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TEST BANK FOR A Manual of Laboratory and Diagnostic Tests 7th edition Frances T Fischbach

A Manual of Laboratory and Diagnostic Tests CONTENTS Editors Contributors Dedication Preface Acknowledgments 1 Diagnostic Testing 2 Blood Studies; Hematology and Coagulation 3 Urine Studies 4 Stool Studies 5 Cerebrospinal Fluid Studies 6 Chemistry Studies 7 Microbiologic Studies 8 Immunodiagnostic Studies 9 Nuclear Medicine Studies 10 X-Ray Studies 11 Cytologic, Histologic, and Genetic Studies 12 Endoscopic Studies 13 Ultrasound Studies 14 Pulmonary Function, Arterial Blood Gases (ABGs), and Electrolyte Studies 15 Prenatal Diagnosis and Tests of Fetal Well-Being 16 Special Systems, Organ Functions, and Postmortem Studies Appendix A Standard/Universal Precautions Appendix B Latex and Rubber Allergy Precautions Appendix C Sedation and Analgesia Precautions Downloaded by: SuperA | Appendix D Conversions From ConventionDa i sl ttro ibSuty iosnt éom f e t hI isntdeor cnuamtioenntails(SillIe) gUan l its Corrinne Strandell, RN, BSN, MSN, PhD Nursing Research, Home Care and Rehabilitation Specialist, West Allis, WI Bernice Gestout DeBoer, RN, BSN, CPAN Parish Nurse, Covenant Health Care, Milwaukee, WI Mary Pat Haas Schmidt, BS, MT Manager, Laboratory Services, Pre-insurance testing; Instructor, Medical technology, Waukesha, W Jean Schultz, ES, RT, RD, MS Director of Ultrasound and Radiology Education, St. Luke's Medical Center, Milwaukee, WI Patricia Pomohac, MT (ASCP) Supervisor, Diagnostic Immunology, Department of Pathology, United Regional Medical Services, Teresa Friedel Abrams, RN, BSN, MSN Geriatric Nurse Specialist, Menomonee Falls Health Care Center, Menomonee Falls, WI Carol Colasacco, CT (ASCP), CMIAC Cytotechnologist, Department of Pathology, Fletcher Allen Health Care, Burlington, VT Emma Felder, RN, BSN, MSN, PhD Professor Emeritus, Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI Ann Shafranski Fischbach, RN, BSN Occupational Health; Case Manager, Johnson Controls, Milwaukee, WI Bonnie Grahn, RN, CIC Infection Control Coordinator, Froedtert Memorial Lutheran Hospital, Milwaukee, WI Roger Groth Ophthalmic Technologist, Eye Institute, Froedtert Memorial Lutheran Hospital, Milwaukee, WI Gary Hoffman Manager, Laboratory for Newborn Screening, State of Wisconsin, Madison, WI Karen Kehl, PhD Assistant Professor-Pathology, Children's Hospital of Wisconsin, Milwaukee, WI Susan Kirkpatrick, MS Genetic Counselor, Waisman Center, Madison, WI Stanley F. Lo, PhD Assistant Professor-Pathology, Children's Hospital of Wisconsin, Milwaukee, WI Lynn Mehlberg, ES, CNMDTownloaded by: SuperA | Director, Quality Assurance-ImDaisgtriibnugtionDoef tphias rdtomcuemnentt, isSiltle.gLaluke's Medical Center, Milwaukee, WI Contributors Family Nurse Practitioner, EM Care S.C., Milwaukee, WI Tracey Ryan, RD Chief Clinical Dietitian, Froedtert Memorial Lutheran Hospital, Milwaukee, WI Julie Saavedra, RN, BA, BSN, CGRN Nursing Manager, Department of Endoscopy, Rush-Presbyterian-St. Luke's Medical Center, Chica John Shalkham Program Director for School of Cytotechnology, State Laboratory of Hygiene, Clinical Assistant Pathology, University of Wisconsin, Madison, WI Eleanor C. Simms, RNC, BSN Specialist, Nursing Student Enrichment Program, Coppin State College, Helene Fuld School of Nur Nancy A. Staszak, RN, BSN, CCRN Education Coordinator-QA & Staff Development, Froedtert Memorial Lutheran Hospital, Milwaukee Frank G. Steffel, BS, CNMT Program Director-Nuclear Medicine Technology, Department of Radiology, Froedtert Memorial Lut Milwaukee, WI Rosalie Wilson Steiner, RN, BSN, MSN, PhD Community Health Specialist, Milwaukee, WI Thudung Tieu QA/Safety Coordinator, United Dynacare Laboratories, Milwaukee, WI Jean M. Trione, RPh Clinical Specialist, Wausau Hospital, Wausau, WI Beverly Wheeler, RN, BSN, MSN, CS Cardiology; Cardiothoracic Nurse Specialistm, National Naval Medical Center, Bethesda, MD Michael Zacharisen, MD Assistant Professor-Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI To Michael, Mary, Paul, and Margaret DEDICATION FRANCES TALASKA FISCHBACH, RN, BSN, MSN Associate Clinical Professor of Nursing Department of Health Restoration School of Nursing University of Wisconsin-Milwaukee Milwaukee, Wisconsin; Associate Professor of Nursing (Ret) School of Nursing University of Wisconsin-Milwaukee Milwaukee, Wisconsin MARSHALL BARNETT DUNNING, III, BS, MS, PHD Associate Professor of Medicine Department of Medicine Division of Pulmonary/Critical Care Medicine Medical College of Wisconsin, Milwaukee Wisconsin; Director Pulmonary Diagnostic Laboratory Froedtert Memorial Lutheran Hospital Milwaukee, Wisconsin QUINCY MCDONALD Acquisitions Editor SHARON NOWAK/MARIE RIM Editorial Assistant DEBRA SCHIFF Senior Production Editor HELEN EWAN Senior Production Manager ERIKA KORS Managing Editor / Production CAROLYN O'BRIEN Art Director BJ CRIM Design WILLIAM ALBERTI Manufacturing Manager ALEXANDRA NICKERSON Indexer EDITORS PURPOSE The purpose of A Manual of Laboratory and Diagnostic Tests, in this Seventh edition, is to promote effective, and informed care for patients undergoing diagnostic tests and procedures and also to pr student with a unique resource. This comprehensive manual provides a foundation for understandi simple to the most highly complex diagnostic tests that are delivered to varied populations in varied the clinician's role in providing effective diagnostic services in depth, through affording the necessa quality care planning, individualized patient assessment, analysis of patient needs, appropriate inte education, patient follow-up, and timely outcome evaluation. Potential risks and complications of diagnostic testing mandate that proper test protocols, interferin testing, and collaboration among those involved in the testing process be a significant part of the this text. ORGANIZATION This book is organized into 16 chapters and 12 appendices. Chapter 1 outlines the clinician's role and includes interventions for safe, effective, informed pre-, intra-, and posttest care. This chapter Bill of Rights and Responsibilities, a model for the role of the clinical team in providing diagnostic c environments, reimbursement for diagnostic services, and the importance of communication as key The intratest section is expanded to include information about collaborative approaches facilitating during invasive procedures, risk management, the collection, handling, and transport of specimens controlling pain, comfort measures, administration of drugs and solutions, monitoring fluid intake an equipment kits and supplies, properly positioning the patient for the procedure, managing the envir monitoring. The reader is referred back to Chapter 1, Diagnostic Testing, throughout the text for clinician's role and diagnostic services. Chapter 2, Chapter 3, Chapter 4, Chapter 5, Chapter 6, C Chapter 9, Chapter 10, Chapter 11, Chapter 12, Chapter 13, Chapter 14, Chapter 15 and Chapter categories that include: Chapter 2: Blood Studies Chapter 3: Urine Studies Chapter 4: Stool Studies Chapter 5: Cerebrospinal Fluid Studies Chapter 6: Chemistry Studies Chapter 7: Microbiologic Studies Chapter 8: Immunodiagnostic Studies Chapter 9: