In this session we are going to talk about
diagnostic tests. We are going to talk about
risk potentials when helping or monitoring a
patient before, after or during a diagnostic
tests. My name is Diana Shenefield. Let’s
get started. The review of diagnostic tests
falls under the NCLEX heading of reduction
of risk potential. Because we know a lot of
things can go wrong during a diagnostic test
depending on what’s going on. So we want
to make sure that we understand what our role
is getting the patient ready. If we are helping
with the diagnostic test and then afterwards
how can we monitor the patient.
Learning outcomes, make sure that you understand
the diagnostic test. Even if you are not the
one performing it you need to have an understanding
of what the patient is going to be going through,
what kind of dyes, what kind of drinks, maybe
that they are going to be given, what kind
of medications are they going to be given.
So that when they come back to you, you will
be able to monitor them effectively. So we
are going to start with a question. A patient
is undergoing a peritoneal dialysis. If you
don’t know a peritoneal dialysis you just
need to go back and review that. The dialysate
dwell time is completed, and the clamp is
opened to allow the dialysate to drain back in
to the bag. The nurse notes that the drainage
has stopped and only 500 ml of dialysate has
drained. She knows or he knows that they put
in 1500. So what is the best thing for the
patient to do? What for the nurse to do?
What intervention do we need to do to keep our
patient safe? A, should we just change the
patient’s position? B, should we call the
physician? C, should we check the catheter
for kinks and obstructions? Or D, should we clamp
the catheter and instill more dialysate at
the next exchange time. So think about
what’s going on with the
patient, and think about what could be wrong, and
hopefully you picked to check the catheter
of kinks. That’s one of the first things you
should always do when you have a catheter
or you have an IV line. Always look to make sure
that there is not any kinks. Second question.
Which nursing action is required before a
patient in labor receives an epidural?
Now even if you are not planning on to working
in OB you need to make sure that you understand
when any patients gets an epidural. What do
you need to know as a nurse? A, should you
give a fluid bolus of 500 ml? B, should you
check the maternal pupil dilation? C, assess
maternal reflexes or D, assess maternal gait?
Now lot of those may seem like something that
you should do if you are going to assess with
an epidural. But don’t forget epidurals
cause hypertension. So you want to make sure
you give that 500 ml bolus before. So again
you want to make sure you go back. There is
a lot of tests that you probably can
be very familiar with. But if there is test
that you are not as familiar with, if you
want to make sure you can go back and look
at those. So ideally what should be done?
We know that most tests ideally should be
done in the morning. When the patient first
wakes up, when the body is just getting going.
But we know that does not always happen.
But if you can get your patient prepared for early
morning testing, it work out a lot better.
A lot of times, a lot of the tests, the patients
has to be NPO. If they have to be NPO most
of the time is 8 to 12 hours. That’s something
that you need to know 8 to 12 hours ahead of
time, so that you can make sure that your
patient is NPO.
And then what kind of precautions? Is there
going to be bleeding? Is there going to be
saliva? What are we need to be watching for
this? So that we can prepare ourselves and
anybody elses coming in contact with the
patient that’s going to be getting the test.
What do you need to know pre-op? I need to
know a little bit about my patient. If I am
going to take care of them after the test,
I need to know what their baseline is. I need
to understand what’s their heart rate
before, what’s their blood pressure, what’s
their kidney function. Because I need to be
able to monitor if anything is different.
So understanding what your role is at the
beginning of the diagnostic tests will help
with that the end of the diagnostic
test as well.
One of the things that we want to do is reduce
anxiety. We know the patients coming to the
hospital and they are scared. They don’t know
what’s going on and then all of the sudden
the physician orders diagnostic tests. We
come and then we say you are going to have
this done, you are going to have this done.
All of that causes a lot of anxiety for the
patient because they don’t understand like
we do. What’s going to happen? They don’t
understand which ones are invasive, which
ones are non-invasive. So to put the patient
at ease, we need to do a lot of education.
So that we don’t increase the anxiety level.
We know that increase anxiety causes increased
heart rate, and it also delays healing.
So we want to make sure we are doing our part
with making sure that our patient is well informed.
For non-invasive procedures, we know that their
consent that they signed to be treated is enough.
