ If the patient has a history of severe
allergic reaction to latex, care should
CRITICAL VALUES: N/A be taken to avoid the use of equip-
ment containing latex.
INTERFERING FACTORS: N/A ➤ Instruct the patient to cooperate
fully and to follow directions.
Direct the patient to breathe nor-
Nursing Implications and mally and to avoid unnecessary
Procedure ● ● ● ● ● ● ● ● ● ● ●
movement.
➤ Observe standard precautions, and
Pretest: follow the general guidelines in
Appendix A. Positively identify the
➤ Inform the patient that the test is patient, and label the appropriate
used to identify and monitor idio- tubes with the corresponding patient
pathic myopathies. demographics, date, and time of
➤ Obtain a history of the patient’s collection. Perform a venipuncture;
complaints, including a list of known collect the specimen in a 5-mL red-
allergens (especially allergies or sen- top tube.
sitivities to latex), and inform the ➤ Remove the needle, place a gauze
appropriate health care practitioner over the puncture site and apply gen-
accordingly. tle pressure to stop bleeding.
➤ Obtain a history of the patient’s Observe venipuncture site for bleed-
immune and musculoskeletal sys- ing or hematoma formation. Apply
tems, as well as results of pre- paper tape over gauze or replace
viously performed laboratory tests, with adhesive bandage..
surgical procedures, and other ➤ Promptly transport the specimen to
diagnostic procedures. For related the laboratory for processing and
laboratory tests, refer to the Im- analysis.
mune and Musculoskeletal System
tables. ➤ The results are recorded manually or
in a computerized system for recall
➤ Obtain a list of the medications the and postprocedure interpretation by
patient is taking, including herbs, the appropriate health care practi-
nutritional supplements, and nutra- tioner.
ceuticals. The requesting health
care practitioner and laboratory
should be advised if the patient Post-test:
regularly uses these products so
that their effects can be taken into ➤ A written report of the examination
consideration when reviewing will be sent to the requesting health
results. care practitioner, who will discuss
➤ Review the procedure with the the results with the patient.
patient. Inform the patient that spec- ➤ Reinforce information given by the
imen collection takes approximately patient’s health care provider regard-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 140

140 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ing further testing, treatment, or Related laboratory tests:


referral to another health care provi-
der. Answer any questions or add- ➤ Related laboratory tests include
ress any concerns voiced by the alanine aminotransferase, aldolase,
patient or family. antinuclear antibody, aspartate
➤ Depending on the results of this aminotransferase, creatine kinase,
procedure, additional testing may be erythrocyte sedimentation rate,
performed to evaluate or monitor extractable nuclear antibodies, lac-
progression of the disease process tate dehydrogenase and isoen-
and determine the need for a change zymes, muscle biopsy, myoglobin,
in therapy. Evaluate test results in rheumatoid factor, anti-scleroderma
relation to the patient’s symptoms antibody, skin biopsy, and urine crea-
and other tests performed. tinine.

ANTICONVULSANT DRUGS:
CARBAMAZEPINE, ETHOSUXIMIDE,
PHENOBARBITAL, PHENYTOIN,
PRIMIDONE, VALPROIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Carbamazepine (Carbatrol, Tegretol, Tegretol XR);


Ethosuximide (Zarontin); Phenobarbital (Luminal, Phenobarb); Phenytoin
(Cerebyx, Dilantin, Fenytoin, Phenytek); Primidone (Mysoline); Valproic acid
(Depacon, Depakene, Depakote).

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Drug Route of Administration


Carbamazepine* Oral
Ethosuximide* Oral
Phenobarbital* Oral
Phenytoin* Oral
Primidone* Oral
Valproic Acid* Oral

* Recommended collection time  trough: immediately before next dose (at steady
state) or at a consistent sampling time.
Therapeutic Volume of Protein
Drug Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion
(SI  Conventional Units  4.23)
Carbamazepine 4–12 g/mL 17–51 mol/L 15–40 0.8–1.8 60–80 Hepatic
(SI  Conventional Units  7.08)
01Van Leewan(F) (1-188)

Ethosuximide 40–100 283–708 25–70 0.7 0–5 Renal


g/mL mol/L
(SI  Conventional Units  4.31)
Phenobarbital Adult: 15–40 Adult: 65–172 Adult: 0.5–1.0 L/kg 40–50 80%
12/15/05

g/mL mol/L 50–140 Hepatic


Child: 15–30 Child: 65–129 Child: 20% Renal
g/mL mol/L 40–70
REFERENCE VALUE: (Method: Immunoassay)

(SI  Conventional Units  3.96)


8:34 PM

Phenytoin 10–20 g/mL 40–79 mol/L Adult: 0.6–0.7 85–95 Hepatic


Neonatal: Neonatal: 20–40
6–14 g/mL 24–55 mol/L Child: 10
(SI  Conventional Units  4.58)
Page 141

Primidone Adult: 5–12 Adult: 23–55 4–12 0.5–1.0 0–20 Hepatic


g/mL mol/L
Child: 7–10 Child: 32–46
g/mL mol/L

(SI  Conventional Units  6.93)


Valproic Acid 50–120 347–832 12–16 0.1–0.5 85–95 Hepatic
g/mL mol/L

141
* Conventional units.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 142