Nuclear Medicine Studies Chapter 10: X-ray Studies Chapter 11: Cytology, Histology, and Genetic Studies Chapter 12: Endoscopic Studies Chapter 13: Ultrasound Studies Chapter 14: Pulmonary Function and Blood Gas Studies Chapter 15: Prenatal Diagnosis and Tests of Fetal Well-Being Chapter 16: Special Systems, Organ Functions, and Postmortem Studies Downloaded by: SuperA | CHAPTER CONTENT AND FE DiAstrTi bUutiR onE ofSthis document is illegal PREFACE CURRENT DEVELOPMENTSDIi Ns tribLuAtioBn O of tR hisAd T ocO umRe Y nt i As i N llegD al DIAGNOSTIC TESTING Downloaded by: SuperA | component of normal reference values. Numerous examples of test values and clinical considerations for newborn, infant, child, adol groups where appropriate. A bibliography at the end of each chapter representing a composite of selected references fro and directs the clinician to information available beyond the scope of this book. Extensive appendices providing the clinician with additional data for everyday practice. Current, complete, and accurate content, which has been compiled from various multidisciplin carefully scrutinized and continually reevaluated. NEW INFORMATION IN THE SEVENTH EDITION The addition of many new tests and methodologies includes: Newborn screening for inherited disease Updated Pap smears and protocols for further testing Cytokines Metabolic autopsy Tissue (histology) biopsies and predictive markers for treatment response Tests for bone disease Tests for heart disease, congestive and acute MI disease Microbiological testing, bioterrorism agents, detecting food poisoning, anthrax, plague, and Breast diagnostic and prognostic markers Fetal predictive tests of abnormal development Breath tests for ulcers, alcohol, lactose, etc. Fertility tests Expanded scope of magnetic resonance (MRI) scans Expanded scope of sleep/sleepiness studies in newborns, children, older adults New nuclear tumor and infection scans PET scans combined with CT spiral imaging and ultrasound Ductal lavage for determining Gail Index for breast cancer risk New sentinel node localization LEEP GYN procedure Eye tests for retinal disorders, macular degeneration, visual acuity, and glaucoma Expanded content on keeping records of diagnostic tests, use of proper forms, and standardi Panels of multiple tests (e.g., metabolic syndrome, syndrome X) within Chapter 6 Chemistry The appendices are completely revised and contain many additions. For example, Appendix D offe regarding collection of saliva, breath, nail, sputum, and hair specimens. Appendix H provides exam used forms and infrequently used forms (videotaping, refusal). Appendix L deals with guidelines for specimens. Revised chapters include changes in the clinician's role and reflect current laboratory and diagnosti Throughout the text, a greater emphasis is placed upon communication skills and collaboration bet significant others, and health professionals from diverse disciplines. When clinicians see patients in the patient and loved ones are experiencing (ie, situational needs, expectations, previous experien environment in which they live), only then can they offer meaningful support and care. When patien is on their side, they have an increased sense of control. Identifying with the patient's point of view profound level of communication. A resurgence in the use of traditional, trusted diagnostic modalities, such as electroencephalogram in certain areas. Diseases such as HIV, antibiotic-resistant strains of pathological organisms, and T becoming more prevalent. In the workplace, thorough diagnostic testing is more common as applic disability benefits. Also, requirements for periodic monitoring of exposures to potentially hazardous substances (chemicals, heavy metals), breathing and hearing tests, and TB and latex allergy testin administering and procuring specimens. The number of forensic DNA tests being performed has in Concurrently, consumer perceptions have shifted from implicit faith in the health care system to co control over choices for health care and more distrust of the system in general. These trends—combined with a shift in diagnostic care from acute care hospital settings to outpatie physicians' offices, clinics, community-based centers, nursing homes, and sometimes even church pharmacies—challenge clinicians to provide standards-based, safe, effective, and informed care. care system is becoming a community-based model, the clinician's role is also changing. Updated flexibility, and a heightened awareness of the testing environment (point of care testing) are neede services in these settings. Clinicians must also adapt their practice to changes in other areas. This includes developing, coord policies and standards set forth by institutions, governmental bodies, and regulatory agencies. Bein ethical and legal implications of such things as informed consent, privacy, patient safety, the right t end-of-life decisions, and trends in diagnostic research procedures add another dimension to the accountability and responsibility. The consequences of certain types of testing (ie, HIV and genetic of confidential versus anonymous testing must also be kept in mind. For example, anonymous test individual to give his or her name, whereas confidential tests do require the name. This difference requirements and process of agency reporting all patients as well as for select groups of infectious Responding to these trends, the Seventh edition of A Manual of Laboratory and Diagnostic Tests i up-to-date diagnostic reference source that includes information about newer technologies, togethe time-honored classic tests that continue to be an important component of diagnostic work. It meets clinicians, educators, researches, students, and others whose work and study requires this type of manual. Frances Talaska Fischbach It is with sincere gratitude and pleasure that I acknowledge the collaboration of Dr. Marshall B. Dun extra effort, and graciousness in accomplishing the task of renewal and enhancement for the revisi 7th edition, all in a timely manner. I want to give special praise and recognition to my husband, Jack Fischbach, the best researcher I Corrinne Strandell, Mary Pat Schmidt, Bernice DeBoer, Pat Pomohac, and Jean Schultz for their support, and generous help in manuscript preparation; to Kathie Gordon, Kathleen Dunning, Deann Margaret Fischbach, for carefully arranging, organizing, and typing the manuscript. I would also like to acknowledge and thank all the reviewers, researchers, and consultants who pro manuscript revision and whose comments to me have helped make the book better. This work wou complete without the help and information provided by the librarians and staff of the Todd Wehr Lib College of Wisconsin, the Marquette University Library, and St. Joseph's Hospital Library; with than Laboratories and Medical Science Laboratories, especially for referencing their Laboratory Handbo Infection Control Staff, Neuroscience Center, Transplant Services, Transfusion Services, Eye Instit Memorial Hospital of Milwaukee, Wisconsin. Appreciation and recognition are also due these persons who helped with this and previous edition Fischbach Johnson, BS, MS Ed, and Margaret Fischbach, BA, JD; my son-in-law, Richard Johnson