But I also need to know which procedures do they
need to have consent for the procedure.
I would need to know that so that I can help
the patient prepare. Does there need to be
medications at the beginning? Does the patient
need to half voided? Or are they going to need
to have a full bladder? All of those things
are things that I need to understand
because I don’t want to send a patient for a diagnostic
tests have them not be prepared. Because that
is just going to increase their anxiety. It
also increases length of stay, it also cost
on the patient and the hospital a lot of money.
So I need to understand what’s going on,
what body part is going to be examined, and
what’s going to happen to the patient.
Invasive tests. Don’t forget you got to have
that informed consent and to get an informed
consent, your patient needs to understand exactly
what is going to happen to them. That also
means pediatric patients and that means parents
as well. You need to make sure that when they
sign that consent that they know exactly what
the physician is going to be doing to them.
They need to know the procedure, they need
to know how they are going to feel afterwards,
not only what’s going to happen to them
during, but what’s going to happen afterwards.
Again does the patient need to be NPO or is
that okay for them to eat and drink. If I let
a patient that needs to be NPO eat or drink,
that just delays treatment and it delays length
of stay and causes a lot of anxiety. Does
there a need to be any kind of pretesting.
We know for some procedures maybe they need
to have an EKG if their heart problems before.
I need to make sure as a nurse that I understand
that and I have that done. Again to release
a lot of anxiety so that patients are coming
back and forth and also it doesn’t make
you look very confident as a nurse and the
patients not going to trust you as much.
So what are the complications? I need to know
that. What are the things that could happen
to the patient during the procedure and after
the procedure? What is my responsibility during
and after? What should I be doing to help
prevent any complications?
Diagnostic tests. There are a lot of diagnostic
tests and I know that you have seen in clinical
patients going for a lot of tests and depending
on what floor you work on or what group of
patients you work on, you know some of the
common ones. So you need to review those
and some of the common kind of general tests
are biopsies, CT scan, fluoroscopy, MRIs,
nuclear scans, PET scans, ultrasound,
x-rays. Again for the nursing profession lot
of those seem like no big deal but for the
patient coming in they don’t understand
everything that’s going to happen to them
and so a lot of education needs to go on.
Respiratory. If they are looking at the lungs
they may going for bronchoscopy. And that may
sound like no big deal but there is your patient
know that that they are going to have a tube
put down their throat. That right there can
cause a lot of anxiety. They may be worried
that they are going to be awake. They may
be worried that they might stop breathing
if they are messing with their lungs.
Again that needs to come from the nerves.
That needs to have them explain to them what’s
going to happen and what you are going to
do afterwards. Things like ventilation scans
or pulmonary function tests. Many patients
that have respiratory problems know about
pulmonary function test. But maybe you have
a 12-year old who is just recently been diagnosed
with asthma. They don’t know what’s going
to happen to them. So make sure that you are
talking to them about their lungs and what
the physicians looking for. Cardiovascular. If
you have been in the Cath lab,
they do lots of diagnostic tests. Things like
angiogram, cardiac cath, echos, EKGs, Holter
monitoring, stress tests. Again some of those
are invasive and some of them are not. So
preparing your patient. Especially they are
going to have a Holter monitoring, do they
understand that they are going to have to
wear that for 24 hour or may be a week at
a time. They may think they are just walking
in and getting a test and walking out.
So if all of the sudden the doctor says "See you in
a week, you got to wear of that." All of the
sudden they are confused, they are anxious,
they may be think something went wrong, so they
have to wear it for longer. So giving a lot education,
you know is anything bad going to happen, know
the Holter Monitor. If they take it off the
only thing is that they're not going to get to the
readings from their heart. But other tests
say that they have a cardiac cath. We know
that cardiac cath when they come back post
op, and there is a risk of bleeding.
There is a risk of bleeding when they go home. So
we need to understand as nurses what do I
need to know right away and what do I need
to teach the patient to help to lower their
anxiety. Urinary. Cystography.
Do they have to have
a fully catheter put in? A lot of times patients
don’t understand when they are going to
have urine testing that it isn't just looking
at their urine. But they may have to have
a fully catheter put in and that can cause
a lot of anxiety. We also have to watch for
infection with that or is that a retrograde
or is that an IVP and are they allergic to
the dyes. We need to watch for that and we
need to ask that. We can’t just assume that
somebody else has done that for them.
