DIAGNOSTIC AND LAB RESULTS

FECAL ANALYSIS

CHEST X-RAY

PAP SMEAR

HOLTER MONITORING

CYSTOSCOPY

MAMMORAPHY

ECHOCARDIOGRAM

COLONOSCOPY

LUMBAR PUNCTURE

BRONCHOSCOPY

COMPUTED TOMOGRAPHY (CT) SCAN
FECAL ANALYSIS
is a noninvasive laboratory test useful in identifying disorders of the digestive tract. These disorders
may include malabsorption, inflammation, infection (bacteria, viruses, or fungi), or cancer. It is
performed in combination with blood work, physical examination, x-ray imaging, and endoscopy in
order to confirm these conditions. The most common test done on a stool is called fecal occult blood
test (FOBT) wherein it can detect traces of blood in the feces.
Feces is a solid body waste discharged from the large intestine through the anus by the process of
defecation. It is made of cellulose and other indigestible food matter, water, and bacteria. Furthermore,
other substances usually found in feces include epithelial cells shed from the gastrointestinal tract,
small amounts of fats, bile pigments in the form of urobilinogen, GI and pancreatic
secretions, electrolytes, and trypsin. Trypsin is a proteolytic enzyme produced in the pancreas.
About 100 to 300 gram of fecal material is being excreted by an average adult daily, the residue of
approximately 10 liters of liquid material that enters the GI tract each day. The laboratory analysis of
feces includes macroscopic examination (volume, odor, shape, color, consistency, the presence of
mucus), microscopic examination (leukocytes, epithelial cells, meat fibers), and chemical tests for
specific substances (occult blood, trypsin, estimation of carbohydrates).
The role of the nurses during a stool collection and fecal analysis are as follows: proper specimen
collection and handling, accurate sample identification, ensure all supplies are appropriate for
collection, and timely transport of specimen to the laboratory.
This fecal analysis study guide can help nurses understand their tasks and responsibilities when
collecting a stool sample.
INDICATIONS OF FECAL ANALYSIS
Stool analysis is used to:

Aid in diagnosing disorders related to gastrointestinal (GI) bleeding or medication therapy that
results in bleeding

Assist in the diagnosis of pseudomembranous enterocolitis following the use of broad-spectrum
antibiotic therapy

Help diagnose suspected inflammatory bowel syndrome (IBS)

Identify the cause of diarrhea of unknown origin

Investigate disorders of protein digestion

Screen for colorectal cancer

Screen for cystic fibrosis

Determine intestinal parasitic infestation, as indicated by diarrhea of unknown cause

Evaluate the effectiveness of therapeutic regimen for intestinal malabsorption or pancreatic
insufficiency
INTERFERING FACTORS
These are factors or conditions that may affect the outcome of the study:

Medications that irritate the gastric mucosa such as non-steroidal anti-inflammatory medicines
(NSAIDs), anticoagulants, colchicine, corticosteroids, phenylbutazone, and iron preparations can
cause positive results for occult blood

High doses of vitamin C (more than 250 mg per day) can cause false negative occult blood

Dietary intake of high in red meat, certain vegetables (radish, turnips, cauliflower, broccoli), and
fruits (bananas, apples, cantaloupe) can cause false-positive results for occult blood

Constipated stools may not show any trypsin activity due to prolonged exposure to intestinal
bacteria
PROCEDURE FOR STOOL ANALYSIS
The following are steps in collecting a stool specimen:
1. Collect a fecal sample
Wear clean gloves and collect a stool specimen and put it directly in a leak-proof container with a tightfitting lid. If the patient is bedridden, collect the specimen in a clean, dry bedpan, and then, using a
tongue blade, transfer into a properly labeled container. If doing a rectal swab, insert the swab 2-3 cm
through the rectal sphincter, rotate gently, and remove. Transfer swab in the container.
2. Fill out the test request form completely
Note on the laboratory request the patient’s demographics, stool consistency, and date and time of
collection. Indicate previous or present antibiotic therapy and any pertinent history
3. Transport the specimen to the laboratory
Send the specimen to the laboratory immediately for processing and analysis. If a liquid or soft stool
sample can’t be processed within 30 minutes of passage, placed in a preservative; If a formed stool
specimen can’t be studied immediately, place it in a preservative or refrigerator.
NURSING RESPONSIBILITY FOR STOOL ANALYSIS
The following are the nursing interventions and nursing care considerations for the patient:
BEFORE THE PROCEDURE
The following are the nursing interventions prior to a stool analysis.

Assess the patient’s level of comfort. Collecting stool specimen may produce a feeling of
embarrassment and discomfort to the patient.

Encourage the patient to urinate. Allow the patient to urinate before collecting to avoid
contaminating the stool with urine.

Avoid laxatives. Advise patient that laxatives, enemas, or suppositories are avoided three days
prior to collection.

Instruct a red-meat free and high residue diet. The patient is indicated for an occult blood test,
must follow a special diet that includes generous amounts of chicken, turkey, and tuna, raw and
uncooked vegetables and fruits such as spinach, celery, prunes and bran containing cereal for two
(2) days before the test.
AFTER THE PROCEDURE

The nurse should note of the following nursing interventions after fecal analysis:

Instruct patient to do handwashing. Allow the patient to thoroughly clean his or her hands and
perianal area.

Resume activities. The patient may resume his or her normal diet and medication therapy unless
otherwise specified.

Recommend regular screening. The American Cancer Society recommends yearly occult blood test
as part of the screening for colorectal cancer starting at the age of 45 years old for people with
average risk.
NORMAL RESULTS
There are two methods where stool can be examined:

Macroscopic examination: for appearance and color

Microscopic examination: for cell count and presence of meat fibers; leukocyte esterase, for
leukocytes; Benedict’s solution (copper sulfate) for reducing substances; guaiac, for occult blood;
x-ray paper, for trypsin
Characteristic of stool
Normal findings
Appearance
Solid and formed
Color
Brown
Epithelial cells
Few to moderate
Fecal fat
Less than 7 grams of fat per 24 hours
Leukocytes (white blood cells)
Negative
Meat fibers
Negative
Occult blood
Negative
Reducing substances
Negative
Trypsin
2+ to 4 +
ABNORMAL RESULTS
Abnormal findings in a stool exam may reveal the potential medical diagnosis. These includes:
UNUSUAL APPEARANCE:

Mucous: Intestinal wall inflammation

Bloody: Excessive intestinal wall irritation or malignancy

Frothy or bulky: Malabsorption

Ribbonlike or slender: Obstruction
UNUSUAL COLOR:

Red: Beets and food coloring, lower GI bleed, phenazopyridine hydrochloride compounds,
rifampicin

Black: Bismuth (antacid) or charcoal ingestion, iron therapy, upper GI bleeding

Yellow: Rhubarb

Green: Antibiotics, biliverdin, green vegetables

Grayish white: Barium ingestion, bile duct obstruction
INCREASED:

Blood: related to GI bleeding

Occult blood: Diverticular disease, esophagitis, gastritis, esophageal varices, anal fissure,
hemorrhoids, infectious diarrhea, inflammatory bowel disease, polyps, tumors, ulcers, MalloryWeiss tears

Leukocytes: Inflammation of the intestines related to bacterial infections of the intestinal wall,
ulcerative colitis, shigellosis, or salmonellosis

Epithelial cells: Inflammatory bowel disorders

Carbohydrates/reducing substances: Inability to digest some sugar, malabsorption syndromes

Fats: Sprue (celiac disease), cystic fibrosis related to malabsorption, pancreatitis

pH: Related to inflammation in the intestine from colitis, cancer, or antibiotic use

Meat fibers: Pancreatitis, impaired protein digestion
DECREASED:

Leukocytes: Disorders resulting from toxins, cholera, viral diarrhea, amebic colitis, parasites

Carbohydrates/reducing substances: Cystic fibrosis, sprue, malnutrition, medications such as
colchicine or birth control pills

pH: Related to poor absorption of carbohydrate or fat

Trypsin: Malabsorption syndrome, pancreatic deficiency, cystic fibrosis
CHEST X-RAY (CHEST RADIOGRAPHY, CXR)
is one of the most frequently performed radiological examination. A chest x-ray is a painless, noninvasive test uses electromagnetic waves to produce visual images of the heart, lungs, bones,
and blood vessels of the chest. Air spaces normally seen in the lungs appear dark on the chest films. A
basic chest x-ray includes posteroanterior (PA) view, in which x-rays pass from the back to the front of
the body, and a left lateral view. Other projections such as lateral decubitus, lordotic views, or oblique
view can be requested also. For critically ill patients who cannot leave the nursing unit, a portable x-ray
machine is performed at the bedside using anteroposterior (AP) projections with an addition of a
lateral decubitus view if a free flow fluid or air is suspected.
Chest images should be examined in full inspiration and erect if feasible to reduce cardiac
magnification and demonstrate fluid levels. Expiration images may be needed to identify
a pneumothorax or locate foreign materials. Rib detail images may be taken to delineate bone
pathology, helpful when chest radiographs illustrate metastatic lesions or fractures. In the onset of the
disease process of asthma, tuberculosis, and chronic obstructive pulmonary disease, chest x-ray results
may not correlate with the patient’s clinical status and may even be normal.
Nurses are responsible for ensuring the comfort of the patient while at the x-ray room since some may
experience pain from injury or symptoms from a disease condition as well as the apprehension about
what the result may show. In addition, producing a good quality image relies on the ability of the
patient to cooperate such as holding breath for a period of time. Providing a calm and relaxed
environment for the patient is indeed vital.
This diagnostic and laboratory procedure study guide can help nurses understand their tasks and
responsibilities during a chest x-ray.
INDICATIONS OF CHEST X-RAY
Here are some of the reasons why a Chest x-ray is performed:

Assist in the diagnosis of diaphragmatic hernia, lung tumors, and metastasis

Detect known or suspected pulmonary, cardiovascular, and skeletal disorders

Identify the presence of chest trauma

Confirm correct placement and position of the endotracheal tube, tracheostomy tube, chest tubes,
central venous catheters, nasogastric feeding tube, pacemaker wires, intraortic balloon pump,
Swan-Ganz catheters, and automatic implantable cardioverter defibrillator

Evaluate positive purified protein derivative (PPD) or Mantoux test for pulmonary tuberculosis.