daughter-in-law, Ann Shafranski Fischbach, BSN; and the hard work on this edition and in the past Lippincott Williams & Wilkins, especially Sharon Nowak, Marie Rim, Quincy McDonald, Debra Schi Barrie, and, as always, Jay Lippincott. Writing a book is truly a labor of love, and the process make thankful to many, many individuals, named and unnamed, who have made it possible. Thanks for a Frances Fischbach ACKNOWLEDGMENTS OVERVIEW OF THE CLINICIAN'S ROLE: RESPONSIBILITIES, STANDARDS, AND REQUISITE KNOWLEDGE Education Alert Chart 1.1 Grading Guidelines for Scientific Evidence Chart 1.2 Basics of Informed Care PRETEST PHASE: ELEMENTS OF SAFE, EFFECTIVE, INFORMED CARE Basic Knowledge and Necessary Skills Testing Environments History and Assessment Reimbursement for Diagnostic Services Chart 1.3 Tests Covered by Most Insurance Carriers Methodology of Testing Interfering Factors Avoiding Errors Proper Preparation Patient Education Testing Protocols Patient Independence Test Results Laboratory Reports Margins of Error Ethics and the Law Patient's Bill of Rights and Patient Responsibilities Cultural Sensitivity INTRATEST PHASE: ELEMENTS OF SAFE, EFFECTIVE, INFORMED CARE Basic Knowledge and Required Skills Infection Control NOTE Collaborative Approaches Risk Management Specimens and Procedures Equipment and Supplies Family Presence Positioning for Procedures Administration of Drugs and Solutions Management of Environment Pain Control, Comfort Measures, and Patient Monitoring POSTTEST PHASE: ELEMENTS OF SAFE, EFFECTIVE, INFORMED CARE Basic Knowledge and Necessary Skills Abnormal Test Results Clinical Alert Follow-Up Counseling Monitoring for Complications Test Result Availability Clinical Alert Referral and Treatment Follow-Up Care Documentation, Record Keeping, anDdoRwenplooardtiendgby: SuperA | Chart 1.4 Diseases and Conditions ReportaDbisletribbuytiHoenaoltfhthCisadreocPurmoveindteisrsillaengdalOthers Chart 1.5 Diseases and Conditions Reportable by Laboratory Directors Diagnostic Testing 1 5. Evaluating disease severity 6. Monitoring course of illness and response to treatment 7. Group and panel testing 8. Regularly scheduled screening tests as part of ongoing care 9. Testing related to specific events, certain signs and symptoms, or other exceptional situations inflammation [bladder infection or cellulitis], sexual assault, drug screening, pheochromocyto to name a few) ( Table 1.1 ) Table 1.1 Examples of Selecting Tests Diagnostic Test Indication Stool occult blood Yearly screening after 45 years of age Serum potassium Yearly in patients on diuretic agents or potassium supple some cardiac arrhythmias Liver enzyme levels Monitoring patient on hepatotoxic drugs; establish baselin Serum amylase In the presence of abdominal pain, suspect pancreatitis Thyroid-stimulating hormone (TSH) test Suspicion of hypothyroidism, hyperthyroidism, or thyroid of age and older Chlamydia and gonorrhea In sexually active persons with multiple partners to monito inflammatory disease Hematocrit and hemoglobin Baseline study; abnormal bleeding; detection of anemia ( are recent) Papanicolaou cervical smear (Pap) Yearly for all women = 18 years of age; more often with dysplasia, human immunodeficiency virus [HIV], herpes human papillomavirus (HPV), chlamydia, and gonorrhea, Urine culture Pyuria Syphilis serum fluorescent treponemal antibody (FTA) test Positive rapid plasma reagin (RPR) test result Tuberculosis (TB) skin test Easiest test to use for TB screening of individuals < 35 ye with history of negative TB skin tests, for persons in resid Fasting blood glucose (FBG) Every 3 years starting at 45 years of age; monitor diabete Urinalysis (UA) Signs or history of recurrent urinary tract disease; pregna prostatic hypertrophy Prothrombin time (PT) (INR) Monitoring anticoagulant treatment Prostate-specific antigen (PSA) and digital rectal examination Screen men = 50 years of age for prostate cancer yearly Chest x-ray Monitor for lung lesions and infiltrates; congestive heart fa deformities, posttrauma, before surgery, follow-up for pos monitor treatment Mammogram Screen by 40 years of age in women, then every 12–18 49 years of age, annually = 50 years of age; follow-up for of breast cancer; routine screening when strong family his carcinoma Colon x-rays and Screen adults for colon cancer beginning at age 45; follow proctosigmoidoscopy hemoglobin- or guaiac-positive stools, polyps, diverticulos Computed tomography (CT) Before and after treatment for certain cancers, injuries, illn scans DNA testing of hair, blood, skin tissue, or semen samples transient ischemic attack, cerebro-vascular accident; diag certain signs/symptoms) To gather postmortem evidence, in certain criminal cases and parentage Downloaded by: SuperA | Some tests are mandateDdistbribyutgioon vofet hrins mdoec unmtenat gi sei lnlegca iles or clinical practice guidelines of professio are deemed part of necessary care based on the individual practitioner's judgment and exper As an integral part of their practice, clinicians have long supported patients and their significant oth demands and challenges incumbent in the simplest to the most complex diagnostic testing. This te birth and frequently continues after death. The clinician who provides diagnostic services must hav knowledge to plan patient care and an understanding of psychoneuroimmunology (effects of stress must make careful judgments, and must gather vital information about the patient and the testing appropriately within the parameters of the clinician's professional standards ( Table 1.2 ; Chart 1.2 Table 1.2 Examples of Inappropriate Tests and Replacement Tests Inappropriate Prostatic acid phosphatase Ammonia Crossmatch (needed if blood is actually to be given) Calcium CBC HCV antibody Iron Lupus cell Creatinine CRP PSA, prostate-specific antigen; AST, aspartate transaminase; GGT, gamma-glutamyltransferase; count; HCV, hepatitis C virus; PCP, polymerase chain reaction; ANA, antinuclear antibody; CRP, ESR, erythrocyte sedimentation rate. Chart 1.1 Grading Guidelines for Scientific Evidence A. Clear evidence from all appropriately conducted trials B. Supportive evidence from well-conducted studies or registries C. No published evidence; or only case, observational, or historical evidence D. Expert consensus or clinical experience or Internet polls A. Measure plasma glucose through an accred or screen for diabetes B. Draw fasting blood plasma specimens for gl C. Self-monitoring of blood glucose may help t control D. Measure ketones in urine or blood to monito diabetic ketoacidosis (DKA) (in home or clin Chart 1.2 Basics of Informed Care Manage testing environment using collaborative approach Communicate effectively and clearly Prepare the patient propeDrolywnloaded by: SuperA | Distribution of this document is illegal FIGURE 1.1 Model* for the role** of the clinical team in diagnostic care*** and services.