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(NOTE: These values are generalizations. Each laboratory has specific ranges.) Blood Count/Hematology
5-10 × 109/L
4.7 – 6.1 × 106/µL; 4.2-5.4 × 106/µL
Electrolytes and Gastrointestinal, Renal, and Liver Function
Lipids
transpeptidase (GGT): 8-38 U/L
40-180 mg/dL
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MOSBY'S DIAGNOSTIC AND LABORATORY TEST REFERENCE, FOURTEENTH EDITION
ISBN: 978-0-323-60969-2
Copyright © 2019 by Elsevier, Inc. All rights reserved.
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The 14th edition of Mosby’s Diagnostic and Laboratory Test Reference provides the user with an up-to-date, essential reference that allows easy access to clinically relevant laboratory and diagnostic tests. A unique feature of this handbook is its consistent format, which allows for quick reference without sacrificing the depth of detail necessary for a thorough understanding of diagnostic and laboratory testing. All tests begin on a new page and are listed in alphabetical order by their complete names. The alphabetical format is a strong feature of the book; it allows the user to locate tests quickly without first having to place them in an appropriate category or body system. The User’s Guide to Test Preparation and Procedures section outlines the responsibilities of health-care providers to ensure that the tests are accurately and safely performed. Use of this guide should eliminate the need for test repetition resulting from problems with patient preparation, test procedures, or collection techniques. Information on radiation exposure and risks has been added. Every feature of this book is designed to provide pertinent information in a sequence that best simulates priorities in the clinical setting. The following information is provided, wherever applicable, for effective diagnostic and laboratory testing:
• Name of test. Tests are listed by their complete names. A complete list of abbreviations and alternate test names follows each main entry.
• Type of test. This section identifies whether the test is, for example, an x-ray procedure, ultrasound, nuclear scan, blood test, urine test, sputum test, or microscopic examination of tissue. This section helps the reader identify the source of the laboratory specimen or location of the diagnostic procedure.
• Normal findings. Where applicable, normal values are listed for the infant, child, adult, and elderly person. Also, where appropriate, values are separated into male and female. It is important to realize that normal ranges of laboratory tests vary from institution to institution. This variability is even more obvious among the various laboratory textbooks. For this reason, we have deliberately chosen not to add a table of normal values as an appendix, and we encourage the user to check the normal values at the institution where the test is performed. This should be relatively easy because laboratory reports include normal values. Results are given in both conventional units and the International System of Units (SI units) where possible.
Standard guidelines for routine blood and urine testing are located on the inside front cover for easy access. A list of abbreviations for test names is included on the book’s endpapers.
Appendix A includes a list of studies according to body system. This list may familiarize the user with other related studies the patient or client may need or the user may want to review. This should be especially useful for students and health-care providers working in specialized areas.
Appendix B provides a list of studies according to test type This list may help the user read and learn about similarly performed tests and procedures (e.g., barium enema and barium swallow).
Appendix C provides a list of blood tests used for disease and organ panels.
Appendix D provides a list of symbols and units of measurement. Finally, a comprehensive index includes the names of all tests, their synonyms and abbreviations, and any other relevant terms found in the tests.
New to this edition is a table of Common Reference Ranges added to the inside front cover. This adds to the user-friendly aspect of this book by quickly identifying common reference ranges. This is a good starting point for students and a quick reference for routine lab values. However, because lab values vary from institution to institution, be sure to use the normal values of the lab performing the test.
Many new studies, such as alpha defensin, ceramides, and small intestinal bacterial overgrowth tests, have been added. All other studies have been revised and updated. Outdated studies have been eliminated.
We sincerely thank our editors for their enthusiasm and continued support. We are most grateful to the many nurses and other health-care providers who made the first 13 editions of this book so successful. Thank you so much. This success validated the need for a user-friendly and quick-reference approach to laboratory and diagnostic testing.
We sincerely invite additional comments from current users of this book so that we may continue to provide useful, relevant diagnostic and laboratory test information to users of future editions.
Kathleen D. Pagana
Timothy J. Pagana
Theresa N. Pagana
Health-care economics demands that laboratory and diagnostic testing be performed accurately and in the least amount of time possible. Tests should not have to be repeated because of improper patient preparation, test procedure, or specimen collection technique. Patient identification protocols should be followed to avoid wrong patient events. Two patient identifiers, such as name and date of birth, are usually used. The following guidelines delineate the responsibilities of health-care providers to ensure safety of test procedures and accuracy of test results. Guidelines are described for the following major types of tests: blood, urine, stool, x-ray, nuclear scanning, ultrasound, and endoscopy.
