Diagnostic Tests (Nursing)

00:01 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.

00:39 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.

02:13 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.

03:19 But if you can get your patient prepared for early morning testing, it work out a lot better.

03:24 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.

03:39 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.

03:55 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.

04:15 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.

04:23 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.

04:56 We know that increase anxiety causes increased heart rate, and it also delays healing.

05:01 So we want to make sure we are doing our part with making sure that our patient is well informed.

05:07 For non-invasive procedures, we know that their consent that they signed to be treated is enough.

05:14 But I also need to know which procedures do they need to have consent for the procedure.

05:20 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.

05:57 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.

06:17 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.

06:27 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.

06:45 We know for some procedures maybe they need to have an EKG if their heart problems before.

06:49 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.

07:07 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.

08:05 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.

08:26 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.

09:20 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.

09:49 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.

10:43 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.

11:39 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.

11:55 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.

13:27 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.

14:35 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.

14:53 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.

17:11 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 yourself about.

18:22 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.

18:51 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.

19:22 Respiratory failure should always be on your mind as with cardiopulmonary failure.

19:27 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.