**** Pretest Interventions: Intratest Interventions: Posttest Interventions 1. Test background 1. Actual description of procedures 1. Patient aftercare information 2. Specimen collection and transport 2. Clinical, education 2. Normal (reference values) 3. Clinical implications of abnormal results alerts 3. Special cautions 3. Explanation of test 4. Interfering factors 4. Interpretation of te 4. Indications for testing Each phase of testing requires that a specific set of guidelines and standards be followed for accur results. Patient care standards and standards of professional practice are key points in developing approach to patient care during diagnostic evaluation. Standards of care provide clinical guidelines requirements for professional practice and patient care. They protect the public against less-than-q 1.3). Table 1.3 Standards for Diagnostic Evaluation Source of Standards for Diagnostic Service Standards for Diagnostic Testing Examples of Ap Diagnostic Testi Professional practice parameters of American Nurses Association Use a model as a framework for choosing the proper test or procedure and in the Test strategies in combinations/ pa (ANA), American Medical interpretation of test results. Use can be performed Association (AMA), American Society of Clinical Pathologists (ASCP), American College of Radiology, Centers for Disease Control and Prevention (CDC), JCAHO health care practice requirements laboratory and diagnostic procedures for screening, differential diagnoses, follow-up, and case management. both. The guidelines of the major Order the correct test, appropriately collect Patients receive agencies, such as AmericaDnowHnloeaaderdt by: SaunpderAtr|aabnieskpayo1r2t@ens. Properly perform based on a docu Association, Cancer Society, aDnisdtributiontoefsthtiss dioncuamnenat ics cillreegadl ited laboratory or need for diagnost American Diabetes Association diagnostic facility. Accurately report test have the right to State and federal government Clinical laboratory personnel and other The clinician repo communicable disease reporting health care providers follow regulations to evidence of certai regulations; Centers for Disease Control and Prevention (CDC), U.S. control the spread of communicable diseases by reporting certain disease sexually transmitt diphtheria, Lyme Department of Health and Human conditions, outbreaks, and unusual HIV infection; see Services, Agency for Health Care manifestations, morbidity, and mortality diseases). Person Policy and Research (AHCPR), and data. Findings from research studies may not handle fo Clinical Laboratory Improvement Act provide health care policy makers with young children, o (CLIA) evidence-based guidelines for appropriate specific period of selection of tests and procedures. government regul diagnostic specim used to evaluate pain according to U.S. Department of Transportation Alcohol testing is done in emergency Properly trained rooms in special situations (eg, following a blood, saliva, and motor vehicle accident, homicide, or suicide, or an unconscious individual). and use required federal law. Occupational Safety and Health Administration (OSHA) Workplace testing The clinician is pr mandated guideli employee medica respirator qualific JCAHO, Joint Commission on Accreditation of Healthcare Organizations; HIV, human immunodefic magnetic resonance; CT, computed tomography. If test results are inconclusive or negative and no definitive medical diagnosis can be established, procedures may be ordered. Thus, testing can become an involved and lengthy process (see Fig. Understanding the basics of safe, effective, and informed care is important. These basics include and modifying care accordingly, using a collaborative approach, following proper guidelines for pro collection, and delivering appropriate care throughout the process. Providing reassurance and sup his or her significant others, intervening appropriately, and clearly documenting patient teaching, outcomes during the entire process are important (see Fig. 1.1). A risk assessment before testing identifies risk-prone patients and helps to prevent complications. increase a patient's risk for complications and may affect test outcomes: 1. Age > 70 years 2. History of falls 3. History of serious chronic illnesses 4. History of allergies (eg, latex, contrast iodine, radiopharmaceuticals, and other medications) 5. Infection or increased risk for infection (eg, human immunodeficiency virus [HIV], organ trans chemotherapy, radiation therapy) 6. Aggressive or antisocial behavior 7. Seizure disorders 8. Uncontrolled pain 9. Gastric motility dysfunction 10. Use of assistive devices for activities of daily living (ADLs) 11. Unsteady gait, balance problems 12. Neuromuscular conditions 13. Weakness, fatigabilitDyownloaded by: SuperA | 14. Paresthesias Distribution of this document is illegal 15. Impaired judgment or illogical thinking diagnostic services are used. Clear, timely, accurate communication among all patients and profes minimizing problems and frustrations. As societies become more culturally blended, the need to appreciate and work within the realm of becomes imperative. Interacting with patients and directing them through diagnostic testing can pre challenges if one is not familiar and sensitive to the health care belief system of the patient and his others. Something as basic as attempting to communicate in the face of language differences may arrangements for a relative or translator to be present during all phases of the process. Special atte communication skills are necessary for these situations as well as when caring for children and for or frail patients. Consideration of these issues will significantly influence compliance, outcomes, an to the procedure. To be most effective, professional care providers must be open to a holistic persp that affects their care giving, communication, and patient-empowering behaviors. Clinicians who basic needs and expectations and strive to accommodate those as much as possible are truly actin advocates. Preparing patients for diagnostic or therapeutic procedures, collecting specimens, carrying out and procedures, and providing follow-up care have long been requisite activities of professional practic continue even after the patient's death. Diagnostic postmortem services include death reporting, po investigations, and sensitive communication with grieving families and significant others regarding unexplained death, other postmortem testing, and organ donation (see Chap. 16). Professionals need to work as a team to meet diverse patient needs, to facilitate certain decisions, comprehensive plans of care, and to help patients modify their daily activities to meet test requirem phases. It is a given that institutional protocols are followed. PRETEST PHASE: ELEMENTS OF SAFE, EFFECTIVE, INFORMED CARE The emphasis of pretest care is on appropriate test selection, obtaining proper consent, proper pati individualized patient education, emotional support, and effective communication. These interventio achieving the desired outcomes and preventing misunderstandings and errors. Basic Knowledge and Necessary Skills Know the test terminology, purpose, process, procedure, and normal test reference values or resul diseases are a convenient way of briefly stating the endpoint of a diagnostic process that begins wi symptoms and signs and ends with knowledge of causation and detection of underlying disorders o function. The clinical value of a test is related to its sensitivity, its specificity, and the incidence of the diseas tested. Sensitivity and