Monitor progressions, resolutions, or maintenance of disease

Evaluate the patient’s response to a therapeutic regimen (antibiotic, chemotherapy)
CONTRAINDICATION
Chest X-ray is not advisable for:

Patients who are pregnant or suspected of being pregnant unless the potential benefits of a
procedure using radiation outweigh the risk of maternal and fetal damage

Interfering Factors

These are factors or conditions that may alter the outcome of Chest X-ray:

Presence of metallic objects within the area of examination

Excessive or unnecessary movements made by the patient during the procedure

Incorrect position of the patient, which may produce poor exposure of the area to be examined

Inability of the patient to take full inspiration

Improper adjustment of the radiographic equipment to serve thin or obese patients, which can
result in underexposure or overexposure of the films
PROCEDURE
1. ITEMS ARE REMOVED
Patients will be asked to remove any clothing, jewelry, or other articles that may interfere with the
study.
2. APPROPRIATE CLOTHING IS GIVEN
Patients will be provided by an X-ray gown to wear.
3. POSITIONING THE PATIENT
The patient in a standing or sitting position will face the cassette or image detector with hands on hips,
inhale deeply, hold one’s breath until the X-ray image is made. For a lateral view, the chest is position
on the left side against the image holder with hands raised above the head.
4. IMAGES ARE TAKEN
The x-ray technician will stand behind a protective shield while the films are being developed within a
few minutes.
NURSING RESPONSIBILITIES FOR CHEST X-RAY
The following are the nursing interventions and nursing care considerations for the patient
BEFORE CHEST X-RAY
The following are the nursing interventions prior to chest x-ray:

Remove all metallic objects. Items such as jewelry, pins, buttons etc can hinder the visualization of
the chest.

No preparation is required. Fasting or medication restriction is not needed unless directed by the
health care provider.

Ensure the patient is not pregnant or suspected to be pregnant. X-rays are usually not
recommended for pregnant women unless the benefit outweighs the risk of damage to the
mother and fetus.

Assess the patient’s ability to hold his or her breath. Holding one’s breath after inhaling enables
the lungs and heart to be seen more clearly in the x-ray.

Provide appropriate clothing. Patients are instructed to remove clothing from the waist up and
put on an X-ray gown to wear during the procedure.

Instruct patient to cooperate during the procedure. The patient is asked to remain still because
any movement will affect the clarity of the image.
AFTER CHEST X-RAY
The nurse should note of the following nursing interventions after chest x-ray:

No special care. Note that no special care is required following the procedure

Provide comfort. If the test is facilitated at the bedside, reposition the patient properly.
NORMAL RESULTS
Normal findings in a chest x-ray will show a:

Normal lung fields, cardiac size, mediastinal structures, thoracic spine, ribs, and diaphragm
ABNORMAL RESULTS
The following abnormalities can be seen on a chest x-ray test. These includes:

Atelectasis (collapse or incomplete expansion of pulmonary parenchyma)

Bronchitis (inflammation of the bronchial tube)

Cardiomegaly (enlargement of the heart)

Flattened diaphragm associated with hyperinflation of the lung (indicator for COPD)

Foreign bodies lodged in the pulmonary system as seen by a radiopaque object

Irregular patchy infiltrates in the lung fields (suggestive of pneumonia)

Lung tumors (irregular and abnormal white shadow on the lung fields)

Malposition of tubes or wires

Misalignment or break of bones (indicating fracture)

Pericardial effusion (fluid accumulation around the heart)

Pericarditis (inflammation of the pericardium)

Pleural effusion (fluid accumulation within the pleural space)

Pneumothorax (presence of air within the pleural space)

Pulmonary bases, infiltrates, fibrosis,

Scoliosis (curvature of the spinal column)

Swollen lymph nodes

Tuberculosis (patchy, nodular infiltrates usually located on the upper lobe lung fields; cavities in
the lung)

Widened mediastinum (suggesting neoplasm or aortic aneurysm)
PAPANICOLAOU SMEAR (PAP SMEAR, CERVICAL SMEAR)
is a safe, noninvasive cytological examination for early detection of cervical cancer. During the 1900s,
cervical cancer was one of the leading cause of death among women. It was until the year 1928, where
a greek physician George Nicholas Papanicolaou was able to discover the difference between normal
and malignant cervical cells by viewing the samples microscopically, hence Pap smear was invented.
For women ages 30 and above, this procedure can be done in conjunction with a test on Human
papillomavirus (HPV), the most common sexually transmitted disease and primary causative agent for
cervical cancer. The American Cancer Society recommends a Pap smear at least once every three years
for women ages 21 to 29 who are not in a high-risk category and who have had negative results and
who have had negative results from three previous Pap tests. While a Pap test and an HPV test is
recommended every five years for women ages 30 to 65 years old. If a Pap smear is positive or
suggests malignancy, a cervical biopsy can confirm the diagnosis.
Nurses play an important role in promoting public health awareness to inform, encourage and
motivate the public in considering health screening such as pap smear. This pap smear study guide can
help nurses understand their tasks and responsibilities during the procedure.
INDICATIONS OF PAP SMEAR
Pap smear is indicated for the following reasons:

Identify the presence of sexually transmitted disease such as human papillomavirus (HPV), herpes,
chlamydia, cytomegalovirus, Actinomyces spp., Trichomonas vaginalis, and Candida spp.

Detect primary and metastatic neoplasms

Evaluate abnormal cervical changes (cervical dysplasia)

Detect condyloma, vaginal adenosis, and endometriosis

Assess hormonal function

Evaluate the patient’s response to chemotherapy and radiation therapy
INTERFERING FACTORS
These are factors or conditions that may alter the outcome of the study

Delay in fixing a specimen, allows the cells to dry therefore destroying the effectiveness of
the stain and makes cytologic interpretation difficult

Improper collection site may cause rejection of the specimen. Samples for hormonal evaluation
are taken from the vagina while samples for cancer screening are obtained from the vaginal fornix

Use of lubricating jelly on the speculum that may affect the viability of some organisms

Specimen collection during normal menstruation since blood can contaminate the sample

Douching, using tampons, or having sexual intercourse within 24 hours before the exam can wash
away cellular deposits

Existing vaginal infections that may interfere with hormonal cytology
PAP SMEAR PROCEDURE
Pap smear is performed by a practitioner and takes approximately about 5 to 10 minutes. The step-bystep procedure is as follows:
1.THE PATIENT IS POSITIONED.
The client is assisted in a supine, dorsal lithotomy position with feet in stirrups.
2. A SPECULUM IS INSERTED.
The practitioner puts on gloves and inserts an unlubricated plastic or metal speculum into the vagina
and is opened gently to spread apart the vagina to access the cervix. The speculum may be moistened
with saline solution or warm water to make insertion easier.
3. CERVICAL AND VAGINAL SPECIMENS COLLECTION.
After positioning the speculum, specimen from the vagina and cervix are taken. A cytobrush is inserted
inside the cervix and rolls it firmly into the endocervical canal. The brush is then rotated one turn and
removed. A plastic or wooden spatula is utilized to scrape the outer opening of the cervix and vaginal
wall.
4. COLLECTION TECHNIQUE (USING THE CONVENTIONAL COLLECTION).
The specimen from the brush and spatula is wiped on the slide and fixed immediately by immersing
the slide in equal parts of 95% ethanol or by using a spray fixative.
5. COLLECTION TECHNIQUE (USING THE THINPREP COLLECTION).
The brush and spatula are immediately immersed in a ThinPrep solution with a swirling motion to
release the material. The brush and spatula are then removed from the solution and the bottle lid is
replaced and secured.
6. LABEL THE SPECIMEN
The slides are properly labeled with the patient’s name, age, initials of the health care provider
collecting the specimen, date, and time of collection.
7. SPECIMENS ARE SENT TO THE LABORATORY
The specimens are transported to the laboratory for cytologic analysis.
8. BIMANUAL EXAMINATION MAY FOLLOW.
After the removal of the speculum, a bimanual examination may be performed wherein the health care
provider will insert two fingers of one hand inside the vaginal canal to feel the uterus and ovaries with
the other hand on top of the abdomen.
NURSING RESPONSIBILITY FOR PAP SMEAR
The following are the nursing interventions and nursing care considerations for a patient indicated for
Pap smear.
BEFORE THE PROCEDURE
The following are the nursing interventions prior to pap smear:

Secure patient’s consent. The test must be adequately explained and understood by the patient
before a written, and informed consent is obtained.

Obtain the patient’s health history. These include parity, date of last menstrual period, surgical
status, contraceptive use, history of vaginal bleeding, history of previous Pap smears, and history
of radiation or chemotherapy.

Ask lists of the patient’s current medications. If a patient is taking a vaginal antibiotic, the pap
smear is delayed for one month after the treatment has been completed.

Explain that Pap smear is painless. The test requires that the cervix may be scraped and may
experience minimal discomfort but no pain from the insertion of the speculum.

Avoid interfering factors. Having sexual intercourse within 24 hours, douching within 48 hours,
using a tampon, or applying vaginal creams or lotions is avoided before the test since it can wash
away cellular deposits and change the ph of the vagina.

Empty the bladder. Pap smear involves the insertion of the speculum into the vagina and could
press down the lower abdomen.
AFTER THE PROCEDURE
The nurse should note the following nursing interventions after pap smear:

Cleanse the perineal area. Secretions or excess lubricant from the vagina are removed and
cleansed.

Provide a sanitary pad. Slight spotting may occur after the pap smear.

Provide information about the recommended frequency of screening. The American Cancer
Society recommends screening every three years for women aged 21 to 29 years old and cotesting for HPV and cytological screening every five years for women aged 30 to 65 years old.

Answer any questions or fears by the patient or family. Anxiety related with the pending test
results may occur. Discussion of the implications of abnormal test results on the patient’s lifestyle
may be provided to the patient.
RESULTS
Normal findings in a Pap smear will indicate a negative result which means that no abnormal,
malignant cells or atypical cells are found. While a positive result signifies that there are abnormal or
unusual cells discovered, it is not synonymous to having cervical cancer.
The Bethesda System (TBS) is the current method for interpreting cervical cytology and it includes the
following components.
1. ADEQUACY OF SPECIMEN
Satisfactory for evaluation: Describe the presence or absence of endocervical transformation zone
component and other quality indicators such as partially obscuring blood, inflammation.
Unsatisfactory for evaluation: Specimen is rejected (specify reason) or the specimen is processed and
examined but unsatisfactory for evaluation of epithelial abnormalities (specify reason)
2. INTERPRETATION/RESULT

Negative for intraepithelial lesion or malignancy

Showing evidence of organism causing infection:
 Trichomonas vaginalis; fungal organisms morphologically consistent with Candida spp.; a
shift in flora indicative of bacterial vaginosis (coccobacillus); bacteria consistent
with Actinomyces spp.; cellular changes consistent with herpes simplex virus.

Other non-neoplastic findings:


Reactive cellular changes related to inflammation (includes repair), radiation, intrauterine
device use, atrophy, glandular cell status after hysterectomy.
Epithelial cell abnormalities

Squamous cell abnormalities
 Atypical squamous cells of undetermined significance (ASC-US) cannot exclude HSIL (ASCH):
 Low-grade squamous intraepithelial lesion (LSIL) encompassing HPV, mild dysplasia,
cervical intraepithelial neoplasm (CIN) grade 1
 High-grade squamous intraepithelial lesion (HSIL) encompassing moderate and severe
dysplasia, CIS/CIN grade 2 and CIN grade 3 with features suspicious for invasion (If
invasion is suspected).
 Squamous cell carcinoma: indicate the presence of cancerous cells.


