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Chapter 008
- 1. Chapter 8 Diagnostic Procedures Copyright © 2018, Elsevier Inc. All rights reserved.
- 2. Diagnostic Procedures Nurse is responsible for Assessing a patient’s knowledge Preparing the patient Providing a safe environment and emotional support through the procedure Providing preprocedure and postprocedure assessment, care, and documentation Providing discharge teaching Copyright © 2018, Elsevier Inc. All rights reserved. 2
- 3. Principles for Practice Ensure patient understands test Nurse must understand procedure Use ASA physical status classification system to determine patients at risk for undesirable outcomes Copyright © 2018, Elsevier Inc. All rights reserved. 3
- 4. Patient-Centered Care Explain test and give patient the opportunity to ask questions Understand patient fears; you may have an opportunity to alleviate them Plan the diagnostic testing schedule to provide rest periods between multiple tests performed on the same day Provide reassurance to patient throughout the procedure Copyright © 2018, Elsevier Inc. All rights reserved. 4
- 5. Evidence-Based Practice Lumbar puncture Risk for oversedation, site complications Headaches Pain management for children Postprocedure complications Copyright © 2018, Elsevier Inc. All rights reserved. 5
- 6. Safety Guidelines Before a Procedure 1. It is essential to patient safety to ensure that the patient undergoes the correct procedure. 2. Assess for completion of relevant documentation. 3. Identify any medications for which uninterrupted dosing is required. Copyright © 2018, Elsevier Inc. All rights reserved. 6
- 7. Safety Guidelines Before a Procedure (Cont.) 4. Verify that informed consent was obtained before administering any sedatives. 5. Make sure emergency equipment is available in procedure area. 6. Confirm presence and date of expiration for sedation reversal agents. Copyright © 2018, Elsevier Inc. All rights reserved. 7
- 8. Safety Guidelines During a Procedure 1. If a procedure involves use of radiation, minimize the amount of radiation exposure. 2. Monitor physiological parameters indicated by the procedure. 3. Position patients carefully to avoid musculoskeletal or neurological injury. 4. Properly label any specimens obtained during a procedure. Copyright © 2018, Elsevier Inc. All rights reserved. 8
- 9. Safety Guidelines After a Procedure 1. Know possible procedural complications and conduct appropriate assessments. 2. Monitor oxygen saturation and vital signs to detect sedation failure and adverse effects. 3. Know the uses, side effects, and complications of the sedative agent(s) and reversal agents to be administered. Copyright © 2018, Elsevier Inc. All rights reserved. 9
- 10. Safety Guidelines After a Procedure (Cont.) 4. Be able to recognize cardiac dysrhythmias. 5. Institute fall precautions until patient has recovered from the effects of sedatives. 6. Check for postprocedure limb ischemia or other arterial complications. Copyright © 2018, Elsevier Inc. All rights reserved. 10
- 11. Intravenous Moderate Sedation Skill 8-1 With moderate sedation, no interventions are required during the procedure to maintain a patent airway; spontaneous ventilation is adequate A risk for deep sedation is present Benzodiazepines and opiates are commonly used to achieve moderate sedation Monitoring continues after procedure Copyright © 2018, Elsevier Inc. All rights reserved. 11
- 12. Delegation and Collaboration The task of assisting with IV moderate sedation, including the preprocedure assessment, cannot be delegated to NAP In most agencies, a registered nurse (RN) or a health care provider assesses and monitors the patient’s level of sedation, airway patency, and level of consciousness Roles in monitoring depend on scope-of-practice guidelines as determined by state regulations (see agency policy) Copyright © 2018, Elsevier Inc. All rights reserved. 12
- 13. Quick Quiz! After the nurse performs the preprocedure assessment, NAP can assist the health care provider with IV sedation. True or false? A.True. B.False. Copyright © 2018, Elsevier Inc. All rights reserved. 13
- 14. Recording and Reporting • Document vital signs, arterial oxygen saturation (SpO2), end-tidal carbon dioxide (CO2), and sedation level at baseline, then every 5 minutes during the procedure, and every 15 minutes for at least 30 minutes after the procedure per agency policy • Record dosage, route, and time of administration for drugs given during and after the procedure, including reversal agents. Record significant patient reactions during the procedure. Include IV fluids and blood products if administered Copyright © 2018, Elsevier Inc. All rights reserved. 14
- 15. Recording and Reporting (Cont.) • Immediately report to the patient’s health care provider any respiratory distress, cardiac compromise, or unexpected altered mental status • Document discharge teaching, medication reconciliation, discontinuation of IV access, final/discharge assessment, and to whom/how discharged Copyright © 2018, Elsevier Inc. All rights reserved. 15
- 16. Special Considerations Teaching Explain amnesiac effect, transportation requirements, and discharge instructions Pediatric Patients are more likely than adults to have serious complications; preprocedure medical evaluation is required; answer parent questions in a relaxed, confident manner Copyright © 2018, Elsevier Inc. All rights reserved. 16
- 17. Special Considerations (Cont.) Gerontological Closely monitor effects of medications on respiratory status and pulse Patient may experience frustration, sense of loss of control Home care Advise patient to avoid making legally binding decisions for at least 24 hours after the procedure Copyright © 2018, Elsevier Inc. All rights reserved. 17
- 18. Contrast Media Studies: Arteriogram (Angiogram), Cardiac Catheterization, and Intravenous Pyelogram Skill 8-2 Arteriogram (angiogram) Provides visualization of blood vessels and internal organs 18Copyright © 2018, Elsevier Inc. All rights reserved.