specificity do not change with different populations of ill and healthy patients of the same test can vary significantly with age, gender, and geographic location. Specificity refers to the ability of a test to identify correctly those individuals who do not have the formula for specificity is as follows: Sensitivity refers to the ability of a test to correctly identify those individuals who truly have the dis formula for sensitivity is as follows: Thus, this new screening test will give a false-negative result about 20% of the time (eg, the person fibrosis gene but his or her test results are negative). Thus, there is about an 8% change that the person will test positive for the cystic fibrosis gene but Thus, there is about a 5% chance that the person will test negative for the cystic fibrosis gene but Look at both current and previous test results and review the most recent laboratory data first, then backward to evaluate trends or changes from previous data. The patient's plan of care may need to of test results and changes in medical management. Testing Environments Diagnostic testing occurs in many different environments. Many test sites have shifted into commu from hospitals and clinics. Point-of-Care Testing refers to tests done in the primary care setting. In acute care settings (eg, ambulances), state-of-the-art testing can produce rapid reporting of test results. Testing in the home care environment requires skill in procedures such as drawing blood samples, from retention catheters, proper specimen labeling, documentation, specimen handling, and specim Moreover, teaching the patient and his or her significant others how to collect specimens is an imp process. In occupational health environments, testing may be done to reduce or prevent known workplace to lead) and to monitor identified health problems. This can include preemployment baseline scree monitoring of exposure to potentially hazardous workplace substances, and drug screening. Skill in samples, performing breathing tests, monitoring chain of custody (see page 226 in Chap. 3), and signed and witnessed consent forms for drug testing is required. More pretest, posttest, and follow-up testing occurs in nursing homes because patients are more transferred to hospitals for more complex procedures (eg, computed tomography [CT] scans, endo is not the case with routine testing. Increasing numbers of ―full code‖ (ie, resuscitation) orders leads and varieties of tests. Additionally, confused, combative, or uncooperative behaviors are seen mor Downloaded by: SuperA | settings. An attitude adopted by nursing home patients of ―not wanting to be bothered‖ or engaging Distribution of this document is illegal undergo prescribed tests can make testing difficult. Consequently, understanding patient behaviors 4. Assess fears and phobias (eg, claustrophobia, ―panic attacks,‖ fear of needles and blood). As strategies the patient uses to deal with these reactions and try to accommodate these. 5. Observe standard/universal precautions with every patient (see Appendix A). A patient may drug or alcohol use or HIV and hepatitis risks. 6. Document relevant data. Address patient concerns and questions. This information adds to th collaborative problem-solving activities among the medical, laboratory/ diagnostic, and nursin Reimbursement for Diagnostic Services Differences in both diagnostic care services and reimbursement may vary between private and gov Nonetheless, quality of care should not be compromised in favor of cost reduction. Advocate for pa insurance coverage for diagnostic services. Inform the patient and his or her family or significant ot necessary to check with their insurance company before laboratory and diagnostic testing to make covered. Many insurance companies employ case managers as gatekeepers for monitoring costs, diagnosti other care. As a result, the insurance company or third-party payer may reimburse only for certain may not cover tests considered by them to be preventive care. So that reimbursement completely services provided, be sure to include proper documentation and proper Common Practice Termino Note date laboratory service is performed and date specimen is collected (must use). Based on 19 laboratory tests that are covered by most insurance carriers, both private and government. Chart 1.3 Tests Covered by Most Insurance Carriers Alpha-fetoprotein Blood counts Blood glucose testing Carcinoembryonic antigen Human chorionic gonadotropin Lipids Partial thromboplastin time Prostate-specific antigen Collagen crosslinks, any method (urine osteoporosis) Prothrombin time Digoxin therapeutic drug assay Fecal occult blood Gamma-glutamyltransferase Glycated hemoglobin/glycated protein Hepatitis panel HIV testing (diagnosis) HIV testing (prognosis including monitoring) Serum iron studies Thyroid testing Tumor antigen by immunoassay—CA125 Tumor antigen by immunoassay—CA15-3/ Tumor antigen by immunoassay—CA19-9 Urine culture Reasons for deviations may include the following: 1. Incorrect specimen collection, handling, storage, or labeling 2. Wrong preservative or lack of preservative 3. Delayed specimen delivery 4. Incorrect or incomplete patient preparation 5. Hemolyzed blood samples 6. Incomplete sample collection, especially of timed samples 7. Old or deteriorating specimens Patient factors that can alter test results may include the following: 1. Incorrect pretest diet 2. Current drug therapy 3. Type of illness 4. Dehydration 5. Position or activity at time of specimen collection 6. Postprandial status (ie, time patient last ate) 7. Time of day 8. Pregnancy 9. Level of patient knowledge and understanding of testing process 10. Stress 11. Nonadherence or noncompliance with instructions and pretest preparation 12. Undisclosed drug or alcohol use 13. Age and gender Avoiding Errors To avoid costly mistakes, know what equipment and supplies are needed and how the test is perfo errors account for more incorrect results than do technical errors. Properly identify and label every it is obtained. Determine the type of sample needed and the collection method to be used. Is the te noninvasive? Are contrast media injected or swallowed? Is there a need to fast? Are fluids restricte medications administered or withheld? What is the approximate length of the procedure? Are cons conscious sedation, oxygen, analgesia, or anesthesia required? Report test results as soon as pos ―panic‖ values must be reported to the proper persons immediately (STAT). Instruct patients and their significant others regarding their responsibilities. Accurately outline the st process and any restrictions that may apply. Conscientious, clear, timely communication among he can reduce errors and inconvenience to both staff and patients. Proper Preparation Prepare the patient correctly. This preparation begins at the time of scheduling. 1. Provide information about testing site and give directions for locating the facility; allow time to find the specific testing laboratory. If a copy of the written test order was given to the patient t laboratory, interpret the test order. For example, an order for a renal sonogram means that an kidney will be done to ―rule out‖ (RO) evidence or presence of abnormality or suspected probl ―ultrasound‖ and ―sonogram‖ are used interchangeably. 