Glandular cell

Atypical glandular cells (not otherwise specify)

Atypical glandular cells, favor neoplastic (not otherwise specify)

Endocervical adenocarcinoma in situ

Adenocarcinoma
Others

Endometrial cells (in woman >=40 years of age)
HOLTER MONITORING (Ambulatory electrocardiography, ambulatory monitoring, event recorder,
Holter electrocardiography)
is a noninvasive procedure that continuously records the heart’s activity as the patient does his normal
routine, usually for 24 to 72 hours.
Holter monitoring involves the use of a portable external monitor worn by means of a strap around the
waist or over the shoulder that measures and records the heart electrical impulses on a tape. The
monitor is equipped with a clock that permits accurate time monitoring. The patient is asked to carry a
diary and record daily activities, as well as any cardiac symptoms that may experience during the
testing. As the patient pushes a button signifying that symptoms have occurred, an event marker is
placed on the tape for later correlation with the cardiac activity recordings and the daily event diary.
The tape is then interpreted by a computer to detect any significant abnormal waveform patterns.
A critical duty of the nurse during this procedure is to make sure the electrodes are placed correctly.
This will ensure the avoidance of having inaccurate results. This study guide can help nurses
understand their tasks and responsibilities when handling a patient with a Holter monitor.
INDICATIONS OF HOLTER MONITORING
Holter monitoring is indicated for the following reasons:

Detect cardiac dysrhythmias that occur during normal activities and correlate them with symptoms
experienced by the patient

Detect sporadic arrhythmias missed by an exercise or resting ECG

Evaluate chest pain, palpitations, dizziness, and syncope

Evaluate activity intolerance associated with an imbalance of oxygen supply and demand

Monitor the effectiveness of antiarrhythmic drug therapy or a pacemaker

Monitor for ischemia and dysrhythmias following myocardial infarction or heart surgery before
changing rehabilitation and other therapeutic regimens
INTERFERING FACTORS
These are factors or conditions that may alter the outcome or results of Holter monitoring: Improper
placement of the electrodes or movement of the electrodes

Failure of the patient to keep an accurate diary of symptoms or to push button to produce a mark
on the strip when experiencing symptoms
HOLTER MONITORING PROCEDURE
The following steps will explain how Holter monitoring is done:
1. PREPARE THE SKIN
The area where the electrode patches are placed are cleaned with alcohol; Excess hair may be shaved
or clipped from the site if appropriate.
2. ATTACH THE ELECTRODES.
Electrodes are applied to the chest wall securely attached to the lead wires and monitor. The monitor
box may be worn around the waist or over the shoulder.
3. CHECK THE EQUIPMENT.
A new or fully charged battery is inserted in the recorder, and the monitor box is checked for paper
supply.
4. ACTIVATE THE DEVICE.
A tape is inserted, and the box is activated. This will record and store continuous cardiac rhythm data
transmitted by the electrodes.
5. KEEP A DIARY.
The patient is advised to keep a diary of activities and of any cardiac symptoms such as chest pain,
palpitations, dizziness, syncope, dyspnea, etc. that can occur while wearing the monitor for 24 to 72
hours.
6. REMOVE THE MONITOR FROM THE BODY.
Once the data measurement period is completed, the pads are removed and the monitor device is
returned to its box.
7. RETURN THE DEVICE.
The monitor is returned to the technician where the tape is interpreted by the computer and is
submitted to the requesting health care provider.
NURSING RESPONSIBILITIES OF HOLTER MONITORING
The following are the nursing interventions and nursing care considerations for a patient indicated for
Holter monitoring
BEFORE THE PROCEDURE
The following are the nursing interventions before wearing a Holter monitor

Advise the patient to wear loose-fitting clothing. This will allow the Holter monitor to stay in
place and to avoid lead dislodgment.

Provide precautionary measures. Advise patient to avoid contact with magnetic or electrical
devices such as magnets, metal detectors, high-voltage areas, and electric blankets where it can
interfere with the function of the monitor; Refrain from taking showers and tub bathing.

Apply electropaste or conductive paste to the skin sites. This will provide conduction between the
skin and electrodes.

Explain the importance of maintaining a diary to record activities. The patient may perform his or
her normal routine such as walking, eating, sleeping, sexual activity, emotional upsets, exercise,
and ingestion of medications and to log them in a diary.

Explain how to check the recorder to make sure it’s working properly. A light signal on the
monitor will signify that an equipment malfunction or that an electrode has accidentally come off.
AFTER THE PROCEDURE
The nurse should note of the following nursing interventions after Holter monitoring

Remove all chest electrodes. After the patient has worn the monitor, gently remove the tape and
other paraphernalia securing the electrodes.

Schedule appointment with the health care provider (HCP). The ECG recording will be interpreted
by a computer and a copy of a report is printed. This will be forwarded to the HCP who will discuss
the results with the patient.
NORMAL RESULTS
Normal findings after Holter monitoring will show:

No significant arrhythmias or ST-segment changes in the electrocardiogram.

Heart changes during various activities
ABNORMAL RESULTS
Abnormalities in a Holter monitoring will reveal:

Palpitations

Cardiomyopathy

Dysrhythmias such as premature ventricular contractions, bradycardias, tachycardias, and
conduction effects.

Hypoxic or ischemic changes

Mitral valve abnormality
CYSTOSCOPY
also known as cystoureterography or prostatography, is an invasive diagnostic procedure that allows
direct visualization of the urethra, urinary bladder, and ureteral orifices through the transurethral
insertion of a cystoscope into the bladder.
There are two types of cystoscopy: rigid and flexible. A rigid cystoscopy uses a thin, lighted tube that
consists of an obturator and a telescope with a lens and light system; It is usually performed to take
tissue samples and carry out complicated surgeries. It is done under general or spinal anesthesia.
While flexible cystoscopy uses a flexible fiber-optic telescope to provide diagnosis of urinary
abnormalities and to evaluate the effectiveness of a treatment. It is performed under local anesthesia.
The nurse needs to help prepare the patient during cystoscopy. This study guide lists the tasks and
responsibilities of the nurse during cystoscopy.
INDICATION
The cystoscopy may be performed for both diagnostic and therapeutic purposes:
DIAGNOSTIC CYSTOSCOPY

Assess the function of the kidneys by taking a urine specimen through ureteral catheters

Assess changes in urinary elimination patterns

Differentiate between benign and malignant bladder lesions

Identify the source of hematuria

Investigate the cause of recurrent urinary tract infection

Evaluate the extent of enlarged prostate and degree of obstructions

Evaluate urinary tract abnormalities such as dysuria, urgency, incontinence, frequency, retention,
and inadequate stream

Diagnose congenital anomalies such as ureteroceles, diverticula, duplicate ureters, urethral or
ureteral strictures, and areas of inflammation or ulceration
THERAPEUTIC CYSTOSCOPY

Coagulate bleeding areas

Dilate the urethra and ureters

Remove and resect polyps and small bladder tumors

Remove foreign bodies and renal calculi

Implant radioactive seeds into a tumor

Place ureteral catheters to drain urine from the renal pelvis or for retrograde pyelography

Resect hypertrophied or malignant prostate gland (transurethral resection of the prostate)
CONTRAINDICATION
Cystoscopy should not be done with the following:

Patients with an acute form of urethritis, prostatitis, or cystitis because instrumentation may
increase the risk of bacterial invasion, leading to sepsis

Patients with bleeding disorders since instrumentation may lead to further bleeding from the
lower urinary tract

Patients who are pregnant, unless the potential benefits of a procedure outweigh the risk of
maternal and fetal damage
INTERFERING FACTORS
These are factors or conditions that may alter the outcome of cystoscopy:

Inability to cooperate or remain still during the procedure due to age, significant pain, or mental
status

Failure to follow dietary restrictions prior that may lead to the cancellation or repetition of the
procedure
PROCEDURE
Cystoscopy is usually performed in the operating room or it can also be done in the clinic setting. The
following are the steps for cystoscopy:
1. EMPTY THE BLADDER.
The patient is asked to empty his or her bladder before the procedure and to change into a surgical
gown.
2. PLACE PATIENT IN A LITHOTOMY POSITION.
The patient is placed in the lithotomy position, the buttocks should be positioned at the edge of the
table and the feet are placed in stirrups.
3. SKIN PREP THE PATIENT.
The genitalia is cleaned with an antiseptic solution, and the patient is draped.
4. SEDATIVE OR LOCAL ANESTHESIA IS GIVEN.
A local anesthetic is instilled into the urethra if general anesthesia will not be used.
5. CYSTOSCOPE IS INSERTED.
The cystoscope or a urethroscope is inserted to examine the urethra before cystoscopy. The
urethroscope has a sheat that may be left in place, and the cystoscope is inserted through it, avoiding
multiple instrumentations.
6. URINE IS EXAMINED.
After insertion of the cystoscope, a sample of residual urine may be taken for culture or other analysis.
7. BLADDER IS FILLED WITH IRRIGATING SOLUTION.
The bladder is irrigated through an irrigation system attached to the scope. The irrigation fluid helps in
bladder visualization.
8. OTHER PROCEDURES MAY BE PERFORMED SUCH AS:
-If a prostatic tumor is found, a biopsy specimen may be obtained by means of a cytology brush or
biopsy forceps inserted through the scope. If the tumor is small and localized, it can be excised and
fulgurated. This procedure is termed transurethral resection of the bladder.
-Polyps can also be identified and excised.
-Ulcers or bleeding sites can be fulgurated using electrocautery.
-Renal calculi can be crushed and removed from the ureters and bladder.
-Ureteral catheters can be inserted via the scope to obtain urine samples from each kidney for
comparative analysis and radiographic studies.
-Ureteral and urethral strictures can also be dilated during this procedure.
9. CYSTOSCOPE IS REMOVED.
Upon completion of the examination and related procedures, the cystoscope is withdrawn.
10. SPECIMEN IS SENT TO THE LABORATORY.
Place obtained specimens in proper containers, label them properly, and immediately transport them
to the laboratory.
CYSTOSCOPY NURSING RESPONSIBILITY
The following are the nursing interventions and nursing care considerations for the patient undergoing
cystoscopy:
BEFORE CYSTOSCOPY
The following are the nursing interventions prior to cystography:

Assess patient’s understanding of the procedure and answer any queries. The procedure is
usually performed in a urology clinic and it takes about 30-45 minutes. Inform the patient who will
perform the test, where it will take place, and other health team members involved in the care.

Obtain informed consent. A written and informed consent is signed prior to the procedure and
before administration of medications.

Withhold blood thinning medications. Some examples are aspirin, warfarin (Coumadin),
enoxaparin (Lovenox), heparin, clopidogrel (Plavix), and dabigatran (Pradaxa).

Provide instruction for fasting and non-fasting preparation. Unless a general anesthetic has been
ordered, inform the patient that he doesn’t need to restrict food and fluids. If a general anesthetic
will be administered, instruct the patient to fast for at least 6 to 8 hours prior to the test.

Establish an IV line. To allow infusion of fluids, anesthetics, sedatives or emergency medications.