142 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

DESCRIPTION & RATIONALE: Anti- Peak and trough collection times


convulsants are used to reduce the fre- should be documented carefully in
quency and severity of seizures for relation to the time of medication
patients with epilepsy. Carbamazepine administration. ■
is also used for controlling neurogenic
IMPORTANT NOTE: This information
pain in trigeminal neuralgia and dia- must be clearly and accurately communi-
betic neuropathy and for treating for cated to avoid misunderstanding of the
bipolar disease and other neurologic dose time in relation to the collection
and psychiatric conditions. Valproic time. Miscommunication between the
acid is also used for some psychiatric individual administering the medication
conditions like bipolar disease and for and the individual collecting the speci-
prevention of migrane headache. men is the most frequent cause of sub-
Many factors must be considered in therapeutic levels, toxic levels, and
effective dosing and monitoring of misleading information used in calcula-
tion of future doses.
therapeutic drugs, including patient
age, patient weight, interacting med- INDICATIONS:
ications, electrolyte balance, protein • Assist in the diagnosis of and preven-
levels, water balance, conditions that tion of toxicity
affect absorption and excretion, and • Evaluate overdose, especially in combi-
foods, herbals, vitamins, and minerals nation with ethanol
that can either potentiate or inhibit • Monitor compliance with therapeutic
the intended target concentration. regimen

RESULT

Level Response
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Carbamazepine Hepatic impairment
Ethosuximide Hepatic impairment
Phenobarbital Hepatic impairment
Phenytoin Hepatic impairment
Primidone Hepatic impairment
Valproic acid Hepatic impairment

CRITICAL VALUES: It is important Carbamazepine: Greater


to note the adverse effects of toxic and Than 12 g/mL
subtherapeutic levels. Care must be taken
to investigate the signs and symptoms of Signs and symptoms of carbamaze-
too little and too much medication. Note pine toxicity include respiratory depres-
and immediately report to the health care sion, seizures, leukopenia, hyponatremia,
practitioner any critically increased values hypotension, stupor, and possible coma.
and related symptoms. Possible interventions include gastric
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 143

Anticonvulsant Drugs 143

lavage (contraindicated if ileus is present); administration of saline or sorbitol cathar-


airway protection; administration of flu- tic, and discontinuing the medication.
ids and vasopressors for hypotension;
treatment of seizures with diazepam, phe- Primidone: Greater
nobarbital, or phenytoin; cardiac moni- Than 12 g/mL
toring; monitoring of vital signs; and
discontinuing the medication. Emetics Signs and symptoms of primidone toxic-
are contraindicated. ity include ataxia, anemia, and central
nervous system depression. Possible inter-
Ethosuximide: Greater ventions include airway protection, treat-
ment of anemia with vitamin B12 and
Than 100 g/mL
folate, and discontinuing the medication.
Signs and symptoms of ethosuximide
toxicity include nausea, vomiting, and Valproic Acid: Greater
lethargy. Possible interventions include Than 120 g/mL
administration of activated charcoal,
Signs and symptoms of valproic acid tox-
administration of saline cathartic and gas-
icity include numbness, tingling, weak-
tric lavage (contraindicated if ileus is pres-
ness, loss of appetite, and mental changes.
ent), airway protection, hourly assessment
Possible interventions include adminis-
of neurologic function, and discontinuing
tration of activated charcoal and naloxone
the medication.
and discontinuing the medication.
Phenobarbital: Greater
INTERFERING FACTORS:
Than 40 g/mL • Blood drawn in serum separator tubes
Signs and symptoms of phenobarbital (gel tubes).
toxicity include cold, clammy skin; ataxia; • Contraindicated in patients with liver
central nervous system depression; hypo- disease, and caution advised in patients
thermia; hypotension; cyanosis; Cheyne- with renal impairment.
Stokes respiration; tachycardia; possible
• Drugs that may increase carbamaze-
coma; and possible renal impairment.
pine levels or increase risk of toxicity
Possible interventions include gastric
include cimetidine, clozapine, danazol,
lavage, administration of activated char-
diazepam, diltiazem, erythromycin,
coal with cathartic, airway protection,
haloperidol, isoniazid, propoxyphene,
possible intubation and mechanical venti-
risperidone, triacetyloleandomycin,
lation (especially during gastric lavage
tricyclic antidepressants, valproic acid,
if there is no gag reflex), monitoring
and verapamil.
for hypotension, and discontinuing the
medication. • Drugs that may decrease carbamaze-
pine levels include phenobarbital, phe-
Phenytoin: Adults: Greater nytoin, and primidone.
Than 20 g/mL; Neonatal: • Drugs that may increase ethosuximide
Greater Than 14 g/mL levels include isoniazid, ritonavir, and
valproic acid.
Signs and symptoms of phenytoin toxi-
city include double vision, nystagmus, • Drugs that may decrease ethosuximide
lethargy, central nervous system depres- levels include phenobarbital, pheny-
sion, and possible coma. Possible toin, and primidone.
interventions include airway support, • Drugs that may increase phenobarbital
electrocardiographic monitoring, admin- levels or increase risk of toxicity include
istration of activated charcoal, gastric barbital drugs, furosemide, primidone,
lavage with warm saline or tap water, salicylates, and valproic acid.
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144 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