Overview
Blood studies are used to assess a multitude of body processes and disorders. Common studies include enzymes, serum lipids, electrolyte levels, red and white blood cell counts, clotting factors, hormone levels, and levels of breakdown products (e.g., blood urea nitrogen).
Multiphasic screening machines can perform many blood tests simultaneously using a very small blood sample. The advantages of using these machines are that results are available quickly and the cost is lower when compared with individually performing each test.
Appendix C provides a list of current disease and organ panels. For example, the basic metabolic panel and the comprehensive metabolic panel have replaced the Chem-7 and Chem-12 panels. These changes are the result of federal guidelines that have standardized the nomenclature for chemistry panels.
Guidelines
• Observe universal precautions when collecting a blood specimen.
• Check whether fasting is required. Many studies, such as fasting blood sugar and cholesterol levels, require fasting for a designated period of time. Water is permitted.
• If ordered, withhold medications until the blood is drawn.
• Record the time of day when the blood test is drawn. Some blood test results (e.g., those for cortisol) vary according to a diurnal pattern, and this must be considered when blood levels are interpreted.
xiv user’s guide to test preparation and procedures
• Do not shake the blood specimen. Hemolysis may result from vigorous shaking and can invalidate test results. Use gentle inversions.
• Collect blood cultures before the initiation of antibiotic therapy. Blood cultures are often drawn when the patient manifests a fever. Often two or three cultures are taken at 30-minute intervals from different venipuncture sites.
• Skin punctures can be used for blood tests on capillary blood. Common puncture sites include the fingertips, earlobes, and heel surfaces. Fingertips are often used for small children, and the heel is the most commonly used site for infants.
• Ensure that the blood tubes are correctly labeled and delivered to the laboratory.
• After the specimen is drawn, apply pressure or a pressure dressing to the venipuncture site. Assess the site for bleeding.
• If the patient fasted before the blood test, reinstitute the appropriate diet.
Overview
Urine tests are easy to obtain and provide valuable information about many body system functions (e.g., kidney function, glucose metabolism, and various hormone levels). The ability of the patient to collect specimens appropriately should be assessed to determine the need for assistance.
Guidelines
• Observe universal precautions in collecting a urine specimen.
• Use the first morning specimen for routine urinalysis because it is more concentrated. To collect a first morning specimen, have the patient void before going to bed and collect the first urine specimen immediately upon rising.
• Random urine specimens can be collected at any time. They are usually obtained during daytime hours and without any prior patient preparation.
• If a culture and sensitivity (C&S) study is required or if the specimen is likely to be contaminated by vaginal discharge or bleeding, collect a clean-catch or midstream specimen. This requires meticulous cleansing of the urinary meatus with an antiseptic preparation to reduce contamination of the specimen by external organisms. Then the cleansing agent must be completely removed because it may contaminate the specimen. Obtain the midstream collection by doing the following:
user’s guide to test preparation and procedures xvii dye-enhanced cardiac catheterization. With the concern about radiation exposure, it is important to realize that the patient may question if the proposed benefits outweigh the risks involved.
There are several units used to quantify amount of radiation absorbed from diagnostic imaging tests. The gray (Gy) is the measure of the amount of energy absorbed per unit mass. Because different organs in the body absorb radiation differently, the sievert (Sv) is often used instead of the gray. The sievert is the biological effect of 1 gray of radiation on human body tissue. The sievert is more helpful in comparing radiation exposure to different parts of the body. Radiation doses in medical imaging are typically measured in millisieverts (mSv) or 1/1000 of a sievert. On average, each person receives about 3 mSv of radiation yearly from natural background radiation.
The roentgen equivalent in man (rem) is an older unit to quantify the amount of radiation absorbed from x-rays. 1 rem is equivalent to 0.01 sievert.
See chart below for average amounts of radiation for adults associated with diagnostic testing.
Radiation exposure can cause damage to DNA. The body usually rapidly repairs this damage. Mistakes in DNA repair can lead to chromosomal or gene abnormalities that may be linked to cancer induction. The likelihood of cancer induction secondary to radiation exposure increases as the amount of radiation exposure increases. A person has a 5% increase in developing cancer over his or her lifetime after radiation exposure of 1 Sv or more. There can be a lag of many years between radiation exposure and cancer diagnosis. The average lag time is about 10 years after exposure.
The cumulative radiation dose from diagnostic imaging is very small and the benefit of proper diagnosis and treatment of disease generally outweighs the risks. However each patient’s current situation and history of radiation must be considered to accurately assess cumulative risks and benefits. Diagnostic procedures with higher radiation doses (e.g., computed tomography [CT] scans) should be clearly justified. Appropriateness Criteria published by the American College of Radiology (acr.org) is helpful in justification of performance of x-ray imaging.