Prepare the patient. Instruct patient to empty the bladder prior to the procedure and to change
into the hospital gown provided.

Administer sedation and other medications as ordered. Preoperative medications are given 1
hour before the test. Sedative decreases the spasm of the bladder sphincter, reducing the
patient’s discomfort.
AFTER CYSTOSCOPY
The nurse should note of the following nursing care after cystoscopy:

Monitor and record vital signs. An increase in pulse (tachycardia) and a decrease in blood
pressure (hypotension) may indicate a sign of hemorrhage.

Assess the patient’s ability to void at least 24 hours after the procedure. Urinary retention may
be secondary to edema as a result from instrumentation.

Observe the color of urine. Pink-tnged urine and burning or mild discomfort when urinating may
be experienced for a few voidings after the procedure. This usually resolves within two or three
days.

Encourage increased fluid intake as indicated. Fluids will help flush the bladder to decrease the
amount of bleeding and to reduce risk of infection.

Encourage deep breathing exercises. These exercises may relieve the patient from bladder spasms.

Provide warm sitz baths and administer mild analgesics as ordered. These may relieve urinary
discomfort and promote muscle relaxation.

Watch out for signs of serious complications (sepsis, bladder perforation, hematuria). Persistent,
severe flank pain, elevated temperature over 101° F, chills, bright red blood or clots in the urine,
painful urination, or urinary retention must be reported immediately to the HCP.
NORMAL RESULTS
Normal findings in a cystography will show a:

Normal size, shape, and position of the urethra, bladder, and urethral structure.
ABNORMAL RESULTS
Abnormalities in a cystography will reveal:

Bladder cancer

Diverticulum of the bladder, fistula, stones, and strictures

Foreign body

Infection or inflammation

Obstruction

Polyps

Prostatic hyperplasia

Prostatitis

Renal calculi

Tumors

Ureteral calculi

Ureteral reflux

Ureteral or urethral strictures

Ureterocele

Urinary fistula

Urinary tract malformation and congenital anomalies
MAMMOGRAPHY
is an X-ray examination of the breasts that can detect cysts or tumors unpalpable during a physical
examination. A biopsy of an area of suspicion may be needed to confirm malignancy. Mammography
may follow screening procedures, such as ultrasonography or thermography.
There are two uses of mammogram (screening and diagnostic):
1.
Screening mammogram is used to screen for unsuspected breast cancer in women with no
signs or symptoms. It usually involves two x-ray images of each breast to detect tumors or small
calcifications within the breast tissue.
2.
Diagnostic mammogram is used to diagnose breast cancer in a patient with a suspicious lump
or other signs such as breast pain, nipple discharge, thickening of breast skin, or sudden change in
breast shape or size. It is also utilized to examine breast abnormalities found during a screening
mammogram and in such cases for patients with breast implants since it provides a more detailed x-ray
of the breast than using a screening mammogram.
Although mammography can detect 90-95 % of breast cancers, this test produces many false-positive
results. The American College of Radiologist, American Cancer Society, and the National Cancer Institue
suggests that women should begin screening mammogram at age 40 annually for women with average
risk while higher-risk women should start earlier and may benefit from supplemental screening
modalities.
Nurses have important responsibilities in assisting patients during mammography by providing
information about breast disease and breast examination, providing emotional support, and
coordinating with other healthcare specialists for further diagnostic and laboratory test.
This study guide can help nurses understand their tasks and responsibilities during mammography.
TYPES
The following are the different types and advances in mammography:

Full-field digital mammography (FFDM). Also known as digital mammography, is performed in the
same manner as conventional screen-film mammography (SFM). The difference is that FFDM
images are generated by digital signals rather than from the traditional x-ray film as with (SFM).
The images of the breast are examined on a computer monitor or printed on a special film.

Computer-aided detection (CAD) system. Uses software to search images from SFM or FFDM for
abnormal areas of breast tissue evidenced by denseness, abnormal size, or calcifications that may
indicate the presence of cancer. Abnormal areas are “marked” for further review by a radiologist.

Three-dimensional (3-D) breast imaging or breast tomosynthesis. Uses equipment that rotates in
an arc over the breast instead of the stationary system used in conventional SFM. The 3-D
equipment produces thin slices of the breast from a great number of angles that generate clearer
images, especially of dense breast tissue.
INDICATION
Mammography is generally indicated to:

Differentiate between benign breast disease and breast cancer

Investigate breast pain, nipple retraction, nipple discharge

Evaluate palpable and unpalpable breast masses

Screen for malignant breast tumors

Monitor effectiveness of breast radiation therapy

Evaluate opposite breast following mastectomy
CONTRAINDICATION
These are the contraindications for the procedure:

Pregnant women, unless the potential benefits of a procedure using radiation outweigh the risks
of maternal and fetal damage

Patients younger than age 25 or patients with very dense breast tissue
INTERFERING FACTORS
These are factors or conditions that may alter the outcome of the study

Application of substances such as antiperspirants (deodorants), talcum powder, lotions or creams
to the underarm and breast area that may interfere with the accuracy of the results

Failure to remove metallic objects and clothing

Previous breast surgery, active lactation, and glandular breast (common in women age 30 below),
which can affect the quality of the images

Breast implants which may prevent full visualization of the breast

Inability to cooperate or remain still during the procedure due to age, health condition, or mental
status
PROCEDURE
A mammography is performed on an outpatient basis and the step-by-step procedure is as follows:
1. PREPARE THE PATIENT.
The patient stands and is asked to rest one breast on a table above an X-ray cassette.
2. TECHNICIAN PLACES BREAST ONTO COMPRESSION PLATE.
The compression plate is placed on the breast and the patient is told to hold her breath. A radiograph
is taken of the craniocaudal view. The machine is rotated, the breast is compressed again, and a
radiograph of the lateral view is taken.
3. REPEAT PROCEDURE ON OTHER BREAST.
The procedure is repeated on the opposite breast.
4. REVIEW IF FILMS ARE RELIABLE
After the films are developed, they are checked to make sure they’re reliable.
NURSING RESPONSIBILITY
The following are the nursing interventions and nursing care considerations for a patient indicated for
mammography:
BEFORE THE PROCEDURE
The following are the nursing interventions prior to mammography:

Explain the procedure and what to expect after. Tell the patient who will perform the test and
where it will take place. Inform the patient that although the test takes only about 15 minutes to
perform, she may be asked to wait while the films are checked to make sure they are readable.
Advise her that there’s a high rate of false-positive results.

Allow the patient to express concerns and fears about the procedure. Assess the patient’s
understanding of the procedure, answer any questions, and correct any misconceptions.

Remove interfering factors. Instruct the patient to avoid using underarm deodorant or powder on
the day of the examination.

Schedule a senior technologist on a patient with breast implants. If the patient has breast
implants, notify him/her to inform the staff when he/she schedules the mammogram so that a
technologist familiar with imaging implants is on duty.

Prepare the patient. Just before the test, give the patient a gown to wear that opens in the front,
and ask her to remove all jewelry and clothing above the waist.
DURING THE PROCEDURE
The following are the nursing interventions during mammography:

Assist with patient positioning. Place patient in a standing or sitting position in front of the X-ray
machine, which is adjusted to the level of the breast. Place the patient’s arms out of the range of
the area to be imaged.

Tell the patient that some discomfort may be felt. Pain/discomfort may be caused by the
pressure required to compress the breast tissue against the X-ray plate.

Advise the patient to cooperate completely and follow directions. Instruct patient to remain still
throughout the procedure since movement produces unreliable results. Ask the patient to hold
breath while the x-ray films are being taken.
AFTER THE PROCEDURE
The nurse should note of the following nursing interventions after:

Provide information about the availability of the results. Inform the patient a report of the
findings will be given to the requesting physician, who will discuss the results with the patient.

Reinforce the information given by the patient’s HCP. Assist the patient in arranging an additional
test, therapy, or referral to another HCP if an abnormality is found.
NORMAL RESULTS
Normal findings in mammography will show:

Normal breast tissue, with an absence of cysts, tumors, or calcification
ABNORMAL RESULTS
Abnormalities in mammography will reveal:

Breast abscesses or cysts

Breast tumors

Breast calcifications

Hematoma resulting from trauma

Mastitis (inflammation of breast tissue)

Soft tissue masses

Vascular calcification (small calcium deposit within breast tissue)
ECHOCARDIOGRAM
also known as echocardiography, or heart ultrasound is a noninvasive, painless test that uses highfrequency sound waves to visualize the shape, size, and movement of the structures of the heart. It is
useful to evaluate patients with chest pain, enlarged cardiac silhouettes on X-rays, electrocardiogram
(ECG) changes unrelated to CAD, and abnormal heart sounds on auscultation.
In this test, a transducer directs ultrahigh-frequency sound waves toward cardiac structure, which
reflect these waves. The echoes are converted to images that are displayed on a monitor and recorded
on a strip chart or videotape. Results are correlated with clinical history, physical examination, and
findings from the additional test.
The techniques most commonly used in echocardiography are M-mode (motion mode), for recording
the motion and dimensions of intracardiac structures, and two-dimensional (cross-sectional), for
recording lateral motion and providing the correct spatial relationship between structures.
The responsibilities of a nurse during echocardiography includes explanation of the procedure to the
patient, monitoring during tranesophageal and stress examinations, and establishing intravenous
access for sonicated saline, microsphere contrast, and medication administration.
TYPES
The different types of echocardiogram are:

Transthoracic Echocardiogram (TTE). It is the most common type of echocardiogram and is
noninvasive. A device called transducer is placed on the patient’s chest and transmits ultrasound
waves into the thorax. These waves bounce off the structures of the heart, creating images and
sounds that are shown in a monitor.

Transesophageal Echocardiogram (TOE). It is a special type of echocardiography that uses an
endoscope to assist the transducer down to the esophagus where it produces a more detailed
image of the heart than a transthoracic echocardiogram.

Stress Echocardiogram. An echocardiogram that is performed while the patient is using a treadmill
or stationary bicycle. This type can be used to measure the function of the heart both at rest and
while exercising.

Dobutamine Stress Echocardiogram. For patients who are unable to exercise on a treadmill, a
drug called dobutamine is given instead through a vein that stimulates the heart in a similar
manner as exercise. This type of echocardiogram is used to evaluate coronary artery disease
and measures the effectiveness of cardiac therapeutic regimen.