• Phenobarbital may affect the meta- • Drugs that may increase valproic acid
bolism of other drugs, increasing levels or increase risk of toxicity include
their effectiveness, such as -blockers, dicumarol, phenylbutazone, and high
chloramphenicol, corticosteroids, doxy- doses of salicylate.
cycline, griseofulvin, haloperidol,
• Drugs that may decrease valproic acid
methylphenidate, phenothiazines, phe-
levels include carbamazepine, pheno-
nylbutazone, propoxyphene, quinidine,
barbital, phenytoin, and primidone.
theophylline, tricyclic antidepressants,
and valproic acid.
• Phenobarbital may affect the metabo- Nursing Implications and
lism of other drugs, decreasing their Procedure ● ● ● ● ● ● ● ● ● ● ●
effectiveness, such as chloramphenicol,
cyclosporine, ethosuximide, oral anti- Pretest:
coagulants, oral contraceptives, pheny-
toin, and theophylline. ➤ Inform the patient that the test is
used to monitor for therapeutic and
• Phenobarbital is an active metabolite toxic drug levels.
of primidone, and both drug levels ➤ Obtain a history of the patient’s com-
should be monitored while the patient plaints, including a list of known
is receiving primidone to avoid either allergens (especially allergies or sen-
toxic or subtherapeutic levels of both sitivities to latex), and inform the
medications. appropriate health care practitioner
accordingly.
• Drugs that may increase phenytoin lev- ➤ Obtain a history of the patient’s gen-
els or increase the risk of phenytoin itourinary and hepatobiliary systems
toxicity include amiodarone, azapropa- as well as results of previously per-
zone, carbamazepine, chlorampheni- formed laboratory tests, surgical
col, cimetidine, disulfiram, ethanol, procedures, and other diagnostic
fluconazole, halothane, ibuprofen, procedures. For related laboratory
imipramine, levodopa, metronidazole, tests, refer to the Genitourinary
miconazole, nifedipine, phenylbuta- and Hepatobiliary Systems and
Therapeutic/Toxicology tables.
zone, sulfonamides, trazodone, tricyclic
antidepressants, and trimethoprim. ➤ Obtain a list of medications the
Small changes in formulation (i.e., patient is taking, including herbs,
nutritional supplements, and nutra-
changes in brand) also may increase ceuticals. Note the last time and
phenytoin levels or increase the risk dose of medication taken. The
of phenytoin toxicity. requesting health care practitioner
and laboratory should be advised if
• Drugs that may decrease phenytoin the patient regularly uses these
levels include bleomycin, carbamaze- products so that their effects can
pine, cisplatin, disulfiram, folic acid, be taken into consideration when re-
intravenous fluids containing glucose, viewing results.
nitrofurantoin, oxacillin, rifampin, sal- ➤ Review the procedure with the
icylates, and vinblastine. patient. Inform the patient that spec-
imen collection takes approximately
• Primidone decreases the effectiveness 5 to 10 minutes. Address concerns
of carbamazepine, ethosuximide, fel- about pain related to the procedure.
bamate, lamotrigine, oral anticoagu- Explain to the patient that there
lants, oxcarbazepine, topiramate, and may be some discomfort during the
valproate. venipuncture.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 145

Anticonvulsant Drugs 145

➤ Sensitivity to cultural and social Post-test:


issues, as well as concern for mod-
esty, is important in providing psy- ➤ A written report of the examination
chological support before, during, will be sent to the requesting health
and after the procedure. care practitioner, who will discuss
➤ There are no food, fluid, or medica- the results with the patient.
tion restrictions unless by medical ➤ Reinforce information given by the
direction. patient’s health care provider regard-
ing further testing, treatment, or
Intratest: referral to another health care
➤ If the patient has a history of severe provider. Explain to the patient the
allergic reaction to latex, care should importance of following the medi-
be taken to avoid the use of equip- cation regimen and instructions
ment containing latex. regarding drug interactions. Instruct
the patient to immediately report
➤ Direct the patient to breathe nor- any unusual sensations (e.g., ataxia,
mally and to avoid unnecessary dizziness, dyspnea, lethargy, rash,
movement. tremors, mental changes, weakness,
➤ Observe standard precautions, and or visual disturbances) to his or
follow the general guidelines in her health care practitioner. Answer
Appendix A. Consider recommended any questions or address any con-
collection time in relation to dos- cerns voiced by the patient or family.
ing schedule. Positively identify the
patient, and label the appropriate ➤ Instruct the patient to be prepared
tubes with the corresponding patient to provide the pharmacist with a list
demographics, date, and time of col- of other medications he or she is
lection, noting the last dose of already taking in the event that the
medication taken. Perform a veni- requesting health care practitioner
puncture; collect the specimen in a prescribes a medication.
5-mL red-top tube. ➤ Depending on the results of this
➤ Remove the needle, place a gauze procedure, additional testing may be
over the puncture site and apply gen- performed to evaluate or monitor
tle pressure to stop bleeding. progression of the disease pro-
Observe venipuncture site for bleed- cess and determine the need for a
ing or hematoma formation. Apply change in therapy. Evaluate test
paper tape over gauze or replace results in relation to the patient’s
with adhesive bandage. symptoms and other tests per-
➤ Promptly transport the specimen to formed.
the laboratory for processing and
analysis.
Related laboratory tests:
➤ The results are recorded manually
or in a computerized system for ➤ Related laboratory tests include albu-
recall and postprocedure interpreta- min, blood urea nitrogen, creatinine,
tion by the appropriate health care complete blood count, electrolytes,
practitioner liver function tests, and total protein.
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146 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ANTIDEOXYRIBONUCLEASE-B,
STREPTOCOCCAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: ADNase-B, AntiDNase-B titer, antistreptococcal


DNase-B titer, streptodornase.