- 19. Contrast Media Studies: Arteriogram (Angiogram), Cardiac Catheterization, and Intravenous Pyelogram Skill 8-2 (Cont.) Cardiac catheterization Heart and lungs Intravenous pyelography (IVP) Kidneys, bladder 19Copyright © 2018, Elsevier Inc. All rights reserved.
- 20. Delegation and Collaboration When can the task of assisting with angiography and IVP be delegated to NAP? The nurse directs NAP about: When to obtain and report vital signs, urinary output, and weight Signs and symptoms to report to the nurse Accompanying patient to the procedure room and assisting radiology personnel with specific angiography procedures Copyright © 2018, Elsevier Inc. All rights reserved. 20
- 21. Recording and Reporting • Record patient’s status: vital signs, SpO2/end-tidal CO2, status of peripheral pulses for equality and symmetry, blood pressure for hypotension, temperature and color of catheterized extremity, condition of IV site, and level of patient responsiveness • Record any drainage from puncture site, appearance of dressing, and condition of puncture site Copyright © 2018, Elsevier Inc. All rights reserved. 21
- 22. Recording and Reporting (Cont.) • Report to health care provider any vital sign changes, excessive bleeding or increasing hematoma at puncture site, decreased or absent peripheral pulses, persistent pain, altered neurological status, dysrhythmias, decreased SpO2 or increased end-tidal CO2, or decreased responsiveness after sedation Copyright © 2018, Elsevier Inc. All rights reserved. 22
- 23. Special Considerations Teaching Prepare for hospital stay in case of complications; do not feed infants breast milk produced for 24 hours after the procedure Pediatric Infants and children are particularly susceptible to diuretic effects of radiocontrast dyes Risk of dehydration is present Copyright © 2018, Elsevier Inc. All rights reserved. 23
- 24. Special Considerations (Cont.) Gerontological Monitor vital signs and behaviors closely and watch for hypothermia Home care Follow written discharge instructions Contact health care provider or emergency department (ED) about complications or adverse effects Follow exercise limitations For IVP, drink water to flush media Copyright © 2018, Elsevier Inc. All rights reserved. 24
- 25. Assisting with Aspirations: Bone Marrow Aspiration/Biopsy, Lumbar Puncture, Paracentesis, and Thoracentesis Skill 8-3 Bone marrow aspiration Biopsy Bone marrow cultures help differentiate infectious diseases such as tuberculosis and histoplasmosis Copyright © 2018, Elsevier Inc. All rights reserved. 25
- 26. Assisting with Aspirations: Bone Marrow Aspiration/Biopsy, Lumbar Puncture, Paracentesis, and Thoracentesis Skill 8-3 (Cont.) Lumbar puncture Paracentesis Thoracentesis Copyright © 2018, Elsevier Inc. All rights reserved. 26
- 27. Quick Quiz! The nurse is caring for a patient after a lumbar puncture. To prevent the patient from having a spinal headache, what action will the nurse take? A.Immediately begin physical therapy (PT) exercises. B.Have the patient lie flat. C.Encourage the patient to elevate his feet. D.Ambulate 1 hour after the procedure. Copyright © 2018, Elsevier Inc. All rights reserved. 27
- 28. Delegation and Collaboration The task of assisting with aspirations can be delegated to NAP if the patient is stable (check agency policy) The nurse directs NAP about: How to properly position patient during the procedure When to take and report vital signs Which patient signs and symptoms to immediately report to the nurse Copyright © 2018, Elsevier Inc. All rights reserved. 28
- 29. Recording and Reporting • Record in patient’s chart name of procedure; preprocedure preparation; location of puncture site; amount, consistency, and color of fluid drained or specimen obtained; duration of procedure; patient’s tolerance and comfort level; laboratory tests ordered and specimen sent; type of dressing; postprocedure activities; and other procedure-specific assessments Copyright © 2018, Elsevier Inc. All rights reserved. 29
- 30. Recording and Reporting (Cont.) • Immediately report to health care provider any change in vital signs and SpO2, unexpected pain/discomfort, and any excessive drainage from dressing over the puncture site Copyright © 2018, Elsevier Inc. All rights reserved. 30
- 31. Special Considerations Teaching Expect site tenderness for several days Pediatric Conscious or unconscious sedation is commonly used Prepare preschool children before the procedure; make a game out of recalling the next procedural step Copyright © 2018, Elsevier Inc. All rights reserved. 31
- 32. Special Considerations (Cont.) Gerontological Older adults with arthritis may need help to stay in position; risk for hypoxia; specific fears related to postprocedure falling and fatigue Home care Explain complications, reporting to MD If patient is transferred to long-term care agency, ensure thorough communication Copyright © 2018, Elsevier Inc. All rights reserved. 32
- 33. Care of Patient Undergoing Bronchoscopy Skill 8-4 Bronchoscopy Fiberoptic bronchoscope Used for obtaining sputum, foreign bodies, and biopsy specimens 33Copyright © 2018, Elsevier Inc. All rights reserved.