Doppler echocardiogram. Measures and assess the blood flow through the heart and blood
vessels.
INDICATION
Echocardiogram is indicated for several reasons, which includes:

Detect and evaluate valvular abnormalities

Detect atrial tumors

Measure the size of the heart chambers

Evaluate chambers and valves in congenital heart disorders

Diagnose hypertrophic and related cardiomyopathies

Evaluate cardiac function or wall motion after myocardial infarctions

Detect pericardial effusion and mural thrombi
PROCEDURE
The following are the steps and processes on how an echocardiography or echocardiogram is
performed:
1. PLACE PATIENT IN A SUPINE POSITION.
Patient is placed in a supine position and a conductive gel is applied to the third or fourth intercostal
space to the left of the sternum. The transducer is placed directly over it.
2. TRANSDUCER IS PLACED
The transducer directs ultra-high-frequency sound waves towards cardiac structures, which reflect
these waves; the transducer picks up the echoes, converts them to electrical impulses, and relays them
to an echocardiography machine for display.
3. MOTION MODE IS USED
In motion mode (M-mode), a single, pencil-like ultrasound beam strikes the heart and produces a
vertical view, which is useful for recording the motion and dimensions of intracardiac structures.
4. CHANGE IN POSITION
In two-dimensional echocardiography, a cross-sectional view of the cardiac structures is used for
recording the lateral motion and spatial relationship between structures. For a left lateral view, the
patient is placed on his left side.
5. TRANSDUCER IS ANGLED.
The transducer is systematically angled to direct ultrasonic waves at specific parts of the patient’s
heart.
6. RECORD FINDINGS.
During the test, the screen is observed; significant findings are recorded on a strip chart recorder or a
video tape recorder.
7. DOPPLER ECHOCARDIOGRAPHY.
Doppler echocardiography also may be used where color flow stimulates red blood cell flow through
the heart valves. The sound of blood flow also may be used to assess heart sounds and murmurs as
they relate to cardiac hemodynamics.
INTERFERING FACTORS
These are factors that may affect the outcome of echocardiography:

Patient doing unnecessary movement during the procedure.

Incorrect placement of the transducer over the desired test area.

Metallic objects within the examination field, which may hinder organ visualization and cause
unclear images

Patients who are dehydrated, resulting in failure to demonstrate the boundaries between organs
and tissue structures.

Patients who have a severe chronic obstructive pulmonary disease have a significant amount of air
and space between the heart and the chest cavity. Airspace does not conduct ultrasound waves
well.

In obese patients, the space between the heart and the transducers is greatly enlarged; therefore,
the accuracy of the test is decreased.
NURSING RESPONSIBILITIES
The following are the nursing interventions and nursing care considerations for a patient undergoing a
normal echocardiogram:
BEFORE THE PROCEDURE
The following interventions are done prior and during the study:

Explain the procedure to the patient. Inform the patient that echocardiography is used to
evaluate the size, shape, and motion of various cardiac structures. Tell who will perform the test,
where it will take place, and that it’s safe, painless, and is noninvasive.

No special preparation is needed. Advise the patient that he doesn’t need to restrict food and
fluids for the test.

Ensure to empty the bladder. Instruct patient to void prior and to change into a gown.

Encourage the patient to cooperate. Advise the patient to remain still during the test because
movement may distort results. He may also be asked to breathe in or out or to briefly hold his
breath during the exam.

Explain the need to darkened the examination field. The room may be darkened slightly to aid
visualization on the monitor screen, and that other procedure (ECG and phonocardiography) may
be performed simultaneously to time events in the cardiac cycles.

Explain that a vasodilator (amyl nitrate) may be given. The patient may be asked to inhale a gas
with a slightly sweet odor while changes in heart functions are recorded.
DURING THE PROCEDURE
The following are the nursing considerations during echocardiogram:

Inform that a conductive gel is applied to the chest area. A conductive gel will be applied to his
chest and that a quarter-sized transducer will be placed over it. Warn him that he may feel minor
discomfort because pressure is exerted to keep the transducer in contact with the skin.

Position the patient on his left side. Explain that transducer is angled to observe different areas of
the heart and that he may be repositioned on his left side during the procedure.
AFTER THE PROCEDURE
The nurse should be aware of these post-procedure nursing interventions after an echocardiogram,
they are as follows:

Remove the conductive gel from the patient’s skin. When the procedure is completed, remove
the gel from the patient’s chest wall.

Inform the patient that the study will be interpreted by the physician. An official report will be
sent to the requesting physician, who will discuss the findings with the patient.

Instruct patient to resume regular diet and activities. There is no special type of care given
following the test.
NORMAL RESULTS
Normal findings of echocardiogram will reveal the following:

For mitral valve: Anterior and posterior mitral valve leaflets separating in early diastole and
attaining maximum excursion rapidly, then moving toward each other during ventricular diastole;
after atrial contraction, mitral valve leaflets coming together and remaining together during
ventricular systole.

For aortic valve: Aortic valve cusps moving anteriorly during systole and posteriorly during diastole.

For tricuspid valve: The motion of the valve resembling that of the mitral valve.

For pulmonic valve: Movement occurring posterior during atrial systole and ventricular ejection,
cusp moving anteriorly, attaining its most anterior position during diastole.

For ventricular cavities: Left ventricular cavity normally an echo-free space between
the interventricular septum and the posterior left ventricular wall.

Right ventricular cavity: Normally an echo-free space between the anterior chest wall and the
interventricular septum.
ABNORMAL RESULTS:
Abnormal echocardiogram findings will show the following:

In mitral stenosis: Valve narrowing abnormally because of the leaflets’ thickening and disordered
motion; during diastole, both mitral valve leaflets moving anteriorly instead of posteriorly.

In mitral valve prolapse: One or both leaflets ballooning into the left atrium during systole.

In aortic insufficiency: Aortic valve leaflet fluttering during diastole.

In stenosis: Aortic valve thickening and generating more echoes.

In bacterial endocarditis: Disrupted valve motion and fuzzy echoes usually on or near the valve.

Large chamber size: May indicate cardiomyopathy, valvular disorders, or heart failure: small
chamber size: may indicate restrictive pericarditis.

Hypertrophic cardiomyopathy: Identified by a systolic anterior motion of the mitral valve and
asymmetrical septal hypertrophy.

Myocardial ischemia or infarction: May cause absent or paradoxical motion in ventricular walls.

Pericardial effusion: Fluid accumulates in the pericardial space, causing an abnormal echo-free
space.

In large effusions: Pressure exerted by excess fluid restricting pericardial motion.
COLONOSCOPY
is a diagnostic procedure that utilizes a flexible fiberoptic colonoscope inserted into the rectum to
allow visual examination of the large intestine (colon) lining. It is indicated for patients with a history
of constipation, or diarrhea, persistent rectal bleeding, and lower abdominal pain when the results of
proctosigmoidoscopy and a barium enema test are negative or inconclusive.
The nurse‘s responsibility during colonoscopy encompasses different tasks to ensure the safety of the
patient before, during, and after the procedure. It is also the nurse’s responsibility to bowel prep the
patient for colonoscopy, obtaining informed consent, and allaying the patient’s anxiety by providing
information about the procedure.
Aside from assisting the physician during the colonoscopy, another essential task of a the nurse is to
ensure patient safety when colonoscope is reprocessed. Proper cleaning, disinfection, and sterilization
of the equipment is an important step to prevent the transmission of infection from patient to patient.
A proper reprocessing involves wiping the scope tube with a lint-free cloth soaked using a detergent
solution, then taking it to a sterile reprocessing room for meticulous cleaning, leak testing, visual
examination, and sterilizing.
This study guide can help nurses understand their tasks and responsibilities during colonoscopy.
COLONOSCOPY INDICATION
Colonoscopy is indicated for several reasons, which includes:

Screen for colon and rectal cancer

Detect and evaluate inflammatory and ulcerative bowel disease

Locate the source of lower GI bleeding and perform hemostasis by coagulation

Determine the cause of lower GI disorders, especially when barium and proctosigmoidoscopy
results are inconclusive

Assist diagnose colonic strictures and benign or malignant lesions

Evaluate the colon postoperatively for recurrence of polyps and malignant lesions

Investigate iron-deficiency anemia of unknown origin

Remove colon polyps

Remove foreign objects and sclerosing strictures by laser
Contraindication
This procedure is contraindicated for:

Pregnant women near term

Patients with bleeding disorders

Patients who had a recent acute myocardial infarction or abdominal surgery

Patients with ischemic bowel disease, acute diverticulitis, peritonitis, fulminant granulomatous
colitis, perforated viscus, or fulminant ulcerative colitis: For these cases or for screening purposes,
virtual colonoscopy may help visualize polyps before they become concerns.
PROCEDURE
Steps to colonoscopy is performed as follows:
1.
The patient is placed on his left side with his knees flexed and draped.
2.
Baseline vital signs are obtained. Vital signs are monitored throughout the procedure. If the
patient has known cardiac disease, continuous electrocardiographic monitoring should be
instituted. Continuous or periodic pulse oximetry is advisable, particularly in the high-risk patient
with possible respiratory depression secondary to sedation, which may be given.
3.
The patient is instructed to breathe deeply and slowly through his mouth as the practitioner
palpates the mucosa of the anus and rectum and inserts, under direct vision, the lubricated
colonoscope through the patient’s anus into the sigmoid colon.
4.
A small amount of air is insufflated to locate the bowel lumen, and then the scope is advanced
through the rectum.
5.
When the instrument reaches the descending sigmoid junction, the patient is assisted to a supine
position to aid the scope advance, if necessary. After passing the splenic flexure, the scope is
advanced through the transverse colon, through the hepatic flexure, and into the ascending colon
and cecum.
6.
Abdominal palpation or fluoroscopy may be used to help guide the colonoscope through the large
intestine.
7.
Suction may be used to remove blood and secretions that obscure the vision.
8.
Biopsy forceps or a cytology brush may be passed through the colonoscope to obtain specimens
for histologic or cytologic examination; an electrocautery snare may be used to remove polyps.
9.
If the physician removes a tissue specimen, it’s placed immediately in a specimen bottle containing
10% formalin; cytology smears are immediately placed in a Coplin jar containing 95% ethyl alcohol.
Specimens are sent to the laboratory immediately.
INTERFERING FACTORS
These are factors that may affect the outcome of the colonscopy:

Insufficient bowel preparation or failure to restrict food intake prior to the procedure

Retained barium in the intestine from previous diagnostic procedure

Inability of the patient to tolerate introduction of or retention of barium, air, or both in the bowel

Sigmoid colon fixation due to inflammatory bowel disease, surgery, or radiation therapy that may
hinder the passage of the colonoscope

Blood from acute colonic hemorrhage which can interfere with visualization

Colon spasms which can mimic the radiographic signs of cancer
Nursing Responsibilities
The following are the nursing interventions and nursing care considerations for the patient:
BEFORE THE PROCEDURE
The following are the nursing interventions prior to colonoscopy:

Secure an informed consent. Make sure that the patient or a significant other has signed an
informed consent form.

Obtain a medical history of the patient. Check for allergies, bleeding histories, medications, and
information relevant to the current complaint.

Provide information about the procedure. Tell the patient that colonoscopy permits examination
of the large intestine’s lining. Describe the procedure and tell the patient who will perform it and
where it will take place.

Ensure that the patient has complied with the bowel preparation. Explain that the large intestine
must be thoroughly cleaned to be clearly visible. To do so, tell the patient that he must maintain a
clear-liquid diet for 24 to 48 hours before the test, take nothing by mouth after midnight the
before, and take a laxative, as ordered, or 1 gallon of GoLYTELY solution in the evening (drinking
the chilled solutions at 8 oz [236.6 ml] every 10 minutes until the entire gallon is consumed).