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Spectrophotometry)

Normal CRITICAL VALUES: N/A


Age Results
INTERFERING FACTORS: N/A
Preschoolers Less than 61 U
School-age Less than 171 U
children Nursing Implications and
Adults Less than 86 U
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
DESCRIPTION & RATIONALE: The ➤ Inform the patient that the test is
presence of streptococcal deoxyri- used to document recent strepto-
bonuclease (DNase) antibodies is an coccal infection.
indicator of recent infection, espe- ➤ Obtain a history of the patient’s
cially if a rise in antibody titer can be complaints, including a list of known
allergens (especially allergies or sen-
shown. This test is more sensitive than sitivities to latex), and inform the
the antistreptolysin O test. A rise in appropriate health care practitioner
titer of two or more dilution incre- accordingly.
ments between acute and convalescent ➤ Obtain a history of the patient’s
specimens is clinically significant. ■ immune system and results of previ-
ously performed laboratory tests,
INDICATIONS: surgical procedures, and other diag-
• Investigate the presence of streptococ- nostic procedures. For related labo-
ratory tests, refer to the Immune
cal antibodies as a source of recent System table.
infection
➤ Obtain a list of the medications
the patient is taking, including
RESULT herbs, nutritional supplements, and
nutraceuticals. The requesting health
Increased in: care practitioner and laboratory
• Streptococcal infections (systemic) should be advised if the patient
regularly uses these products so
Decreased in: N/A that their effects can be taken
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 147

Antideoxyribonuclease-B, Streptococcal 147

into consideration when reviewing ➤ The results are recorded manually or


results. in a computerized system for recall
➤ Review the procedure with the and postprocedure interpretation by
patient. Inform the patient that spec- the appropriate health care practi-
imen collection takes approximately tioner.
5 to 10 minutes. Address concerns
about pain related to the procedure.
Explain to the patient that there may Post-test:
be some discomfort during the ➤ Administer analgesics and antibiotics
venipuncture. if ordered. Remind the patient of the
➤ There are no food, fluid, or medica- importance of completing the entire
tion restrictions unless by medical course of antibiotic therapy, even if
direction. signs and symptoms disappear
before completion of therapy.
Intratest: ➤ A written report of the examination
➤ If the patient has a history of severe will be sent to the requesting health
allergic reaction to latex, care should care practitioner, who will discuss
be taken to avoid the use of equip- the results with the patient.
ment containing latex. ➤ Reinforce information given by the
➤ Instruct the patient to cooperate fully patient’s health care provider regard-
and to follow directions. Direct the ing further testing, treatment, or
patient to breathe normally and to referral to another health care
avoid unnecessary movement. provider. Inform the patient that a
➤ Observe standard precautions, and convalescent specimen may be
follow the general guidelines in requested in 7 to 10 days. Answer
Appendix A. Positively identify the any questions or address any con-
patient, and label the appropriate cerns voiced by the patient or family.
tubes with the corresponding patient ➤ Depending on the results of this
demographics, date, and time of col- procedure, additional testing may be
lection. Perform a venipuncture; performed to evaluate or monitor
collect the specimen in a 5-mL red- progression of the disease process
top tube. and determine the need for a change
➤ Remove the needle, place a gauze in therapy. Evaluate test results in
over the puncture site and apply gen- relation to the patient’s symptoms
tle pressure to stop bleeding. and other tests performed.
Observe venipuncture site for bleed-
ing or hematoma formation. Apply
paper tape over gauze or replace Related laboratory tests:
with adhesive bandage. ➤ Related laboratory tests include anti-
➤ Promptly transport the specimen to streptolysin O antibody, group A
the laboratory for processing and streptococcal screen, and throat
analysis. culture.
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148 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

ANTIDEPRESSANT DRUGS (Cyclic):


AMITRIPTYLINE, NORTRIPTYLINE,
DOXEPIN, IMIPRAMINE, DESIPRAMINE
SYNONYMS/ACRONYM: Cyclic antidepressants: amitriptyline (Elavil, Endep,
Etrafon, Limbitrol DS, Triavil); nortriptyline (Aventyl HCL, Pamelor); dox-
epin (Adapin, Sinequan); imipramine (Anafranil, Clomipramine, Imavate,
Presamine, Surmontil, Tofranil PM, Trimipramine); desipramine
(Norpramin, pertofrane).