- 34. Quick Quiz! A 54-year-old man who just underwent a bronchoscopy suddenly is unable to speak. What does the nurse suspect? A.Pulmonary edema B.Pneumonia C.Laryngospasm D.Sinus infection Copyright © 2018, Elsevier Inc. All rights reserved. 34
- 35. Delegation and Collaboration The task of assisting with bronchoscopy cannot be delegated to NAP The nurse directs NAP to: Measure follow-up postprocedure vital signs Position the patient appropriately Immediately report to the nurse if patient has possible respiratory distress or is coughing up blood Copyright © 2018, Elsevier Inc. All rights reserved. 35
- 36. Recording and Reporting • Record procedure(s) performed, character of sputum, duration of procedure, patient’s tolerance, and if any complications, as well as the collection and disposition of specimen(s). Document time of return of gag reflex • Report to the physician immediately bleeding or respiratory distress after the procedure and any changes in vital signs beyond patient’s normal limits. Report results of the procedure to appropriate health care personnel Copyright © 2018, Elsevier Inc. All rights reserved. 36
- 37. Special Considerations Teaching Before procedure, instruct patient to perform good mouth care; patients may receive IV sedation; teach controlled coughing for obtaining serial sputum samples, if ordered Pediatric Procedure is usually performed to remove foreign bodies; higher risk for hypoxia Copyright © 2018, Elsevier Inc. All rights reserved. 37
- 38. Special Considerations (Cont.) Gerontological Risk of hypothermia Postprocedure restlessness often indicates hypoxemia or pain Home care Notify physician if adverse symptoms develop Manage throat discomfort with throat lozenges or warm saline gargles Copyright © 2018, Elsevier Inc. All rights reserved. 38
- 39. Care of Patient Undergoing Endoscopy Skill 8-5 Endoscopy Direct visualization Biopsy, polyp removal, assistance with other procedures 39Copyright © 2018, Elsevier Inc. All rights reserved.
- 40. Care of Patient Undergoing Endoscopy Skill 7-5 (Cont.) Visualization of upper gastrointestinal (GI) tract Visualization of hepatobiliary tree and pancreatic ducts Visualization of lower GI tract 40Copyright © 2018, Elsevier Inc. All rights reserved.
- 41. Delegation and Collaboration The task of assisting with endoscopy cannot be delegated to NAP The nurse directs NAP about: How to assist with patient positioning Copyright © 2018, Elsevier Inc. All rights reserved. 41
- 42. Recording and Reporting • Record procedure, duration, patient’s tolerance, complications and interventions, and collection and disposition of specimen • Report to physician onset of bleeding, abdominal pain, dyspnea, and vital sign changes Copyright © 2018, Elsevier Inc. All rights reserved. 42
- 43. Special Considerations Teaching Explain what to expect during and after the procedure Pediatric Introduction of endoscope in infants and small children who have a narrow and collapsible airway may result in respiratory distress Copyright © 2018, Elsevier Inc. All rights reserved. 43
- 44. Special Considerations (Cont.) Gerontological Age-related changes; risk of hypothermia; careful monitoring Home care Patient might have hoarseness or sore throat after upper GI procedure Notify physician if patient has adverse symptoms Copyright © 2018, Elsevier Inc. All rights reserved. 44
Editor's Notes
- This chapter reviews five skills: intravenous moderate sedation; contrast media studies: arteriogram (angiogram), cardiac catheterization, and intravenous pyelogram; assisting with aspirations: bone marrow aspiration/biopsy, lumbar puncture, paracentesis, and thoracentesis; care of patient undergoing bronchoscopy; and care of patient undergoing endoscopy.