Establish an IV line. Inform the patient that an IV line will be started and a sedative will be
administered before the procedure. Because a sedative will be given, advise the patient to arrange
for someone to drive him home after the procedure.

Provide reassurance. Assure the patient that the colonoscope is well lubricated to ease
it’s insertion, that it initially feels cool, and that he may feel an urge to defecate when it’s inserted
and advanced.

Explain to the patient that air may be introduced through the colonoscope. This is done to
distend the intestinal wall and to facilitate viewing the lining and advancing the instrument. Tell
him that flatus normally escapes around the instrument because of air insufflation and that he
shouldn’t attempt to control it.

Instruct the patient to empty bladder prior to the procedure. It is more comfortable if the patient
voids immediately before the procedure and to change into the gown, robe, and foot coverings
provided.

Instruct the patient to remove all metallic objects from the area to be examined. Metallic objects
such as jewelry within the examination area may alter organ visualization and cause unclear
images.

Instruct the patient to cooperate and follow directions. Instruct patient to remain still during the
procedure because movement creates unreliable results.
DURING THE PROCEDURE
The following are the nursing interventions during colonoscopy:

Assist with patient positioning as necessary. Place the patient on the examination table in a left
lateral decubitus position with a sheet draped over the body.

Administer medications as ordered. Pain medication and sedative will be given to reduce
discomfort and to promote relaxation.

Instruct the patient to bear down. Bearing down as if having a bowel movement is advised as the
fiberoptic tube is inserted through the rectum.

Change the position of the patient. When the scope is advanced through the sigmoid. The
patient’s position is changed to supine to allow passage into the transverse colon. Air is insufflated
through the tube during the passage to help in visualization.

Encourage the patient to take slow, deep breaths. Instruct the patient to take deep breaths to aid
in the movement of the scope down through the ascending colon to the cecum and into the
terminal portion of the ileum.
AFTER THE PROCEDURE
The nurse should note of the following nursing interventions post-colonoscopy:

Observe the patient closely for signs of bowel perforation. Signs of bowel perforations such as
severe abdominal pain, nausea, vomiting, fever, and chills must be reported immediately.

Obtain and record the patient’s vital signs. Monitor vital signs and neurological status every 15
minutes for 1 hour, then every 2 hours for 4 hours, or as ordered. Assess temperature every 4
hours for 24 hours.

Instruct patient to resume a normal diet, fluids, and activity as advised by the health care
provider. After the patient has recovered from sedation, allow him to resume his usual diet and
activity unless the practitioner orders otherwise.

Provide privacy while the patient rest after the procedure. Inform that the patient may pass large
amounts of flatus after insufflation.

Monitor for any rectal bleeding. If a polyp has been removed, minimal rectal bleeding is expected
for 2 days but an increasing amount of bleeding should be reported immediately.

Encourage increased fluid intake. Fluids must be given to replace fluid lost during the preparation
of the procedure.
NORMAL RESULTS
Normal findings of colonoscopy will show a:

Light-pink-orange mucosa of the large intestine beyond the sigmoid colon that is marked by
semilunar folds and deep tubular pits.

Visible blood vessels beneath the intestinal mucosa, which glisten from mucus secretions.
ABNORMAL RESULTS
Abnormal colonoscopy findings may reveal:

Benign or malignant lesions

Bowel inflammation and ulceration

Granulomatous or ulcerative colitis

Colonic polyps

Crohn’s disease

Diverticular disease or the site of lower GI bleeding.

Hemorrhoids

Proctitis

Tumors

Vascular abnormalities
LUMBAR PUNCTURE
also known as spinal tap, is an invasive procedure where a hollow needle is inserted into the space
surrounding the subarachnoid space in the lower back to obtain samples of cerebrospinal fluid (CSF)
for qualitative analysis. Most of the disorders of the central nervous system are diagnosed in relation
to the changes in the composition and dynamics of the CSF.
A lumbar puncture may also be used to measure CSF, instill medications, or introduce contrast medium
into the spinal canal. The procedure usually takes around 30 to 45 minutes and can be done on an
outpatient basis at a hospital or clinic.
One of the responsibilities of the nurse during a lumbar puncture is to provide information and
instructions before, during and after the procedure. It will decrease fear and anxiety among the patient
and their families, and it will also lessen the occurrence of potential complications post-lumbar
puncture.
INDICATION
Lumbar puncture is indicated for the following reasons:

Measure cerebrospinal fluid (CSF) pressure

Assist in the diagnosis of suspected CNS infections (bacterial or viral meningitis,
meningoencephalitis), intracranial or subarachnoid hemorrhage, and some malignant disorders

Evaluate and diagnose demyelinating or inflammatory CNS processes such as Multiple Sclerosis,
Guillan-Barré Syndrome (GBS), Acute Disseminated Encephalomyelitis (ADEM)

Infuse medications which include spinal anesthesia before surgery, contrast material for diagnostic
imaging such as CT-myelography, and chemotherapy drugs directly into the spinal canal

Treat normal pressure hydrocephalus, cerebrospinal fistulas, and idiopathic
intracranial hypertension (IIH).

Placement of a lumbar CSF drainage catheter
CONTRAINDICATION
Absolute contraindication for lumbar puncture are as follows:

Increased intracranial pressure due to a brain tumor. Cerebral or cerebellar herniation with
severe neurological deterioration may occur after the withdrawal of CSF fluid.

Skin infection near the puncture site. The presence of skin infection near the site of the lumbar
puncture increases the risk of contamination of infected material into the CSF.

Severe degenerative vertebral joint disease. There will be difficulty in passing the needle through
the degenerated arthritic interspinal space.

Severe coagulopathy. Due to the significant risk of epidural hematoma formation.
EQUIPMENT
The lumbar puncture kit contains:

Sterile gloves

Sterile drapes and procedure tray

Sterile gauze pads

Aseptic solution: povidone-iodine solution (Betadine)

Local anesthetic: Lidocaine 1% solution

25G needle

10ml syringe (1)

Spinal needle with stylet (size 22G or 25G)

CSF tube (2 to 4)

Stopcock

Manometer tubing
PROCEDURE
The step-by-step procedure for a lumbar puncture (spinal tap) is as follows:
1. POSITION THE PATIENT TO FETAL POSITION.
The patient is positioned on his side at the edge of the bed with his knees drawn up to his abdomen
and chin tucked against his chest (fetal position) or sitting while leaning over a bedside table. When the
patient is positioned supine, pillows are provided to support the spine on a horizontal plane.
2. STERELIZE SITE OF INSERTION.
The skin is site is prepared and draped, and a local anesthetic is injected.
3. INSERT THE SPINAL NEEDLE.
The spinal needle is inserted in the midline between the spinous processes of the vertebrae (usually
between the third fourth or the fourth and fifth lumbar vertebrae).
4. REMOVE THE STYLET FROM THE NEEDLE.
The stylet is removed from the needle. CSF will drip out of the needle if it’s properly positioned. A
stopcock and manometer are attached to the needle to measure the initial (opening) CSF pressure.
5. COLLECT SPECIMEN.
Specimens are collected and placed in the appropriate containers.
6. REMOVE THE NEEDLE.
The needle is removed, and a small sterile dressing is applied.
NURSING RESPONSIBILITY FOR LUMBAR PUNCTURE
The following are the nursing interventions and nursing care considerations for a patient indicated for
lumbar puncture:
BEFORE THE PROCEDURE
The following are the nursing interventions prior to a lumbar puncture:

Explain the procedure to the patient. Explain to the patient the purpose of lumbar puncture, how
and where it’s done, and who will perform the procedure.

Obtain informed consent. Make sure the patient has signed a consent form if required by the
institution.

Reinforce diet. Advise the patient that fasting is not required.

Promote comfort. Instruct the patient to empty the bladder and bowel before the procedure.

Establish a baseline assessment data. Do vital signs monitoring and neurologic assessment of the
legs by assessing the patient’s movement, strength, and sensation.

Place the client in a lateral decubitus position. Assist the client to assume a lateral decubitus (fetal)
position, near the side of the bed with the neck, hips, and knees drawn up to the chest. An
alternative position is to have the patient sit on the edge of the bed while leaning over a bedside
table.

Instruct to remain still. Explain that he or she must lie very still throughout the procedure. Any
unnecessary movement may cause traumatic injury.
AFTER THE PROCEDURE
The nurse should note of the following nursing interventions post-lumbar puncture:

Apply brief pressure to the puncture site. Pressure will be applied to avoid bleeding, and the site
is covered by a small occlusive dressing or band-aid.

Place the patient flat on bed. The patient remains flat on bed for 4 to 6 hours depending on the
physician. He or she may turn from side to side as long as the head is not elevated.

Monitor vital signs, neurologic status, and intake and output. Take vital signs, measure intake and
output, and assess neurologic status at least every 4 hours for 24 hours to allow further evaluation
of the patient’s condition.

Monitor the puncture site for signs of CSF leakage and drainage of blood. Signs of CSF leakage
includes positional headaches, nausea and vomiting, neck stiffness, photophobia (sensitivity to
light), sense of imbalance, tinnitus (ringing in the ear), and phonophobia (sensitivity to sound).

Encourage increased fluid intake. An increased amount of fluid intake (up to 3,000 ml in 24 hours)
will replace CSF removed during the lumbar puncture.

Label and number the specimen tube correctly. Ensure all samples are properly labeled and sent
to the laboratory immediately for further evaluations.

Administer analgesia as ordered. Headaches after the procedure can last for a few hours or days
and is usually treated with analgesics.
NORMAL RESULTS
CSF samples for analysis with normal values typically range as follows:

Pressure: 70 to 180 mm H20.

Appearance: CSF is normally clear and colorless.

CSF total protein: 15-45 mg/dL

Gamma globulin: 3 to 12% of the total protein

CSF glucose: 50 to 80 mg/dl

CSF cell count: Normal CSF contains no red blood cells (RBCs), the white blood cell (WBC) count is
0-5 WBCs per microliter (all mononuclear)

CSF Chloride: 118 to 130 mEq/L

Gram stain: No microorganism (bacteria, fungi, or virus) is present.
ABNORMAL RESULTS
These are the abnormal findings that can be found in CSF analysis:




Pressure:

Increased intracranial pressure (ICP) occurs as a result of a tumor, hemorrhage, or traumainduced edema.

Decreased intracranial pressure (ICP) may reveal a spinal subarachnoid obstruction.
Appearance:

Cloudy appearance indicating infection.

Yellow to reddish appearance indicating spinal cord obstruction or intracranial hemorrhage.

Brown to orange appearance indicating increased protein levels or RBC breakdown.
CSF Protein:

Increased protein indicating tumor, trauma, diabetes mellitus, or blood in cerebrospinal fluid
(CSF).