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Route of Recommended
Drug Administration Collection Time
Amitriptyline Oral Trough: immediately before
next dose (at steady state)
Nortriptyline Oral Trough: immediately before
next dose (at steady state)
Doxepin Oral Trough: immediately before
next dose (at steady state)
Imipramine Oral Trough: immediately before
next dose (at steady state)
Desipramine Oral Trough: immediately before
next dose (at steady state)

REFERENCE VALUE: (Method: Chromatography for amitriptyline, nortripty-


line, and doxepin; immunoassay for imipramine and desipramine)
Therapeutic Half- Volume of Protein
Drug Dose* SI Units Life (h) Distribution (L/kg) Binding (%) Excretion
(SI  Conventional Units  3.61)
01Van Leewan(F) (1-188)

Amitriptyline, 80–200 289–722 17–40 10–36 85–95 Hepatic


alone ng/mL nmol/L
(SI  Conventional Units  3.8)
Nortriptyline, alone 50–150 ng/mL 190–570 20–90 15–23 90–95 Hepatic
12/15/05

nmol/L
(SI  Conventional Units  3.58)
Combined doxepin and 150–250 540–900 10–25 10–30 75–85 Hepatic
desmethyldoxepin ng/mL nmol/L
8:34 PM

(SI  Conventional Units  3.57)


Imipramine 150–250 536–892 6–28 9–23 60–95 Hepatic
ng/mL nmol/L
Page 149

(Conventional Units  3.75)


Desipramine 150–250 562–938 6–28 9–23 60–95 Hepatic
ng/mL nmol/L
* Conventional units.

149
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150 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

DESCRIPTION & RATIONALE: Cyclic Trough collection times should be


antidepressants are used in the treat- documented carefully in relation to
ment of major depression. They have the time of medication administra-
also been used effectively to treat tion. ■
bipolar disorder, panic disorder, atten-
tion-deficit hyperactivity disorder
IMPORTANT NOTE: This information
must be clearly and accurately communi-
(ADHD), obsessive-compulsive disor- cated to avoid misunderstanding of the
der (OCD), enuresis, eating disorders dose time in relation to the collection
(bulimia nervosa in particular), time. Miscommunication between the
nicotine dependence (tobacco), and individual administering the medication
cocaine dependence. Numerous drug and the individual collecting the speci-
interactions occur with the cyclic anti- men is the most frequent cause of
depressants. subtherapeutic levels, toxic levels, and
Many factors must be considered in misleading information used in calcula-
effective dosing and monitoring of tion of future doses.
therapeutic drugs, including patient INDICATIONS:
age, patient weight, interacting med- • Assist in the diagnosis and prevention
ications, electrolyte balance, protein of toxicity
levels, water balance, conditions that • Evaluate overdose, especially in combi-
affect absorption and excretion, and nation with ethanol (Note: Doxepin
foods, herbals, vitamins, and minerals abuse is unusual)
that can either potentiate or inhibit • Monitor compliance with therapeutic
the intended target concentration. regimen

RESULT

Level Response
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Amitriptyline Hepatic impairment
Nortriptyline Hepatic impairment
Doxepin Hepatic impairment
Imipramine Hepatic impairment
Desipramine Hepatic impairment

CRITICAL VALUES: It is important Cyclic Antidepressants:


to note the adverse effects of toxic and • Amitriptyline: Greater than 300 ng/mL
subtherapeutic levels of antidepressants.
Care must be taken to investigate signs • Combined amitriptyline and nortripty-
and symptoms of too little and too much line: Greater than 250 ng/mL
medication. Note and immediately report • Combined doxepin and desmethyldox-
to the health care practitioner any epin: Greater than 150 ng/mL
critically increased values and related
symptoms. • Desipramine: Greater than 300 ng/mL
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 151

Antidepressant Drugs 151

• Imipramine: Greater than 250 ng/mL nutritional supplements, and nutra-


ceuticals. Note the last time and dose
Signs and symptoms of cyclic anti- of medication taken. The requesting
depressant toxicity include agitation, health care practitioner and labora-
hallucinations, confusion, seizures, arrhy- tory should be advised if the patient
thmias, hyperthermia, flushing, dilation regularly uses these products so that
of the pupils, and possible coma. Possi- their effects can be taken into consid-
ble interventions include administration eration when reviewing results.
of activated charcoal; emesis; gastric ➤ Review the procedure with the
lavage with saline; administration of patient. Inform the patient that spec-
physostigmine to counteract seizures, imen collection takes approximately
hypertension, or respiratory depression; 5 to 10 minutes. Address concerns
about pain related to the procedure.
administration of bicarbonate, propra- Explain to the patient that there may
nolol, lidocaine, or phenytoin to counter- be some discomfort during the
act arrhythmias; and electrocardiographic venipuncture.
monitoring. ➤ Sensitivity to cultural and social
issues, as well as concern for mod-
INTERFERING FACTORS: esty, is important in providing psy-
• Blood drawn in serum separator tubes chological support before, during,
(gel tubes). and after the procedure.
• Contraindicated in patients with liver ➤ There are no food, fluid, or medica-
disease, and caution advised in patients tion restrictions unless by medical
direction.
with renal impairment.
• Cyclic antidepressants may potentiate
the effects of oral anticoagulants. Intratest:
➤ If the patient has a history of severe
allergic reaction to latex, care should
Nursing Implications and be taken to avoid the use of equip-
ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●