2. Plan to be at the department 15 minutes before testing if the test is scheduled for a specific ti instructions and be cDeorwtanlionadtehdebyy: SaurpeerAex| apbliaekianye12d@m(eg, ―fasting‖ directions for test, tell patie actually means). Distribution of this document is illegal 3. Be aware of special needs of those with conditions such as physical limitations or disabilities, that will be used is important so that patients can ―see‖ a realistic representation of what will and medical jargon and adapt information to the patient's level of understanding. Slang terms get a point across. 2. Encourage questions and verbalization of feelings, fears, and concerns. Do not dismiss, mini patient's anxiety through trivial remarks such as ―Don't worry.‖ Develop ―listening ears and ey nonverbal signals (ie, body language) because these frequently provide a more accurate pict really feels than what he or she says. Above all, be nonjudgmental. 3. Emphasize that there is usually a waiting period (ie, ―turn-around time‖) before test results are clinicians and nursing unit. The patient may have to wait several days for results. Offer listeni support during this time of great concern and anxiety. 4. Record test result information. Include the patient's response. Just because something is tau necessarily mean that it is learned or accepted. The possibility that a diagnosis will require a significant lifestyle changes (eg, diabetes) requires intense support, understanding, education Document specific names of audiovisual and reading materials to be used for audit, reimburs accreditation purposes. Testing Protocols Develop consistent protocols for teaching and testing that encompass comprehensive pretest, intra modalities. Prepare patients for those aspects of the procedure experienced by the majority of patients. Clinici collect data and to develop a list of common patient experiences, responses, and reactions. Patient Independence Allow the patient to maintain as much control as possible during the diagnostic phases to reduce st Include the patient and his or her significant others in decision making. Because of factors such as barriers, and physical or emotional impairments, the patient may not fully understand and assimilat explanations. To validate the patient's understanding of what is presented, ask the patient to repea evaluate assimilation and understanding of presented information. Include and reinforce information about the diagnostic plan, the procedure, time frames, and the pa testing process. Test Results Know normal or reference values. 1. Normal ranges can vary to some degree from laboratory to laboratory. Frequently, this is bec type of equipment used. Theoretically, ―normal‖ can refer to the ideal health state, to average to types of statistical distribution. Normal values are those that fall within 2 standard deviation variation) of the mean value for the normal population. 2. The reported reference range for a test can vary according to the laboratory used, the metho population tested, and methods of specimen collection and preservation. 3. The majority of normal blood test values are determined by measuring ―fasting‖ specimens. 4. Be aware of specific influences on test results. For example, patient posture is important whe measured because this value is 12% to 15% greater in a person who has been supine for sev from a supine to a standing position can alter values as follows: increased hemoglobin (Hb), count, hematocrit (Hct), calcium (Ca), potassium (K), phosphorus (P), aspartate aminotransfe phosphatases, total protein, albumin, cholesterol, and triglycerides. Going from an upright to results in increased hDeowmnlaoatdoecdrbity,: ScuaplecrAiu| mab,iektoayt1a2l@, and cholesterol. A tourniquet applied fo laboratory value increaseDsistirnibuptiornootfethinis d(5oc%um)e,nitrios inlleg(a6l.7%), AST (9.3%), and cholesterol (5%) and (6%) and creatinine (2%–3%). Margins of Error Recognize margins of error. For example, if a patient has a battery of chemistry tests, the possibilit tests will be abnormal owing purely to chance. This occurs because a significant margin of error ari setting of limits. Moreover, if a laboratory test is considered normal up to the 95th percentile, then 5 test will show an abnormality even though a patient is not ill. A second test performed on the same yield the following: 0.95 × 0.95, or 90.25%. This means that 9.75 times out of 100, a test will show though the person has no underlying health disorder. Each successive testing will produce a highe abnormal results. If the patient has a group of tests performed on one blood sample, the possibility will ―read abnormal‖ due purely to chance is not uncommon. Ethics and the Law Consider legal and ethical implications. These include the patient's right to information, properly sig consent forms, and explanations and instructions regarding chain-of-custody requirements and risk of tests. 1. Chain of custody is a legal term descriptive of a procedure to ensure specimen integrity from to receipt to analysis and specimen storage. A special form is used to provide a written recor informed consent before certain tests and procedures pertains to patient autonomy, the ethic self-determination, the legal right to be free of procedures to which one does not consent, an will be done to one's own person. Risks, benefits, and alternatives are explained and written in advance of the procedure. 2. The patient must demonstrate appropriate cognitive and reasoning faculties to sign a legally Conversely, a patient may not legally give consent while under the immediate influence of se agents, or certain classes of analgesics and tranquilizers. If the patient cannot validly and leg form, an appropriately qualified individual may give consent for the patient. 3. Guidelines and wishes set forth in advance directives or ―living will‖–type documents must be life-threatening situations. Such directives may prevent more sophisticated invasive procedur performed. Some states have legislated that patients can procure do-not-resuscitate (DNR) DNR bracelets that indicate their wishes. A copy of a patient's advance directives in the healt very helpful in unpredictable situations. 4. A collaborative team approach is essential for responsible, lawful, and ethical patient-focused who orders the test has a responsibility to inform the patient about risks and test results and t for follow-up care. Other caregivers can provide additional information and clarification and ca and family in achieving the best possible outcomes. The duty to maintain confidentiality, to pr choice, and to report infectious diseases may result in ethical dilemmas. Respect for the dignity of the individual reflects basic ethical considerations. Patients and family ha to question, to request other opinions, and to refuse diagnostic tests. Conversely, caregivers have diagnoses of the patients they care for so that they can minimize the risks to themselves. Patient's Bill of Rights and Patient Responsibilities Patients have a right to expect that an agency's or institution's policies and procedures will ensure responsibilities for them. At all times, the patient has the right: 1. To considerate, honest, respectful care, with consideration given to privacy and maintenance cultural and personal values and beliefs, and physical and developmental needs, regardless 2. To be involved in decision making and to participate actively, if so desired, in the testing proc patient is competent Dtoowmnloaadkeed btyh: eSsupeercAh| 3. To participate in the inforDmisteribdutcioon nofst heisndtopc urmoecnet iss sillebgael fore testing and to be told of the benefits, ris alternative approaches to tests ordered. clinician if they are unable to do so. 2. To report active or chronic disease conditions that may alter test outcomes, be adversely affe process, or pose a risk to health care providers (eg, HIV, hepatitis). 