Neurological testing. EEGs. We do a lot of
EEGs on kids when we looking for seizure
activity and they don’t always understand.
And a lot of times the parents don’t understand
that those can go on for 24 to 72 hours. That
24 to 72 hours of having those electrodes stuck
to your head being combine to one little area
where the camera could keep an eye on you.
If parents are not aware of that, it’s really
hard to keep kids still for 24 to 72 hours. So
they need to know that and nurses need to
come up with ways to entertain the kids. So
that they don’t get frustrated. So again
all of that is knowing what my patients coming
in for, being prepared for that. Now is there
anything bad that is going to happen after
that, probably not. The electrodes come off
when they go home. But again have I caused
a lot of anxiety and a lot of stress by not
preparing my patient. ICP monitoring. Obviously
ICP monitoring usually
happens invasively and usually happens in
the ICU. So may be the patient doesn’t know.
But what about the family members. They are
kind of concerned when they see bolts coming
out of somebody’s head. I need to be watching
for infection. So again a lot of teaching
and a lot of what if this happens, am I
prepared for that.
Muscular. You know, people com in all the time. They
have torn ACL and they may think we will just
go in and fix it. But a lot of times they have
to go in and do scopes. So do they understand
what that means as well? Gastrointestinal testing. We
do those all
the time. Do they understand? Are they going
to be drinking dye or they going to have an
enema? A lot of patients again think that how are
you going to look at my lower intestines?
Can you just take an x-ray? Do they understand
that you are going to put a scope in their
rectum? Are they going to have to be sedated?
May be they did know that. Did they bring
somebody with them that can drive them home
after they have been sedated? As a nurse am
I prepared to watch that patient after they
have been sedated to make sure that they are
not having any problems? All of that comes
from my education of knowing what’s going
on with the tests and how to take care of
the patient and what to teach the patient
when they go home? What about that barium enema
or the barium swallow? We need to make sure
that that gets out of their system. A lot of
teaching, I can’t just send the patient
home. So look through this list of diagnostics.
See if there is one there that may be you are not quite
as familiar with and read through them and
be familiar with the part of the body that
they are looking at to kind of give you a
clue on what you need to watch for afterwards
and what kind of complications or what type
of patient prep you need to be educating the
patient with. Reproductive. Again lots
of reproductive testing.
Mammography is the biggest one. You know the
patient comes in, they go out. You may need
to do some education on what is a mammogram
and is it going to automatically tell them
if they have cancer? What happens if it does
tell them they have cancer? It isn't that the
person that is doing a mammography that’s
going to explain to them what to do. It is going
to be the nurse afterwards. So again make
sure you are reading through this and that you
understand. Skin testing, TB testing. Most
of us know
about TB testing and allergy testing mostly
happens in an allergist office. But again being
able to explain to patient on what’s going
on. Obviously, what both of these tests involves?
Needles. So understanding that you will be
poked with the needle and what that means,
will there be bleeding, and watching for infection.
Again, all of those are the responsibility of
the nurse and for me to take on that responsibility,
I need to understand what’s being tested
and what can happen. Other tests that nurses
do, that don’t involve
blood testing, things like oxygen saturation.
Don’t forget how to do your O2 sat.
Don’t forget what causes low readings and high readings.
Because you are responsible to know if the
result you are getting is accurate? And what
could be variables for that. Gastric pH, making
sure that you are using the right solvent.
Making sure that it’s not expired.
Testing for occult blood, testing for urine specific
gravity. Again these are all tests that nurses
do directly. You want to make sure you know
how to do them correctly. What you are looking
for and is there any post procedure complications
for the patient. Again what must you know?
You got to know is the patient allergic
to dyes. Now lot of times patients will
say “I don’t know. I never had a dye before.”
So what else can we ask them? Are they allergic
to shell fish, to shrimps, those kind of things?
What is their renal function? Does the patient
need to be NPO? What if the patient is diabetic?
What I need to do that to cover that patient
if I am going to make them NPO? When do I
need to check their blood sugar? Will they
be sedated? Do I need to protect their airway?