➤ Instruct the patient to cooperate fully


Pretest: and to follow directions. Direct the
patient to breathe normally and to
➤ Inform the patient that the test is avoid unnecessary movement.
used to monitor for therapeutic and
toxic drug levels. ➤ Observe standard precautions, and
follow the general guidelines in
➤ Obtain a history of the patient’s com- Appendix A. Consider recommended
plaints, including a list of known collection time in relation to dos-
allergens (especially allergies or sen- ing schedule. Positively identify the
sitivities to latex), and inform the patient, and label the appropriate
appropriate health care practitioner tubes with the corresponding patient
accordingly. demographics, date, and time of
➤ Obtain a history of the patient’s gen- collection, noting the last dose
itourinary and hepatobiliary systems of medication taken. Perform a
as well as results of previously venipuncture; collect the specimen
performed laboratory tests, surgical in a 5-mL red-top tube.
procedures, and other diagnos- ➤ Remove the needle, place a gauze
tic procedures. For related laboratory over the puncture site and apply gen-
tests, refer to the Genitourinary tle pressure to stop bleeding.
and Hepatobiliary Systems and Observe venipuncture site for bleed-
Therapeutic/ Toxicology tables. ing or hematoma formation. Apply
➤ Obtain a list of the medications the paper tape over gauze or replace
patient is taking, including herbs, with adhesive bandage.
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152 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Promptly transport the specimen to headache, vomiting, sweating, dia-


the laboratory for processing and phoresis, visual disturbances) to his
analysis. or her health care practitioner. Blood
➤ The results are recorded manually pressure should be monitored regu-
or in a computerized system for larly. Answer any questions or
recall and postprocedure interpreta- address any concerns voiced by the
tion by the appropriate health care patient or family.
practitioner ➤ Instruct the patient to be prepared to
provide the pharmacist with a list of
Post-test: other medications he or she is
already taking in the event that the
➤ Nutritional considerations include requesting health care practitioner
the avoidance of alcohol consump- prescribes a medication.
tion.
➤ Depending on the results of this pro-
➤ A written report of the examination cedure, additional testing may be
will be sent to the requesting health performed to evaluate or monitor
care practitioner, who will discuss progression of the disease process
the results with the patient. and determine the need for a change
➤ Reinforce information given by the in therapy. Evaluate test results in
patient’s health care provider regard- relation to the patient’s symptoms
ing further testing, treatment, or and other tests performed.
referral to another health care
provider. Explain to the patient the Related laboratory tests:
importance of following the medica-
tion regimen and instructions regard- ➤ Related laboratory tests include albu-
ing drug interactions. Instruct the min, blood urea nitrogen, creatinine,
patient to immediately report any complete blood count, electrolytes,
unusual sensations (e.g., severe liver function tests, and total protein.

ANTIDIURETIC HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYM: Vasopressin, arginine vasopressin hormone, ADH.


SPECIMEN: Plasma (1 mL) collected in lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube.

REFERENCE VALUE: (Method: Radioimmunoassay)


RECOMMENDATION: This test should be ordered and interpreted with results
of a serum osmolality.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 153

Antidiuretic Hormone 153

Serum Antidiuretic SI Units (Conversion


Osmolality* Hormone* Factor  0.926)
270–280 mOsm/kg Less than 1.5 pg/mL Less than 1.4 pmol/L
280–285 mOsm/kg Less than 2.5 pg/mL Less than 2.3 pmol/L
285–290 mOsm/kg 1–5 pg/mL 0.9–4.6 pmol/L
290–295 mOsm/kg 2–7 pg/mL 1.9–6.5 pmol/L
295–300 mOsm/kg 4–12 pg/mL 3.7–11.1 pmol/L

* Conventional units.

• Differentiate neurogenic (central) dia-


DESCRIPTION & RATIONALE: Anti- betes insipidus from nephrogenic dia-
diuretic hormone (ADH) is formed betes insipidus by decreased ADH
by the hypothalamus and stored in the levels in neurogenic diabetes insipidus
posterior pituitary gland. ADH is or elevated levels in nephrogenic dia-
released in response to increased betes insipidus if normal feedback
serum osmolality or decreased blood mechanisms are intact.
volume. When the hormone is active, • Evaluate polyuria or altered serum
small amounts of concentrated urine osmolality to identify possible alter-
are produced; in its absence, large ations in ADH secretion as the cause.
amounts of dilute urine are produced.
Although a 1% change in serum RESULT
osmolality stimulates ADH secretion,
blood volume must decrease by Increased in:
approximately 10% for ADH secre- • Acute intermittent porphyria
tion to be induced. Psychogenic stim- • Brain tumor
uli, such as stress, pain, and anxiety,
• Disorders involving the central nervous
may also stimulate ADH release, but
system, thyroid gland, and adrenal
the mechanism is unclear. ■ gland
INDICATIONS: • Ectopic production (systemic neo-
• Assist in the diagnosis of known or sus- plasm)
pected malignancy associated with syn-
drome of inappropriate ADH secretion • Guillain-Barré syndrome
(SIADH), such as oat cell lung cancer, • Nephrogenic diabetes insipidus
thymoma, lymphoma, leukemia, pan-
creatic carcinoma, prostate gland • Pain, stress, or exercise
carcinoma, and intestinal carcinoma; • Pneumonia
elevated ADH levels indicate the pres-
ence of this syndrome. • Pulmonary tuberculosis