Decreased protein indicating rapid CSF production.
Gamma globulin:


Increased gamma globulin indicating a demyelinating disease such as multiple sclerosis,
neurosyphilis, or Guillan-Barré Syndrome.
CSF Glucose:



Increased glucose indicating high blood sugar (hyperglycemia).

Decreased glucose indicating low blood sugar (hypoglycemia), bacterial or fungal
infection, tuberculosis, or meningitis.
CSF cell count:

Increased white blood cells in the CSF suggesting meningitis, tumor, abscess, acute
infection, stroke, or demyelinating disease.

Red blood cells in the CSF indicating bleeding into the spinal fluid or the result of a traumatic
lumbar puncture.
CSF Chloride:


Decreased chloride indicating infected meninges.
Gram stain:

Gram-positive or Gram-negative organism indicating bacterial meningitis.
COMPLICATIONS
The possible complications after a lumbar puncture are:

Post-lumbar puncture headache. The most common complications of LP that occurs due to the
leakage of CSF from the puncture site or into the tissues around it. The pain is aggravated while
sitting, standing, or coughing and resolves after lying down.

Back pain. A pain or discomfort in the lower back may happen as a result of trauma to the local
soft tissue.

Pain or numbness. A feeling of tingling sensation and numbness in the lower back and legs is felt
temporarily.

Bleeding. Bleeding is usually noted in the area of the punctured site, or in some rare cases into the
subarachnoid, subdural or epidural space.

Brainstem herniation: The increased pressure caused by the removal of CSF during LP will cause
sudden shifting of brain tissue that can lead to the compression or herniation of the brainstem.
BRONCHOSCOPY
is an invasive procedure that permits the direct examination of the larynx, trachea, and bronchi using
either a flexible fiberoptic bronchoscope or a rigid metal bronchoscope (see gallery below). It is
performed by a trained practitioner (pulmonologist or thoracic surgeons). A non-invasive approach
called virtual bronchoscopy includes a series of computed tomography (CT) scans to visualize the
tracheobronchial tree.
While a flexible fiberoptic bronchoscope is used more often and provides a wider view, the rigid metal
bronchoscope, on the other hand, is a method of choice for foreign body removal, endobronchial
lesion excision, and massive hemoptysis control. A bronchial brush, forceps, and needle may be passed
through the bronchoscope to get samples for cytological determination.
The nurse‘s responsibility during a bronchoscopy includes maintaining a viable airway and closely
monitoring the patient’s respiratory status. Another role of the nurse during the bronchoscopy is to
relieve patient anxiety by providing information on what to expect and what to avoid.
INDICATION
Bronchoscopy may be performed in patients for diagnostic and/or therapeutic purposes:
DIAGNOSTIC BRONCHOSCOPY

Direct visualization of the tracheobronchial tree for any abnormalities such as inflammatory
process, tumors, or strictures

Direct visualization of the larynx to determine the presence of a vocal cord paralysis

Aspiration of a specimen for culture and sensitivity and for cytological examination

Biopsy of tissue from suspected lesions
THERAPEUTIC BRONCHOSCOPY

Removal of excessive secretions, mucus plugs, benign or malignant tumors to clear airways

Removal of foreign objects or other obstructions

Control of bleeding in the bronchi

Palliative laser therapy or radiation therapy for bronchial tumors
CONTRAINDICATION
As with any procedures, there are times when it is not safe to proceed with bronchoscopy. Nurses
should know that the contraindications for bronchoscopy are:

Patients who are uncooperative

Patients with uncorrectable coagulopathy

Patients with severe acute respiratory failure with hypercapnia who cannot tolerate high flow
oxygen interruption (unless intubated and ventilated)

Severe tracheal obstruction which makes it difficult to pass the scope

History of recent myocardial infarction or unstable angina

History of recent head trauma who are prone to increase intracranial pressure
INTERFERING FACTORS

Failure to place samples in the proper containers
PROCEDURE
Bronchoscopy may utilize fluoroscopic guidance for evaluation of distal lesions for a tracheobronchial
biopsy involving alveolar areas. However, a routine bronchoscopy procedure is as follows:
1. APPLY LOCAL ANESTHETIC.
A local anesthetic is flushed into the throat patient’s throat on a sitting upright or lying supine position.
2. INSERT BRONCHOSCOPE.
As the sedative takes effect, a bronchoscope is inserted through the patient’s mouth or nose.
3. ADDITIONAL ANESTHETIC IS APPLIED.
When the bronchoscope reaches above the vocal cords, about 3 to 4 mL of 2% to 4% lidocaine is
sprayed through the scope’s inner channel to the vocal cords to anesthetize distant areas.
4. EXAMINE THE AREA.
The practitioner examines the anatomic structure of the trachea and bronchi, notes the color of the
mucosal lining, and inspects for tumors or inflamed areas.
5. COLLECT TISSUE SAMPLES.
Tissue samples may be collected from a suspect area; A bronchial brush is needed to collect sample
cells from the surface of a lesion, and a suction apparatus to remove foreign materials or mucus plugs
may be used. Bronchoalveolar lavage may be performed to diagnose the infectious causes of infiltrates
in an immunocompromised patient or to remove copious secretions.
NURSING RESPONSIBILITIES
The following are the nursing interventions and nursing care considerations for a patient undergoing
bronchoscopy:
BEFORE THE PROCEDURE
The following are the nursing interventions before bronchoscopy:

(IMPORTANT) Secure informed consent. A signed consent form is obtained from the patient.

Obtain medical history. Ask for any history of allergies to anesthetic agents and list of medicines
the patient is taking.

Check for NPO status. Withheld food and fluids for 6 to 12 hours prior to the exam to decrease the
risk of aspiration.

Monitor vital signs. Obtain baseline vital signs and inform the practitioner of any abnormal
findings.

Provide oral hygiene. Instruct the patient to do oral care and remove any dentures if appropriate.

Administer preoperative medications as ordered. Explain to the patient that an IV sedative such
as Propofol may be given as an anesthetic agent.

Prepare for local anesthesia. If the bronchoscopy is not conducted under general anesthesia,
inform the patient that a topical anesthetic (e.g., Lidocaine) will be sprayed on the pharynx to
prevent coughing and gagging as the scope is passed down through the throat. Explain that the
spray may have a bitter taste to it.

Relieve anxiety. Reassure the patient that airway blockage won’t occur.

Prepare emergency resuscitation equipment at the bedside. Laryngospasm and respiratory
distress may occur following the procedure.
DURING THE PROCEDURE
The following are the nursing interventions during bronchoscopy:

Position the client. Place patient in a sitting or supine position and provide supplemental oxygen
as ordered.

Provide assistance with the diagnostic procedure and/or treatment. Assist with tissue specimen
collection for testing. Other procedures may be performed as needed such as removal of foreign
body, bronchoalveolar lavage, placement of a bronchial stent, and aspiration of retained
secretions.

Secure specimen. Send the properly labeled specimen to the laboratory immediately.
AFTER THE PROCEDURE
The nurse should be aware of these post-procedure nursing interventions after bronchoscopy:

Assess bleeding episodes. Observe the patient’s sputum and report for any excessive bleeding.
Explain that a minimal amount of blood streak is expected and normal for few hours after the
procedure.

Assess respiratory status. Watch out for signs of bronchial spasm or bronchial perforation such as
facial crepitus, hypoxemia, hemorrhage, and chest tightness.

Monitor vital signs. Changes in the vital signs or any discomforts felt by the patient may indicate a
possible complication.

Position the patient. Place the conscious patient in a semi-Fowler’s position while for an
unconscious patient, place on one side with the head of the bed slightly raised.

Reinforce diet. Maintain NPO status until the anesthesia has worn off and the gag reflex has
returned. The patient may resume his normal diet, starting with sips of water or ice chips.

Prevent aspiration. Provide an emesis basin, and instruct the patient to spit out saliva rather than
swallow it.

Relieve anxiety and provide comfort measures. Reassure the patient that hoarseness, loss of
voice and sore throat may occur temporarily. Offer lozenges or a soothing liquid gargle to relieve
discomfort until gag reflex returns.
NORMAL RESULTS
The following are the expected normal results of bronchoscopy:

Bronchi structurally same with the trachea

Right bronchus more vertical than the left and slightly larger

Smaller segmental bronchi branching off from the main bronchi
ABNORMAL RESULTS
The abnormal results following a bronchoscopy.

Clinical findings of pulmonary diseases that may include the following: tuberculosis (TB), interstitial
pulmonary disease, bronchogenic carcinoma, and other fungal or parasitic lung infections

Foreign substances in the trachea or bronchi, e.g., mucus plugs, blood, stones, and foreign objects

Endotracheal abnormalities, e.g., narrowing (stenosis), compression, ectasia (distention of a
tubular structure), irregular bronchial branching, and abnormal bifurcation due to a diverticulum

Bronchial wall abnormalities, e.g., swelling, inflammation, ulceration, tumors, protruding cartilage,
and mucous gland orifice or submucosal lymph node enlargement
POSSIBLE COMPLICATIONS
Bronchoscopy is usually safe; however, there are risks involved, which includes:

Bleeding from the site of the biopsy. Bleeding can happen when tissue specimens are taken
during the procedure.

Fever. A low-grade fever is usually common but it is not always an indicator of an existing infection.

Hypoxemia. Low blood oxygen concentration that occurs during the procedure and the level
usually returns to normal without any intervention.

Laryngospasm. irritation or spasm of the larynx (vocal cords).