- The health care provider is responsible for providing the patient with an explanation of the test/procedure, risks, benefits, treatment options, and outcomes before the procedure as part of the informed consent process. [Discuss with students: a typical day for a nurse performing diagnostic procedures.]
- It is crucial for nurses to ensure that patients requiring diagnostic testing understand their testing and postprocedural care requirements. Some tests require intravenous (IV) sedation along with the diagnostic procedure, such as a gastrointestinal endoscopy; others require contrast media or aspirations. Diagnostic procedures pose some risk for the patient. It is important that you understand the diagnostic procedure, including why the procedure is needed, which preprocedural assessments are needed, expected outcomes, your role during the procedure, potential risks, actions appropriate in the event or unexpected outcomes, and appropriate postprocedural nursing care, to help ensure patient safety. IV sedation is used for diagnostic or surgical procedures that do not require complete or general anesthesia. Sedation classifications include “minimal,” “moderate,” or “deep” sedation/analgesia, depending on the depth of sedation. Objective scales such as the American Society of Anesthesiologists (ASA) physical status classification system are used to determine if patients are at risk for undesirable outcomes. Use of an objective scale can reduce the risk for complications by determining when it is prudent to involve an anesthesiologist to help manage the care of a complicated patient condition. These scales incorporate evidence-based guidelines to reduce the risk for sedation-induced complications such as cardiac arrhythmias, respiratory failure, renal failure, neurological disorders related to the use of paralytic agents, or bleeding disorders resulting from hepatic failure.
- Most of these procedures cause moderate discomfort, and the patient tolerates them better if you remain at the bedside and explain each step [Ask students: what is an example of a way that you could address a patient’s fears? Discuss: for example, if a patient worries about being physically exposed during a procedure, communicate with procedure staff to see if there is a way to minimize exposure and use more draping.]
- Patients undergoing lumbar puncture (LP) are at risk for experiencing oversedation and site complications of postprocedure headaches (PPHD) and excessive loss of cerebral spinal fluid (CSF). In addition, the procedure itself can be painful for the patient, therefore research has focused on ways to make the patient more comfortable during and after an LP and risk factors of LP. Although an epidural blood patch may be effective in treating postpuncture headaches in some patients, it is not effective in preventing these headaches, and leads to intracranial hypertension. Pain management can be achieved in children by reducing intravenous opioids when using an adjunctive eutectic mixture of local anesthetics (EMLA) pain reliever in conjunction with propofol. Rest, fluids (including caffeinated beverages), and analgesics have been considered effective measures for managing headache, pain, although little evidence supports extensive rest, and fluids. A recent updated review of the literature concluded that there was no evidence suggesting that routine bed rest after LP is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH also remained unclear. There are a variety of factors that contribute to postprocedure complications including puncture needle size, excessive bed rest, epidural injections of saline, and numerous patient characteristics including age, gender, pregnancy, BMI, and previous lumbar puncture history. [Ask students: why do caffeinated beverages help with headache management? Discuss: caffeine can make headache medications more effective. (Caffeine is a common ingredient in over-the-counter (OTC) and prescription headache medicines.)]
- 1. [Ask students: what are some ways to ensure that the right patient is undergoing the right procedure? Discuss: ensure proper identification of a patient by using a minimum of two identifiers, verifying the correct procedure (and site, when applicable). This includes verbal verification and written/computerized documentation of the preceding information on patient arrival, again in the procedure room, and just before the start of a procedure (see agency policy).] Assess for completion of relevant documentation (e.g., history and physical, signed procedure consent form, nursing assessment, preanesthesia assessment) necessary for performing a safe procedure. Identify any medications for which uninterrupted dosing is required (e.g., anticonvulsants, antibiotics, certain cardiac medications). If the procedure requires a patient to have nothing by mouth (NPO), discuss medications with the health care provider to decide whether the patient should take any medications before the procedure. When insulin or oral hypoglycemic medications are given to patients before procedures, arrange to have the patient’s meal or other nutrition support available on completion of the procedure.
- [Ask students: what are some ways to minimize radiation exposure? Discuss: minimize the amount of radiation exposure by using protective shielding devices such as a lead apron and goggles, radioprotective gloves, and/or a thyroid shield. Monitoring staff radiation exposure may require the use of a dosimeter (see agency policy). Remain positioned as far away from the radiographic equipment as possible while still performing required patient care.]