Do I need to watch for them to wake up afterwards?
Those are all things that need to be running
through your mind. How do I know if they've regained
their gag reflex? What’s the possibility
of respiratory depression? If they have been
given a medication to sedate them, what do
I need to be watching for and could they go
into respiratory arrest? What about bleeding?
Do I need to watch for bleeding? Do I need
the hold pressure? Do I need to teach the
patient how long afterwards to watch for bleeding?
Again these are all things that I need to
know when I am following a certain diagnostic
test. Also is there a possibility of a change
in level of consciousness. If the patient
is not acting completely right afterwards,
I don’t just send them on. But is there
something especially with neurological testing,
that could cause a deficit in their level of
consciousness. Is it a GI test could I cause,
by the test, constipation,
when we talk about barium testing? You want
to make sure that the patient drinks plenty
of fluids when you send them out the doors
if they don’t get constipated. Is there
a renal test? Did I put a fully catheter in
Do I need to watch for infection?
Did I stimulate the bladder or did I cause a
bladder infection? I need to make sure
I am watching for urine output. We talk about
claustrophobia. Patients that have CT scans
and MRIs. We may think it’s no big deal.
We may think that we know what’s going on.
But when you are a patient you don’t know
anything about a MRI machine and you walk
into that room and you see this huge machine
that's making all these noise, it causes a lot
of anxiety for patients, whether they are adults
or children. So we need to make sure that
we are educating them and we are getting them
anti-anxiety medicines. If they need it, if
they are claustrophobic. Is there a fetus
involved? You know the patient just because
they are not showing doesn’t mean that they
couldn’t be pregnant. Will the dye or will
the procedure may be cause damage to the fetus.
May be patient doesn’t even know that they
are pregnant. Maybe I need to recommend testing
a pregnancy test for them. That may be they
never even told the physician. I wouldn't know
that if I wasn’t educated on what’s going
to happen to the patient during the testing.
Things like the results, are they going
to affect the patient and the family. You
know we may think “Okay, yeah it is positive”
and we send the patient on. But what’s going
to happen to that patient in family? And do they
understand what a positive test means? All
of those are things that you as a nurse need
to be responsible for and need to educate
You need to again review common complications.
Anaphylaxis should be right at the top of
your list especially if it is somebody who
is allergic to dye. Once they get that dye
they can go into immediate anaphylaxis. You
need to be prepared for that and have your emergency code
ready. Be prepared for bleeding. Anything
can happen. Even though you have taken all
the precautions and you have talk to your
patient. And you know whether there are
blood donors or not. Things always happen.
So making sure you are prepared for bleeding.
Making sure that you are prepared in case
of a perforation. Maybe they are doing a test
and they nip the bladder. Are you prepared
for watching for the signs and symptoms for
that? That should always be at the back of
your mind. Any kind of injury, whether it is
an injury to the limb or a skin injury. Maybe
it is an elderly person that got a skin tear
while you are putting them on and off the
CT table. Again, you need to be prepare for that,
you need to watch for that, and you need to
reassess after the procedure as well.
Respiratory failure should always be on your
mind as with cardiopulmonary failure.
Again hopefully a patient never get to that, but
again when you are adding chemicals to the
body or you are doing certain tasks like bronchoscopy
that always should be in your mind. And you
need to be ready and know how to stop those
things from happening but also how to respond
quickly when they do happen. So enclosing
diagnostic tests. That’s what
we do to the patient. That’s how we know
what’s going on. We need to make sure we
understand the diagnostic test not so much
because you are going to be doing it,
but because you are going to be getting the
patient ready at the beginning and you are
going to be monitoring them afterwards and
you need to educate them so that they know
what’s going on and what to expect. That’s
part of our responsibility as a nurse and
that’s part of being accountable for your
patient. So make sure you are looking over those
diagnostic tests. Again you can look through diagnostic
book, and just run through them and make sure that
you are familiar with what’s going to happen
with the patient. So not only for taking care
your patient but for passing NCLEX, that you can
understand what you need to be monitoring
and what should or should not happen and what your
role is. My name is Diana Shenefield. Good luck on NCLEX.