3. To keep appointments for diagnostic procedures and follow-up testing. 4. To disclose drug and alcohol use as well as use of supplements and herbal products despite these products could affect test outcomes (eg, erroneous test results). 5. To disclose allergies and past history of complications or adverse reactions to tests. Exampl materials. 6. To report any adverse effects attributed to tests and procedures after being advised regardin of such. 7. To supply specimens that are their own. 8. To report visual or hearing impairments or inability to read, write, or understand English. Cultural Sensitivity Preserving the cultural well-being of any individual or group promotes compliance with testing and routine as well as more invasive and complex procedures. Sensitive questioning and observation m information about certain cultural traditions, concerns, and practices related to health. For example believe the soul resides in the head and that no one should touch an adult's head without permissio child on the head may violate this belief. Health care personnel should make an effort to understan differences of populations they serve without passing judgment. Most people of other cultures are information if they feel it will be respected. Sometimes, a translator is necessary for accurate comm Many cultures have diverse beliefs about diagnostic testing that requires blood sampling. For exam having blood specimens drawn or concerns regarding the disposal of body fluids or tissue may req workers to demonstrate the utmost patience, sensitivity, and tact when communicating information INTRATEST PHASE: ELEMENTS OF SAFE, EFFECTIVE, INFORMED CARE Basic Knowledge and Required Skills Intratest care focuses on specimen or tissue collection, monitoring the testing environment tissue and/or assisting with procedures, providing emotional and physical comfort and reassurance, admi and sedatives, and monitoring vital signs and other parameters during testing. The clinician must h about the procedure and test and should have the required skills to perform testing or to assist in th practices, proper collection of specimens, minimizing delays, providing support to the patient, prep analgesia and sedatives, monitoring various parameters as necessary, and being alert to potential complications are integral activities of the intratest phase. Invasive procedures place patients at gre complications and require ongoing vigilance and observation. Monitoring fluid intake and loss, body respiratory and cardiovascular systems and treating problems in these domains require critical thin responses. Infection Control Institute accepted infection control protocols. Observe special measures and sterile techniques as patients at risk for infection. Institute strict respiratory and contact isolation as necessary. Quality proper collection, transport, and receipt of specimens and use of properly cleaned and prepared equipment. Appendix A offers more information on standard precautions for safe practice and infec isolation. The term standard precautions refers to a system of disease control that presupposes ea body fluids or tissues is potentially infectious and that every person exposed to these must protect Consequently, health care workers must be both informed and conscientious about adhering to sta strict infection control guideDoliwnnelosad. eIdt bgyo: SeuspewrAi|thaboieukat ys1a2@mt health care workers must be scrupulou hygiene (see Appendix A). ProDpi setrirbupt iroon toef tchtis ivdeocucm l oe n t ht iisnilglegaalnd other devices must be worn as necessar Risk Management Assess for and provide a safe environment for the patient at all times. Identify patients at risk and pose a risk. Previous falls, cerebrovascular accident (CVA), neuromuscular disorders, loss of balan ambulatory and other assistive devices are contributory risk factors. Prevention of complications an factors are an important part of the intratest phase. As part of risk management, observe standard infection control protocols as necessary (see Appendix A, Appendix B, and Appendix C). Use special care during procedures that include iodine and barium contrasts, radiopharmaceuticals conscious sedation, and analgesia (see Chap. 9, Chap. 10, and Chap. 15 for precautions for imag Certain risk factors contribute to a higher incidence of adverse reactions when contrast agents and are used ( Table 1.5). Table 1.5 Classification of Risk Factors Preexisting Disorders Contributing Elements Asthma Allergy Diabetes Age-related (newborn and older adults) Liver insufficiency Dehydration Multiple myeloma Frequent use of contrast agents Pheochromocytoma High dosage of contrast and radiopharmaceuticals Renal failure Previous reaction to contrast agents Seizure history Remove jewelry, false teeth, and other prosthetic devices as necessary. Check for NPO or fasting Specimens and Procedures Assist with and/or conduct certain diagnostic procedures. Examples of the types of assisted proced endoscopy, lumbar puncture, and cardiac catheterization. Diagnostic procedures often performed medical personnel include Papanicolaou (Pap) smears, centrifugation of blood samples, ECGs, bre pulse oximetry. For example, the pulse oximeter is used to monitor noninvasively the oxygen satur O 2 refers to pulse oximetry, whereas S O 2 refers to arterial saturation measured on an arterial blood sample. Sensors may be applied on ring finger; on the nose, earlobe, toe, or foot; and on the forehead. Be aware of factors that interfer results, such as patient movement, ambient light, electronic interference, artificial nails and polish, poor circulation to an area. Chapter 14 provides more information on pulse oximetry. Collecting specimens and Dcoownnldoaudcetdinbyg: Spu rpoercAe| dabui erkea ys12a@r egmt ah omm ain interventions in the diagnostic prete phases. Procure, process, tranDsi spt roibu rtt i,onaonf dt hissdt oocr ue mes npt ei scilliemgael ns properly. The community environment a Table 1.6 Errors in Collection Specimen Errors Collector Errors Insufficient volume Transport delay Improper type Improper collection method Insufficient number of samples Wrong specimen container Wrong transport medium or wrong or absent preservative Wrong time Air bubbles in tube Incorrect storage Storage at incorrect temperature Unlabeled or mislabeled specimen and/or wron information Incorrect order of draw Improperly completed forms or computer data Do not cut test tapes in half Discrepancies between test ordered and specim Improper