- [Ask students: what are examples of adverse sedative effects after a procedure? Discuss: vomiting, hypoxic events.]
- Moderate sedation/analgesia produces a minimally depressed level of consciousness induced by the administration of pharmacological agents in which a patient retains a continuous and independent ability to maintain protective reflexes and a patent airway and is aroused by physical or verbal stimulation. Moderate sedation improves a patient’s cooperation with a procedure, allows a rapid return to his or her preprocedure status, and minimizes the risk for injury. It often raises a patient’s pain threshold and provides amnesia concerning the actual procedural events. Deep sedation is one risk associated with moderate sedation when a patient’s level of consciousness depresses past the point at which he or she cannot maintain a patent airway. Because of this risk, the use of IV moderate sedation is closely controlled. Because of this risk, the use of IV moderate sedation is closely controlled and normally restricted to physicians and registered nurses (RNs) who receive specialized training or credentialing. Benzodiazepines reduce anxiety and promote muscle relaxation. Midazolam also produces an amnesic effect. Opiates such as morphine sulfate or fentanyl help control pain while achieving sedation. Propofol, a safe, rapid-acting hypnotic, is also commonly used, and may offer a faster recovery time than the combination of benzodiazepines and opiates. Patient risks during IV sedation include hypoventilation, airway compromise, hemodynamic instability, and/or altered levels of consciousness that include an overly depressed level of consciousness or agitation and combativeness. Emergency equipment appropriate for the patient’s age and size and a staff competent in airway management, oxygen delivery, and use of resuscitation equipment are essential Cross reference verified. During a procedure patients need continuous monitoring (recorded at least every 5 minutes) of heart and respiratory rate and rhythm, blood pressure, oxygen saturation, and level of consciousness. End-tidal CO2 is also becoming a common parameter for monitoring sedation tolerance. [Ask students: have you ever been under moderate sedation? Describe your experience. Discuss: answers will vary.]
- [Discuss with students: describe your agency policy and the state regulations in your area.]
- Correct answer: B, False Rationale: The task of assisting with intravenous sedation, including the preprocedure assessment, cannot be delegated to nursing assistive personnel (NAP).
- [Discuss with students’ examples of significant patient reactions and how they would be recorded.]
- [Ask students: what are some examples of how a patient can be discharged? Discuss: designated driver, ambulance/transporter, nursing home.]
- Teaching Explain that it is unlikely for patients to remember the procedure because of the amnesic effect of the sedative(s). Before the procedure, instruct patient to arrange for transportation to home after the procedure because (at most agencies) patient will not be permitted to drive for 24 hours after receiving sedation. Provide patients and family caregivers with discharge instructions that include complications that may occur; how to manage complications; and physical signs and symptoms to be reported to the health care provider, including contact information and postprocedure medication reconciliation and instructions. Pediatric Children are more likely than adults to sustain a serious complication resulting from anesthesia. Such complications are often linked to the cardiovascular or respiratory system. For this reason, the American Academy of Pediatrics recommends that personnel who are able to manage a child’s airway should be present for the procedure. A preprocedure medical evaluation is required. To safely administer sedation to a pediatric patient, consider anatomic and physiological variations, preprocedure assessments, and pharmacological techniques. During the preprocedure assessment, answer parents’ questions in a relaxed and confident manner. [Ask students: should you answer children’s questions? Discuss: yes. When communicating with children, take into account the child’s developmental stage.]
- Gerontological Closely monitor the effects of medications on patient’s respiratory status and pulse. [Ask students: why must these patients be monitored for the effects of medications on respiratory status and pulse rate? Discuss: these drugs interfere with breathing or increase or decrease heart rate as a result of reduced drug clearance through the kidneys or liver.] Physical limitations of the patient, including hearing and vision loss, contribute to frustration and confusion, compounding the sense of loss of control. Due to aging liver some medications are not metabolized as rapidly as they might be in younger patients.
- Contrast media studies involve visualization of blood vessels and internal organs by intravascular injection of a radiopaque medium. An arteriogram (angiogram) permits visualization of the vasculature and arterial system of an organ. Arteriography is usually performed by an interventional radiologist. Arteriography is usually performed by an interventional radiologist to diagnose arterial or venous occlusions; stenosis; emboli; thromboses; aneurysms; tumors; congenital malformations; or trauma to the brain, heart, lung, kidneys, or lower extremities. [Shown is Figure 8-1: Pulmonary arteriogram shows obstruction (arrows) of right pulmonary artery. (From Eisenberg R, Johnson N: Comprehensive radiographic pathology, ed 4, St Louis, 2007, Mosby.)] [Provide students with additional examples.]