Pneumothorax. or a collapsed lung. This happens when the lung is punctured during the
procedure.
COMPUTED TOMOGRAPHY (CT) SCAN
also known as computerized axial tomography (CAT), or CT scanning computerized tomography is a
painless, non-invasive diagnostic imaging procedure that produces cross-sectional images of several
types of tissue not clearly seen on a traditional X-ray.
CT scans may be performed with or without contrast medium. A contrast may either be an iodinebased or barium-sulfate compound that is taken orally, rectally, or intravenously which can enhance
the visibility of specific tissues, organs, or blood vessels. The duration of the procedure will depend on
the area being scanned.
The roles and responsibilities of a nurse extend throughout the whole duration of the CT scan
procedure — from taking patient’s history, obtaining informed consent, preparing the patient, and
providing education. To ensure the safety and accuracy of the procedure, learn about the nursing
interventions and concepts behind computed tomography (CT) scan.
PROCEDURE
The protocol and procedures for computed tomography (CT) scan varies per area but generally, the
following steps are followed:
1.
The patient is positioned on an adjustable table inside an encircling body scanner (gantry); straps
and pillows may be used to help in maintaining the correct position.
2.
The patient may be instructed to hold his breath during the scanning.
3.
A series of transverse radiographs are taken and recorded
4.
The information is reconstructed by a computer and selected images are photographed.
5.
Once the images are reviewed, an I.V. contrast enhancement may be ordered and additional
images are obtained.
6.
The patient is assessed carefully for adverse effects to the contrast medium.
TYPES
The following are the different types of computed tomography (CT) scans:
ABDOMINAL AND PELVIC
CT scan of the abdomen and pelvis combines radiologic and computer technology to determine the
cause of unexplainable abdominal or pelvic pain and diseases of the bladder, uterus, liver, colon, small
bowel, and other internal organs.
INDICATION
ABNORMAL RESULTS

Detects inflammatory process

Inspect soft tissue and organs of the
abdomen, pelvis and retroperitoneal space

Abscesses

Evaluates trauma

Cysts

Helps in the staging of neoplasms

Obstructive disease from a tumor or calculi

Detects edema, hemorrhage, cysts, and
tumors

Primary and metastatic neoplasms

Measures effectiveness to chemotherapy
BONE AND SKELETAL
Computed tomography (CT) scan of the bone is indicated to provide information and assess the
severity of different bone diseases and conditions such as fractures, cancer, and infection.
INDICATION
ABNORMAL RESULTS

Identify any joint abnormalities

Determine abnormalities in the upper and
lower spine

Bone fractures

Joint abnormalities

Detect unsual active bone formation

Primary bone tumors

Establish the presence and extent of fractures,
ligament, or tendon injuries, primary bone
tumors, skeletal metastases, and soft tissue
tumors

Soft-tissue tumors

Skeletal metastasis
BRAIN
Also known as “cranial CT scan” or “Head CT”. It is indicated to provide detailed information on head
injuries, stroke, brain tumors and other diseases affecting the brain.
INDICATION
ABNORMAL RESULTS

Arteriovenous malformation

Identify intracranial abnormalities and lesions

Cerebral atrophy

Determine focal neurological abnormalities

Cerebral edema

Guides brain surgery or biopsy of brain tissue

Congenital anomalies

Evaluate suspected head injury such as
subdural hematoma

Edema

Hydrocephalus

Intracranial tumors

Intracranial hematoma

Infarction

Monitor the effectiveness of chemotherapy,
radiotherapy, or surgery, as part of the
management of intracranial tumors
CARDIAC CALCIUM SCORING
The goal of a cardiac CT for calcium scoring is to detect coronary artery disease (CAD) at an early stage
in individuals who do not yet have any symptoms but are at risk for the disease. Calcium Scoring is
most often suggested for males aged 45 years or older, and for females aged 55 and over.
INDICATION


Identify presence, and extent of calcium
buildup in the coronary arteries
Evaluates the risk of atherosclerosis and
ABNORMAL RESULTS

Score of O: No plaque is present.

Score between 1-10: a minimal amount of
plaque is present.
coronary heart disease

Score between 11-100: evidence of plaque is
present. (Mild or minimal coronary
narrowings).

Score between 101 and 400: signifies
moderate amount of calcified plaque in the
arteries (an increased risk of MI)

Score >400: reveals extensive calcification and
significant narrowing of the arteries due to
plaque
EAR
In CT scan of the ear, the radiologist is able to diagnose conditions such as chronic otitis media, ear
infections, cholesteatoma, conductive hearing loss, mastoiditis, and cochlear implants.
INDICATION
ABNORMAL RESULTS

Diagnose cochlear abnormalities

Investigate ossification of the cochlea coils
prior to cochlear implantation

Depict osseous changes in the petrous
and temporal bone

Determine the appropriate surgical and
therapeutic method for patients with inner
and middle ear disorders

Evaluate postsurgical therapy of patients
with middle and inner ear disorders

Differentiate cholesteatoma from chronic
inflammation

Evaluate the cause of bilateral hearing loss

Cochlear abnormalities

Osseous changes of the external auditory
canal and middle and inner ear structures

Tympanosclerosis
LIVER AND BILIARY TRACT
CT scan of the liver and biliary tract provides an in-depth information about the liver, gallbladder, bile
ducts, and other related structures.
INDICATION

Differentiate obstructive and nonobstructive
jaundice

Detect intrahepatic tumors and abscesses,
subphrenic and subhepatic abscesses, cysts,
and hematomas
ABNORMAL RESULTS

Biliary duct dilation

Calculi

Focal hepatic defects

Hepatic cysts

Hepatic abscesses

Neoplasms

Pancreatic carcinoma

Small lesions
ORBITAL
An orbital CT scan provides detailed information about the eye sockets, eyes, and adjacent bone
structures.
INDICATION

Identify the cause of unilateral exophthalmos

Assess pathologic conditions of the eye and
orbit

Detect fractures of the orbit and adjoining
structures
ABNORMAL RESULTS

Encapsulated tumors (benign hemangiomas
and meningiomas)

Early erosion or expansion of the medial
orbital wall

Intracranial tumors (gliomas, meningiomas,
and secondary tumors)

Lymphomas and metastatic carcinomas

Space-occupying lesions in the orbit or
paranasal sinuses

Space-occupying lesions

Thickening of the medial and lateral rectus
muscles
PANCREAS
CT scan of the pancreas may be useful to diagnose cancer of the pancreas, and pancreatitis, and to
differentiate pancreatic problems and disorders of the retroperitoneum.
INDICATION
ABNORMAL RESULTS

Diagnose or evaluate pancreatitis

Acute and chronic pancreatitis

Identify pancreatic carcinoma or pseudocyst

Abscesses

Differentiate pancreatic disorders and
retroperitoneum disorders

Adenocarcinoma

Ascites

Biliary obstructions

Cystadenocarcinomas

Cystadenomas

Islet cell tumors

Metastases

Pancreatic carcinoma

Pseudocysts

Pleural effusion
RENAL
A renal scan examines the structural and functional abnormalities of the kidney. It is indicated to
detect tumors, obstructions, and lesions.
INDICATION


Identify and diagnose renal abnormalities,
such as calculi, obstruction, tumor, polycystic
disease, congenital anomalies, and abnormal
fluid accumulation
Evaluate retroperitoneal pathologies
ABNORMAL RESULTS

Abscesses

Calculi

Congenital anomalies

Hematomas

Kidney infection or damage

Lymphoceles

Obstructions

Polycystic kidney disease

Renal cell carcinoma

Renal cysts or masses

Vascular or adrenal tumors
SPINAL
CT scan of the spine is performed to gain insight regarding the vertebrae and other spinal structures
and tissues. It is indicated to detect spinal related injuries and diseases of the spine.
INDICATION

Diagnose lesions and abnormalities of the
spine

Detect or rule out spinal damage in patients
with injury

Monitor the results of spinal surgery or
therapy
ABNORMAL RESULTS

Spinal lesions and abnormalities

Cervical spondylosis

Cervical cord compression

Congenital spinal malformations
(meningocele, myelocele, and spina bifida)

Degenerative processes and structural
changes

Facet disorders

Fluid-filled arachnoidal and other paraspinal
cysts

Herniated nucleus pulposus

Lumbar stenosis

Meningioma

Neurinoma (schwannoma)

Spinal cord compression

Spurring of the vertebrae

Vascular malformations
THORACIC
CT scan of the chest aids in determining the cause of an unexplained cough, fever, difficulty of
breath, chest pain, and other respiratory symptoms. It is recommended for screening of possible lung
cancer in its early, curable stage.
INDICATION

Diagnose a dissection or leak of an aortic
aneurysm or aortic arch aneurysm

Diagnose the invasion of a neck mass in the
thorax

Differentiate emphysema or bronchopleural
fistula from a lung abscess

Distinguish tumors adjacent to the aorta from
aortic aneurysms

Differentiate tumors from calcified lesions
(signifies tuberculosis)

Detect the mediastinal lymph nodes

Assess primary malignancy that may
metastasize to the lungs, especially in the
patient with a primary bone tumor, soft-tissue
sarcoma, or melanoma

Identify the extent of lung diseases such as
bronchiectasis, emphysema, and diffuse
interstitial lung disease

Locate observed neoplasms (e.g., Hodgkin’s
disease), especially with the mediastinal
involvement
ABNORMAL RESULTS

Accumulation of fluid, blood, or fat

Aortic aneurysms

Cysts

Enlarged lymph nodes

Nodules

Pleural effusion

Tumors

Plan radiation therapy
CONTRAINDICATION
Computed tomography (CT) is contraindicated in:

Pregnant patient (absolute contraindication)

Patients with a known allergy to iodine

Patients with claustrophobia

Patients with renal impairment unless the benefits outweigh the risks

Patients with hyperthyroidism or toxic goiter (induce thyrotoxic crisis)

Patients with complications after a previous administration of a contrast

Patients with severe obesity (usually more than 300 pounds)
INTERFERING FACTORS

Retained oral or I.V. contrast material from previous diagnostic studies may affect the visibility of
the images.

Metal objects including eyeglasses, dentures, jewelry, and hairpins
NURSING RESPONSIBILITIES FOR CT SCAN
The following are the nursing interventions and nursing care considerations for a patient undergoing
computed tomography:
BEFORE THE PROCEDURE
The following are the nursing interventions before computed tomography:

Informed Consent. Obtain an informed consent properly signed.

Look for allergies. Assess for any history of allergies to iodinated dye or shellfish if contrast media
is to be used.

Get health history. Ask the patient about any recent illnesses or other medical conditions and
current medications being taken. The specific type of CT scan determines the need for an oral or
I.V. contrast medium

Check for NPO status. Instruct the patient to not to eat or drink for a period amount of time
especially if a contrast material will be used.

Get dressed up. Instruct the patient to wear comfortable, loose-fitting clothing during the exam.

Provide information about the contrast medium. Tell the patient that a mild transient pain from
the needle puncture and a flushed sensation from an I.V. contrast medium will be experienced.

Instruct the patient to remain still. During the examination, tell the patient to remain still and to
immediately report symptoms of itching, difficulty breathing or swallowing, nausea, vomiting,
dizziness, and headache.

Inform about the duration of the procedure. Inform the patient that the procedure takes from
five (5) minutes to one (1) hour depending on the type of CT scan and his ability to relax and
remain still.
AFTER THE PROCEDURE
The nurse should be aware of these post-procedure nursing interventions after computed tomography
(CT) scan:

Diet as usual. Instruct the patient to resume the usual diet and activities unless otherwise ordered.

Encourage the patient to increase fluid intake (if a contrast is given). This is so to promote
excretion of the dye.
NORMAL RESULTS
The following are the expected normal results of computed tomography (CT) scan:

Specific type of CT scan reveals normal findings

Normal findings on a CT scan shows bone (which has the densest tissue) appears as white areas.
Tissues densities will show as shades of gray, and fat tissue appear as black or dark
gray. Cerebrospinal fluid (has no tissue) will appear as black. Air will also look black and darker
than fat.
ABNORMAL RESULTS
The abnormal results of a computed tomography (CT) scan varies per area.

The specific type of CT dependent on the area of study (see abnormal results above).
Note: These were taken on the internet. Credits to the rightful owner
https://nurseslabs.com/fecal-analysis-stool-analysis/
https://nurseslabs.com/chest-x-ray/
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https://nurseslabs.com/colonoscopy/
https://nurseslabs.com/lumbar-puncture-spinal-tap/
https://nurseslabs.com/bronchoscopy/
https://nurseslabs.com/computed-tomography-ct-scan/