centrifugation time Failure to properly transcribe and process order Note: Observing institutional protocols can prevent mishaps. Blood collection is normally done by trained persons. (An exception is the self-test for blood glucos designed specifically for that purpose.) The time of collection is an important factor (eg, a sequence cardiac panel). For example, a ―peak‖ drug-level blood specimen is collected when highest drug blood is expected. This type of test is used for therapeutic drug monitoring and dosing. Conversely, collected when lowest drug concentration is expected. These types of tests are used for therapeuti specimens are collected and results reported before the next scheduled dose of medication. Legal and forensic specimens are collected as evidence (see Appendix L) in legal proceedings, cri and after death. Examples include DNA samples and drug and alcohol levels. Factors such as chai situations and witnessed collections may be involved. The following list addresses some general comments about specimen collections: 1. Stool and urine collection requires clean, dry containers and kits. 2. Timed urine collection requires refrigeration and/or containers with special additives. 3. Sterile, dry containers and special kits are needed for midstream clean-catch urine specimen 4. Oral, saliva, and sputum specimens require specific techniques and kits and, sometimes, spe 5. Blood collection equipment includes gloves, needles, collection tubes, syringes, tourniquets, containers, lancets for skin puncture, cleansing agents or antimicrobial skin preparations, and 6. Color-coded stoppers and tubes indicate the type of additive present in the collection tube ( Table 1.7 Blood Specimen Collections Collection Tube Color and Additives * Yellow-topped tube: sodium polyethylene sulfonate (SPS) Use and Precautions For collection of blood cultures; aseptic technique for 7–10 times to prevent clot formation Red or gold serum separator tubes For collecting serum samples such as chemistry analy (SST); no anticoagulant be gently inverted (completely, end over end) 5 times ensure mixing of clot activator with blood and clotting After the 30-minute period, centrifuge promptly at desi Downloaded by: SuperA | abcieeknayt1r2if@mce (rcf) for 15 ± 5 minutes to separate se Distribution of this doccumaenntbiseillesgtaol red in gel separator tubes after centrifugatio Do not freeze SST tubes. If frozen specimen is neede Light green marbled–topped tube: gel separator/lithium, heparin as anticoagulant For potassium determination Tan/brown-topped tube: with For heparinized plasma specimens for testing lead lev heparin as anticoagulant Lavender-topped tube: with EDTA; tube). Invert tube 7–10 times. For whole blood and plasma, for hematology and com removes calcium to prevent clotting (CBCs); prevents the filled tube from clotting. If the tub half-filled, the proportion of anticoagulant to blood may to produce unreliable laboratory test results. Invert tub Royal blue–topped tube: no additive with EDTA or sodium heparin anticoagulant Gray-topped tube: with potassium oxalate and sodium fluoride Plain pink tube: no additive or anticoagulant Black tube: with sodium citrate (binds calcium) For toxicology, cadmium and mercury: tube free of tra tube 7–10 times. For glucose levels, glucose tolerance levels, and alco For blood bank For Westergren sedimentation rate Green-topped tube: with For heparinized plasma specimens, plasma chemistrie anticoagulant heparin (sodium, lithium, and ammonium heparin) gases, and special tests such as ammonia levels, hor electrolytes. Invert 7–10 times to prevent clot formatio *List is arranged in sequence of draw according to NCCLS guidelines. 7. Additives preserve the specimen, prevent deterioration and coagulation, and/or block action o blood cells. 8. Tubes with anticoagulants should be gently and completely inverted (end over end) 7 to 10 ti This process ensures complete mixing of anticoagulants with the blood sample and prevents 9. Store specimens properly after collecting or transport them to the laboratory immediately for analysis if possible. Failure to do so may result in specimen deterioration. STAT-ordered test hand-delivered to the laboratory and then processed as STAT. 10. Unacceptable specimens lead to increased costs and time wasted in getting results to the clin institution, and third-party payer. Exposure to sunlight, air, or other substances and warming examples of things that can alter specimen integrity (see Appendix E). Check with the labora (eg, ice, ice water, separate from ice), transport, and time limits. 11. As environments for specimen collection become more variable, modified procedures and pro clinician to keep abreast of the latest information related to these factors (see Appendix E). Equipment and Supplies 1. Use required kits, equipment, and supplies. Special kits are used for obtaining heel sticks and alcohol samples, saliva or oral fluid specimens, and urine specimens. 2. Do not use if you notice a defect (eg, moisture, pinholes, tears). In cases of sexual assault, s required and a strict procedure, consisting of several steps, is followed. 3. Operating special equipment such as video monitors for endoscopic procedures may be requ instances. Familiarity with current audiovisual technology is necessary. 4. Taking photographs of injuries in suspected abuse situations is another example. 5. Use barrier drapes as directed. For example, arthroscopy drapes are positioned with the fluid knee. 6. Maintain aseptic technique during certain procedures (eg, cystoscopy, bone marrow biopsy). Family Presence All drugs and solutions administered during diagnostic procedures are given according to accepted given by mouth, by intubation, parenterally (intramuscularly, intravenously, or subcutaneously), and skin applications. IV fluids and endoscopic irrigating fluids are commonly administered. Be aware of the potential for adverse reactions to drugs. Before procedure begins, confirm previou the patient before the procedure. Risks for injury are related to hypersensitivity, allergic or toxic rea tolerance due to liver or kidney malfunction, extravasation of intravenous fluids, and absorption of systemic circulation. Required skills include managing airways and breathing patterns; monitoring monitoring body, skin, and core temperature; and observing the effects of sedation and analgesia ( signs, rashes, edema). Use tape with caution, especially when skin integrity can be easily comprom patients. Management of Environment The main goal of environmental control is safe practice to ensure that the patient is free from injury environmental hazards and is free from discomfort. Be attentive to temperature and air quality; the exposure to noise, radiation, latex, and noxious odors; sanitation; and cleanliness. 1. Eliminate or modify sensory stimuli (eg, noise, odors, sounds). 2. Post a PATIENT AWAKE sign if the patient is awake during a procedure or PATIENT ASLEE 3. Be sensitive to conversation among team members in the presence of the patient. At best, it patient; at worst, it may be misinterpreted and have far-reaching negative effects and conseq Pain Control, Comfort Measures

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