- Cardiac catheterization is a specialized form of angiography performed by an interventional cardiologist. A contrast medium is injected, and the structures and functions of the heart and lungs are assessed. The test studies pressures within the heart, cardiac volumes, valvular function, and patency of coronary arteries. Cardiac catheterizations are performed in specially equipped laboratories. Cardiac catheterizations are contraindicated in patients who would refuse needed surgery, are allergic to iodine contrast media, are uncooperative or cannot lie still during the entire procedure, or are susceptible to dye-induced renal failure. People at particular risk for renal issues or contrast induced nephrotoxicity (CIN) are those with preexisting renal dysfunction, diabetes mellitus, congestive heart failure, hyper- or hypotension, advanced age, anemia, or multiple myeloma. Interventions to help prevent dye-induced renal failure are controversial and include ensuring that the patient is well hydrated using bicarbonate solution or sodium chloride with or without prophylactic N-acetylcysteine. Additionally, statins and vasodilators have also been explored as agents to reduce dye-induced renal failure. Intravenous pyelography (IVP) (also called intravenous urography) is a venographic examination of the flow of radiopaque contrast medium through the kidneys, ureters, and bladder to identify obstruction, hematuria, stones, bladder injury, or renal artery occlusion. Dye is injected into a peripheral vein, and serial radiographs are taken over the subsequent 30 minutes. [Shown is Figure 8-2: Cardiac catheterization laboratory. (Image used with permission, Flagstaff Medical Center, Northern Arizona Healthcare. All rights reserved.)] [Provide students with additional examples.]
- Can be delegated if patient is stable and no IV sedation is used. The skill of assisting with cardiac catheterization can be delegated to specially trained NAP with a nurse continuously present. The nurse provides continuous patient assessment and monitoring for serious complications. The NAP helps with patient transport, positioning, and obtaining supplies.
- Teaching See Skill 8-1, Teaching Considerations. Prepare patient to stay in the hospital if complications occur, or if an intervention necessitates prolonged postprocedure vascular checks. Because the dye can transfer to breast milk, teach women who are breastfeeding to substitute formula or previously pumped breast milk for infant feedings, disposing of any pumped breast milk for 24 hours after the procedure. Pediatric [Ask students: why are infants and children particularly susceptible to the diuretic effects of radiocontrast dyes? Discuss: because of their small body size and immature renal/hepatic system.] In addition, those with congenital cardiac anomalies develop compensatory erythrocytosis and thus experience complications from dehydration very quickly. Emphasize to the parent(s) or caregiver the importance of fluid intake for the child after the procedure. Urinary output should exceed 1 mL/kg/hr.
- Gerontological Physical exposure and low room temperature contribute to hypothermia in frail older adults who are unable to communicate that they are cold. Use heated blankets or forced-air heat to maintain core temperature at comfortable, safe levels. In older adults, slight alterations in vital signs or behavior are signs of impending problems; therefore, close monitoring is important. Home care [Ask students: what are some of the symptoms of complications and adverse effects? Discuss.] On discharge, provide patient with written instructions to contact the health care provider (or affiliated emergency department) if the following should occur after arteriogram or cardiac catheterization: Bleeding from the catheterization puncture site; apply gentle pressure with a clean gauze or cloth. Formation of a knot or a lump under the skin that increases in size. Worsening of a bruise or its movement down the extremity rather than disappearing. Pain at puncture site or in the extremity used for the catheterization. Extremity is pale and cool to the touch where arterial puncture is made. Appearance of redness, swelling, or warmth of the affected extremity. After arteriogram or cardiac catheterization, instruct patient not to drive or climb stairs for 24 hours; to avoid sports, strenuous activity/housework, and lifting (e.g., groceries, children) for 3 days; and to avoid taking baths until the wound has healed. On discharge after an IVP, instruct patient to: Drink at least 64 ounces (1 to 2 liters) of water to help flush contrast media through the kidneys. Watch for signs of a delayed reaction to the contrast medium for 24 hours after the procedure, and call the health care provider or go to the nearest emergency department.
- Aspirations are sterile invasive procedures involving the removal of body fluids or tissue for diagnostic procedures. Bone marrow aspiration is the removal of a small amount of the liquid organic material in the medullary canals of selected bones. A biopsy is the removal of a core of marrow cells for laboratory analysis. Both aspiration and biopsy diagnose and differentiate leukemia, certain malignancies, anemia, and thrombocytopenia. The marrow is examined in a laboratory to reveal the number, size, shape, and development of red blood cells (RBCs) and megakaryocytes (platelet precursors). Bone marrow cultures help differentiate infectious diseases such as tuberculosis (TB) or histoplasmosis. Potential complications of bone marrow aspiration or biopsy include bleeding, especially if coagulopathy is present; infection; and, less commonly, organ puncture. [Review with students Table 7-3, Summary of Aspiration Procedures.]