• Assist in the diagnosis of known or sus- • SIADH


pected pulmonary conditions associ- • Tuberculous meningitis
ated with SIADH, such as tuberculosis,
pneumonia, and positive-pressure Decreased in:
mechanical ventilation. • Nephrotic syndrome
• Detect central nervous system trauma,
• Pituitary (central) diabetes insipidus
surgery, or disease that may lead to
impaired ADH secretion. • Psychogenic polydipsia
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154 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

CRITICAL VALUES: Effective treatment of ➤ Obtain a history of the patient’s


SIADH depends on identifying and res- endocrine and genitourinary sys-
tems, as well as results of previously
olving the cause of increased ADH pro-
performed laboratory tests, surgical
duction. Signs and symptoms of SIADH procedures, and other diagnostic
are the same as those for hyponatremia, procedures. For related laboratory
including irritability, tremors, muscle tests, refer to the Endocrine and
spasms, convulsions, and neurologic Genitourinary System tables.
changes. The patient has enough sodium, ➤ Note any recent procedures that can
but it is diluted in excess retained water. interfere with test results.
➤ Obtain a list of the medications
INTERFERING FACTORS: the patient is taking, including
• Drugs that may increase ADH levels herbs, nutritional supplements, and
include barbiturates, carbamazepine, nutraceuticals. The requesting health
chlorpropamide, chlorthalidone, cis- care practitioner and laboratory
platin, clofibrate, ether, furosemide, should be advised if the patient reg-
haloperidol, hydrochlorothiazide, lith- ularly uses these products so that
ium, methyclothiazide, narcotic anal- their effects can be taken into con-
sideration when reviewing results.
gesics, phenothiazides, polythiazide,
tolbutamide, tricyclic antidepressants, ➤ Review the procedure with the
vidarabine, vinblastine, and vincristine. patient. Inform the patient that spec-
imen collection takes approximately
• Drugs that may decrease ADH levels 5 to 10 minutes. Address concerns
include clonidine, demeclocycline, about pain related to the procedure.
ethanol, lithium carbonate, and pheny- Explain to the patient that there may
toin. be some discomfort during the
venipuncture.
• Recent radioactive scans or radiation
within 1 week before the test can inter- ➤ There are no food, fluid, or medica-
tion restrictions unless by medical
fere with test results when radioim-
direction.
munoassay is the test method.
➤ Prepare an ice slurry in a cup or plas-
• ADH exhibits diurnal variation, with tic bag to have ready for immediate
highest levels of secretion occurring at transport of the specimen to the lab-
night; first morning collection is rec- oratory. Prechill the lavender-top tube
ommended. in the ice slurry.
• ADH secretion is also affected by pos-
Intratest:
ture, with higher levels measured while
upright. ➤ If the patient has a history of severe
allergic reaction to latex, care should
be taken to avoid the use of equip-
Nursing Implications and ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Instruct the patient to cooperate fully
and to follow directions. The patient
Pretest: should be encouraged to be calm
and in a sitting position for specimen
➤ Inform the patient that the test is collection. Direct the patient to
used to assist in the diagnosis of dis- breathe normally and to avoid unnec-
orders affecting urine concentration. essary movement.
➤ Obtain a history of the patient’s ➤ Observe standard precautions, and
complaints, including a list of known follow the general guidelines in
allergens (especially allergies or sen- Appendix A. Positively identify the
sitivities to latex), and inform the patient, and label the appropriate
appropriate health care practitioner tubes with the corresponding patient
accordingly. demographics, date, and time of col-
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 155

Antigens/Antibodies, Anti Extractable Nuclear 155

lection. Perform a venipuncture; col- care practitioner, who will discuss


lect the specimen in a prechilled 5- the results with the patient.
mL lavender-top tube. ➤ Reinforce information given by the
➤ Remove the needle, place a gauze patient’s health care provider regard-
over the puncture site and apply gen- ing further testing, treatment, or
tle pressure to stop bleeding. referral to another health care pro-
Observe venipuncture site for bleed- vider. Inform the patient, as appropri-
ing or hematoma formation. Apply ate, that treatment may include
paper tape over gauze or replace diuretic therapy and fluid restriction
with adhesive bandage. to successfully eliminate the excess
water. Answer any questions or
➤ The sample should be placed in an
address any concerns voiced by the
ice slurry immediately after collec-
patient or family.
tion. Information on the specimen
label can be protected from water in ➤ Depending on the results of this pro-
the ice slurry by first placing the cedure, additional testing may be
specimen in a protective plastic bag. performed to evaluate or monitor
Promptly transport the specimen to progression of the disease process
the laboratory for processing and and determine the need for a change
analysis. in therapy. Evaluate test results in
relation to the patient’s symptoms
➤ The results are recorded manually
and other tests performed.
or in a computerized system for
recall and postprocedure interpreta-
tion by the appropriate health care
Related laboratory tests:
practitioner. ➤ Related laboratory tests include
serum and urine electrolytes, serum
Post-test: and urine osmolality, serum and urine
sodium, thyroid-stimulating hor-
➤ A written report of the examination mone, blood urea nitrogen, uric acid,
will be sent to the requesting health and urinalysis.