Special consideration should be given to pregnant women and children before ordering x-ray imaging because the effects of radiation are more profound in fetuses and young children.
If a woman is pregnant, the risks versus benefits must be carefully considered. Certain studies with low radiation in which the focus of radiation is not on the fetus are obviously safer. (Leadcontaining shields can reduce x-ray exposure to fetuses.) Imaging using higher dose of radiation should be given only if the risk of not making the diagnosis is greater than the radiation risk.
Radiation risks are most significant in early fetal period and are less significant as the pregnancy progresses.
Patients with high body mass indexes should also be given extra consideration before ordering imaging studies. These patients often require greater radiation doses to penetrate body thickness to create acceptable images. Nuclear medicines studies are not affected in the same way. Although the x-ray exposure needed to produce one fluoroscopic image is low (compared with radiography), high exposures to patients can result from the time that may be encountered in fluoroscopic procedures.
(hands, feet, and so on)
user’s guide to test preparation and procedures xxi
• Note whether other x-ray studies are being planned; schedule them in the appropriate sequence. For example, x-ray examinations that do not require contrast should precede examinations that do require contrast. X-ray studies with barium should be scheduled after ultrasonography.
• Note the necessary dietary restrictions. Such studies as barium enema and intravenous pyelogram (IVP) are more accurate if the patient is kept NPO (fasting from food and liquids) for several hours before the test.
• Determine whether bowel preparations are necessary. For example, barium enemas and IVPs require bowel-cleansing regimens.
• Determine whether signed consent forms are required. These are necessary for most invasive x-ray procedures.
• Remove metal objects (e.g., necklaces, watches) because they can hinder visualization of the x-ray field.
• Patient aftercare is determined by the type of x-ray procedure. For example, a patient having a simple chest x-ray study will not require postprocedure care. However, invasive x-ray procedures involving contrast dyes (e.g., cardiac catheterization) require extensive nursing measures to detect potential complications.
With the administration of a radionuclide and subsequent measurement of the radiation of a particular organ, functional abnormalities of various body areas (e.g., brain, heart, lung, bones) can be detected. Because the half-lives of the radioisotopes are short, only minimal radiation exposure occurs (See p. xx).
• Radiopharmaceuticals concentrate in target organs by various mechanisms. For example, some labeled compounds (e.g., hippuran) are cleared from the blood and excreted by the kidneys. Some phosphate compounds concentrate in the bone and infarcted tissue. Lung function can be studied by imaging the distribution of inhaled gases or aerosols.
• Note whether the patient has had any recent exposure to radionuclides. The previous study could interfere with the interpretation of the current study.
• Note the patient’s age and current weight. This information is used to calculate the dose of radioactive substances.
xxii user’s guide to test preparation and procedures
• Nuclear scans are contraindicated in pregnant women and nursing mothers.
• Many scanning procedures do not require special preparation. However, a few have special requirements. For example, for bone scanning, the patient is encouraged to drink several glasses of water between the time of the injection of the isotope and the actual scanning. For some studies, blocking agents may need to be given to prevent other organs from taking up the isotope.
• For most nuclear scans, a small amount of an organ-specific radionuclide is given orally or injected intravenously. After the radioisotope concentrates in the desired area, the area is scanned. The scanning procedure usually takes place in the nuclear medicine department.
• Instruct the patient to lie still during the scanning.
• Usually encourage the patient to drink extra fluids to enhance excretion of the radionuclide after the test is finished.
• Although the amount of radionuclide excreted in the urine is very low, rubber gloves are sometimes recommended if the urine must be handled. Some hospitals may advise the patient to flush the toilet several times after voiding.
Overview
In diagnostic ultrasonography, harmless high-frequency sound waves are emitted and penetrate the organ being studied. The sound waves bounce back to the sensor and are electronically converted into a picture of the organ. Ultrasonography is used to assess a variety of body areas, including the pelvis, abdomen, breast, heart, and pregnant uterus.
Guidelines
• Most ultrasound procedures require little or no preparation. However, the patient having a pelvic sonogram needs a full bladder, and the patient having an ultrasound examination of the gallbladder must be kept NPO before the procedure.
• Ultrasound examinations are usually performed in an ultrasound room; however, they can be performed in the patient unit.
• For ultrasound, a greasy paste is applied to the skin overlying the desired organ. This paste is used to enhance sound transmission and reception because air impedes transmission of sound waves to the body.