- A lumbar puncture (LP), called a spinal puncture or tap, involves the introduction of a needle into the subarachnoid space of the spinal column. The purpose of the test is to measure pressure in the subarachnoid space; obtain cerebrospinal fluid (CSF) for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. CSF is examined in a laboratory to help diagnose spinal cord tumors, central nervous system (CNS) infections, hemorrhage, and degenerative brain disease. The major contraindication for LP is evidence of increased intracranial pressure (ICP). Spinal punctures are contraindicated in patients who are suspected of having increased intracranial pressure. Abdominal paracentesis involves aspiration of peritoneal fluid from the abdomen. Cytological analysis of the aspirate detects the presence of bacteria, blood, glucose, and protein to help diagnose the causes of an abdominal effusion. Lavage paracentesis, in which a lavage of solution is instilled and then is withdrawn, is done to detect the presence of bleeding, as in cases of blunt abdominal trauma or tumor cells when cancer is suspected. Thoracentesis is performed to analyze or remove pleural fluid or to instill medications intrapleurally. Cytological studies of specimens reveal presence of blood, glucose, amylase, lactate dehydrogenase (LD), and cellular composition. Cytological specimens are also examined for malignancy, differentiated between transudative and exudative characteristics, and cultured for pathogens. The following cause transudate in the pleural space: ascites, cirrhosis (hepatic), heart failure, hypertension (pulmonary, systemic), nephritis, and nephrosis. Therapeutic thoracentesis relieves pain, dyspnea, and signs of pleural pressure.
- Correct answer: B Rationale: Instruct patient to remain flat and to logroll according to physician orders. Postprocedure headache (PPH) is evidenced by headache, blurred vision, and tinnitus.
- Assessment of the patient’s condition must be completed by the nurse and cannot be delegated.
- [Ask students: what are examples of other procedure-specific assessments? Discuss: extremity assessment, abdominal girth, level of consciousness.]
- Teaching Mild analgesia often helps to relieve some of the discomfort of site tenderness. Pediatric If unconscious sedation is used, an anesthesiologist or nurse anesthetist will be needed for the procedure. [Ask students: what is the purpose of making a game out of the procedure for children? Discuss: it will serve as a distraction.]
- Gerontological Older adults have reduced elastic lung recoil, weaker cough efficiency, and decreased chest expansion. Restlessness may indicate hypoxia after thoracentesis. Be aware that older adults may have specific fears and anxiety related to postprocedure falling and fatigue. Home care Teach patients and family caregivers about specific postprocedure complications and when to report them to the health care provider. If patient is transferred to long-term care agency, ensure thorough communication between facilities regarding results of procedure and patient condition.
- Laser ablation of endotracheal lesions may also be performed through the bronchoscope. Bronchoscopy is the examination of the tracheobronchial tree through a lighted tube containing mirrors. A flexible fiberoptic bronchoscope has lumens that allow both visualization and simultaneous administration of oxygen. [Shown is Figure 8-4: Flexible fiberoptic bronchoscopy.] Bronchoscopy may be an emergency or elective procedure and may be performed for diagnostic or therapeutic reasons. The main purposes of this procedure include aspirating excessive sputum or mucus plugs that airway suctioning cannot remove; visualizing the tracheobronchial tree for assessment of abnormalities of the mucosa, abscesses, aspiration pneumonia, strictures, and tumors; obtaining deep-tissue biopsy and sputum specimens; and/or removing foreign bodies. This procedure is contraindicated in patients who cannot tolerate interruption of high-flow oxygen unless intubated. Potential complications of bronchoscopy include fever, infection, hypoxemia, bronchospasm and/or laryngospasm, pneumothorax, aspiration, dysrhythmias and hypotension, hemorrhage (after biopsy), and cardiac arrest. The procedure is performed at the bedside or in a specially equipped endoscopy room.
- Correct answer: C Rationale: Potential complications of bronchoscopy include fever, infection, hypoxemia, bronchospasm and/or laryngospasm, pneumothorax, aspiration, dysrhythmias and hypotension, hemorrhage (after biopsy), and cardiac arrest. Symptoms of laryngospasm include the following: the vocal cords suddenly seize up, blocking the flow of air into the lungs; people with this condition may be awakened from a sound sleep and may find themselves momentarily unable to speak or breathe.