ANTIGENS/ANTIBODIES,
ANTI–EXTRACTABLE NUCLEAR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYMS/ACRONYMS: La antibodies, Ro antibodies, SS-A antibodies,


SS-B antibodies, ENA.

SPECIMEN: Serum (1 mL) collected in a red-top tube.


REFERENCE VALUE: (Method: Immunoassay) Negative.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 156

156 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

INTERFERING FACTORS: N/A


DESCRIPTION & RATIONALE: The
extractable nuclear antigens (ENAs)
include ribonucleoprotein (RNP), Nursing Implications and
Smith (Sm), SS-A/Ro, and SS-B/La Procedure ● ● ● ● ● ● ● ● ● ● ●

antigens. ENAs and antibodies to


Pretest:
them are found in various combina-
tions in individuals with combinations ➤ Inform the patient that the test is
of overlapping rheumatologic symp- used to detect the presence of anti-
bodies associated with autoimmune
toms. ■ disorders such as systemic lupus
erythematosus and mixed connec-
INDICATIONS: tive tissue disease.
• Assist in the diagnosis of mixed con- ➤ Obtain a history of the patient’s
nective tissue disease complaints, including a list of known
• Assist in the diagnosis of Sjögren’s syn- allergens (especially allergies or sen-
drome sitivities to latex), and inform the
appropriate health care practitioner
• Assist in the diagnosis of systemic lupus accordingly.
erythematosus (SLE) ➤ Obtain a history of the patient’s
immune and musculoskeletal sys-
RESULT tems, as well as results of previously
performed laboratory tests, surgical
Increased in: procedures, and other diagnostic pro-
• Anti-RNP is associated with mixed cedures. For related laboratory tests,
refer to the Immune and Muscu-
connective tissue disease.
loskeletal System tables.
• Anti-SS-A and anti-SS-B are helpful in ➤ Obtain a list of medications the
antinuclear antibody (ANA)–negative patient is taking, including herbs,
cases of SLE. nutritional supplements, and nutra-
ceuticals. The requesting health care
• Anti-SS-A/ANA–positive, anti-SS- practitioner and laboratory should be
B–negative patients are likely to have advised if the patient regularly uses
nephritis. these products so that their effects
can be taken into consideration
• Anti-SS-A/anti-SS-B–positive sera are when reviewing results.
found in patients with neonatal lupus.
➤ Review the procedure with the
• Anti-SS-A–positive patients may also patient. Inform the patient that spec-
have antibodies associated with anti- imen collection takes approximately
phospholipid syndrome. 5 to 10 minutes. Address concerns
about pain related to the procedure.
• Anti-SS-A/La is associated with pri- Explain to the patient that there may
mary Sjögren’s syndrome. be some discomfort during the
venipuncture.
• Anti-SS-A/Ro is a predictor of congen-
➤ There are no food, fluid, or medica-
ital heart block in neonates born to
tion restrictions unless by medical
mothers with SLE. direction.
• Anti-SS-A/Ro–positive patients have
photosensitivity. Intratest:
➤ If the patient has a history of severe
Decreased in: N/A allergic reaction to latex, care should
be taken to avoid the use of equip-
CRITICAL VALUES: N/A ment containing latex.
01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 157

Antigens/Antibodies, Anti Extractable Nuclear 157

➤ Instruct the patient to cooperate fully ence, and fear of shortened life
and to follow directions. Direct the expectancy. Collagen and connective
patient to breathe normally and to tissue diseases are chronic. As such,
avoid unnecessary movement. they must be addressed on a contin-
uous basis and may require signifi-
➤ Observe standard precautions, and
cant changes in lifestyle. Discuss the
follow the general guidelines in
implications of abnormal test results
Appendix A. Positively identify the
on the patient’s lifestyle. Provide
patient, and label the appropriate
teaching and information regarding
tubes with the corresponding patient
the clinical implications of the test
demographics, date, and time of col-
results, as appropriate. Educate the
lection. Perform a venipuncture;
patient in the importance of prevent-
collect the specimen in a 5-mL red-
ing infection, which is a significant
top tube.
cause of death in immunosup-
➤ Remove the needle, place a gauze pressed individuals. Educate the
over the puncture site and apply gen- patient regarding access to counsel-
tle pressure to stop bleeding. ing services.
Observe venipuncture site for bleed-
➤ Reinforce information given by the
ing or hematoma formation. Apply
patient’s health care provider regard-
paper tape over gauze or replace
ing further testing, treatment, or
with adhesive bandage.
referral to another health care pro-
➤ Promptly transport the specimen to vider. Answer any questions or
the laboratory for processing and address any concerns voiced by the
analysis. patient or family.
➤ The results are recorded manually ➤ Depending on the results of this pro-
or in a computerized system for cedure, additional testing may be
recall and postprocedure interpreta- performed to evaluate or monitor
tion by the appropriate health care progression of the disease process
practitioner. and determine the need for a change