- NAP may measure follow-up postprocedure vital signs after the nurse’s initial assessment. Patient positioning is based on the procedure and on the patient’s limitations.
- Teaching Before the procedure, instruct patient to perform good mouth care. [Ask students: what is the purpose of performing mouth care before the procedure? Discuss: this decreases the risk for introducing bacteria into the lungs during the procedure.] In some cases, patients may receive IV sedation (refer to Skill 8-1, Teaching Considerations). If ordered, teach patient how to perform controlled coughing techniques for obtaining serial sputum samples. Pediatric In children, the procedure is most frequently performed with the patient under general anesthesia to remove foreign bodies from the larynx or trachea. Follow-up care after the foreign body is removed includes chest physiotherapy, monitoring for respiratory distress, and teaching of parents. Children are at higher risk for hypoxemia than adults because their bronchus is smaller and the bronchoscope decreases the available breathing space.
- Gerontological Physical exposure and room temperature contribute to hypothermia in frail older adults who are unable to communicate that they are cold. Use warmed blankets or forced-air heat to maintain core temperature at comfortable, safe levels. Postprocedure restlessness often indicates hypoxemia or pain. Thoroughly assess pulmonary capacity before administering opioids, which may depress the respiratory centers. Home care Instruct ambulatory care patients to notify the physician if the following symptoms develop: fever, chest pain or discomfort, dyspnea, wheezing, or hemoptysis. Throat discomfort is managed with throat lozenges or warm saline gargles.
- Endoscopy allows direct visualization of an internal organ or structure by means of a long, flexible fiberoptic scope. The tip of the scope has a light source and a camera lens that allow visualization of the lining of gastrointestinal (GI) structures on a large display screen. Besides direct observation, endoscopy enables biopsy of suspicious tissue, polyp removal, and performance of many other procedures such as direct visual guidance for fine-needle aspiration biopsies and dilation and stenting of strictures. Risks of endoscopic procedures include intestinal perforation, hemorrhage, peritonitis, aspiration, respiratory depression, and/or myocardial infarction secondary to vasovagal response. Both upper and lower GI endoscopic examinations may be performed in a specially equipped endoscopic unit or at the patient’s bedside. [Shown is Figure 8-5: A, Scope view of healthy colon. B, Overview of colonoscopy process. C, Path of scope through colon.]
- For visualization of the upper GI tract, esophagoscopy, gastroscopy, gastroduodenojejunoscopy (GDJ), or duodenoscopy is performed, or, more frequently, esophagogastroduodenoscopy (EGD), which permits visualization of the esophagus, stomach (Fig. 8-6), and duodenum in one examination. For visualization of the hepatobiliary tree and pancreatic ducts, an endoscopic retrograde cholangiopancreatography (ERCP) is performed. For visual examination of the lower GI tract, proctoscopy, sigmoidoscopy, or colonoscopy is performed. Typically, patients receive IV moderate sedation. [Shown is Figure 8-6: Stomach may be visualized by means of a fiberscope.]
- Teaching Upper GI endoscopy: Explain method for endoscope insertion. Prepare patient for a slight feeling of not being able to breathe. Assure him or her that this feeling is common, but that air is delivered through the endoscope and suffocation will not occur. [Ask students: during the procedure, the patient will not be able to speak after the endoscope is positioned in the esophagus. What can you do to be sure the patient is able to communicate? Discuss: teach patient simple hand signals for pain or discomfort.] Lower GI procedures (colonoscopy, sigmoidoscopy, proctoscopy): Explain that it is normal to experience increased flatus and abdominal cramping Small amounts of blood in the stool are common if a biopsy specimen was taken.
- Gerontological Older adults frequently have reduced drug clearance from decreased glomerular filtration rate (GFR) and nephron activity or decreased hepatic function. It is important to monitor the effects of medications given to older adults. Because of age-related changes in older adults, the gastric mucosa is thinner, and this increases the incidence of irritation and ulceration. Physical exposure and room temperature contribute to hypothermia in frail older adults who are unable to communicate that they are cold. Use warmed blankets or forced-air heat to maintain core temperature at comfortable, safe levels. Some older adults experience dehydration, electrolyte imbalance, and exhaustion from pretest preparation. If the procedure is done on an ambulatory care basis, it is helpful to have someone stay with the patient for at least 24 hours afterward. Home care Explain that patient might have hoarseness or a sore throat after an upper GI procedure. Patient can be given ice chips or anesthetic lozenges after gag reflex returns. Instruct patient or family to notify physician if patient has a fever, abdominal pain, rigid abdomen, and rectal bleeding or blood in stool.