Collection of OBJECTIVE data

Diagnostic Procedures

  • Client Monitoring: Vital signs are always obtained before, during, and after any procedure for monitoring purposes.

Classification of Procedures

  1. Non-Invasive Procedures

    • Requires informed consent only when there is an injection of a contrast medium or dye.

    • Informed consent must be obtained from the physician.

  2. Invasive Procedures

    • Always requires informed consent.

    • Explanation of the procedure must be provided by the physician.

  3. Laboratory Tests

    • Involve obtaining specimens from the patient's body; no consent is needed for laboratory exams.

    • Routinely done as part of patient care.

Invasive vs. Non-Invasive Procedures

Non-Invasive Procedures

  • Conservative treatments that do not require incision into the body.

  • No contact with mucous membranes or internal body cavities except through natural or artificial openings. Examples:

    • Radiography (X-rays)

    • Eye exams, CT scans, MRI, ECG, Holter Test

Invasive Procedures

  • Involve tools that break the skin or physically enter the body.

  • Require cutting through mucous membranes and insertion of instruments through natural body orifices. Examples:

    • Lumbar puncture, thoracentesis, paracentesis, bone marrow biopsy, liver biopsy.

Non-Invasive Procedures Detailed

1. Radiography (X-ray)

  • Characteristics: Painless; no jewelry or belts; contraindications include pregnancy.

  • Procedure: Uses radiation, radiopaque substances do not allow radiation to pass easily.

2. Upper G.I. Series (Barium Swallow)

  • Preparation: NPO after midnight; client ingests barium sulfate; several positions during the test.

  • Contraindications: Esophageal/intestine perforation, pregnancy, swallowing issues, severe constipation.

  • Post-Procedure: Encourage fluid intake to help clear barium.

3. Lower G.I. Series (Barium Enema)

  • Focus: Small intestine (ileum, jejunum), large intestine (colon).

  • Preparation: 1-2 days low residue diet; laxative; cleansing enema followed by barium enema.

4. Ultrasound (UTZ)

  • Preparation: Full bladder for UTZ-KUB; liquid intake to fill bladder.

  • Indications: Abdominal pain, suspected abscesses, jaundice, etc.

  • Variations: Depends on organ being examined (e.g., fasting for the gallbladder).

5. Computed Tomography (CT) Scan

  • Characteristics: Uses radiation through computer processing for clearer results.

  • Uses: Trauma assessments, neoplasm analysis, inflammatory conditions.

6. Magnetic Resonance Imaging (MRI)

  • Characteristics: Uses magnetic fields; pre-procedure assessment for metal objects.

  • Indications: Brain imaging, soft tissue visualization.

Invasive Procedures Detailed

1. Lumbar Puncture (Spinal Tap)

  • Procedure: Needle inserted to collect cerebrospinal fluid (CSF).

  • Uses: Diagnosing CNS diseases like meningitis.

  • Post-Care: Flat rest to avoid headaches.

2. Abdominal Paracentesis

  • Focus: Draining fluid from the peritoneal cavity due to ascites.

  • Procedure: Weigh and measure abdominal girth; high-Fowler's position during the procedure.

3. Thoracentesis

  • Purpose: Draining excessive fluid from the pleural space; positioning and patient cooperation crucial during the procedure.

4. Bone Marrow Biopsy

  • Procedure: Tissue sampling from the pelvic bone; assess blood cell production.

  • Post-Care: Monitor for bleeding, soreness, and potential infection.

5. Liver Biopsy

  • Types: Percutaneous, transjugular, and laparoscopic biopsy.

  • Indications: Assessing liver problems and tumor presence.

6. Direct Visualization Procedures

  • Types: Endoscopy, Bronchoscopy, Laryngoscopy.

  • Preparation: NPO, check gag reflex post-procedure.

  • Common Effects: Bloating, mild crampy abdominal pain.

Laboratory Tests

Complete Blood Count (CBC)

  • Key Components:

    • RBC (red blood cells)

    • WBC (white blood cells with differential)

    • HGB (hemoglobin)

    • PLT (platelets)

Serum Electrolytes

  • Importance: Detect electrolyte imbalances critical for homeostasis.

  • Normal Values: Sodium (135–145 meq/L), Potassium (3.5–5.0 meq/L), etc.

Arterial Blood Gases (ABG)

  • Purpose: Measures acidity and oxygen/CO2 levels in arterial blood.

  • Norms: pH (7.35–7.45), paO2 (75-110 mmHg), paCO2 (35-45 mmHg).

Specimen Collection

  • Types:

    • Stool

    • Urine (mid-stream clean catch)

    • Sputum (for TB testing).

Vital Signs

  • Definition: Provide data reflecting the status of various body systems.

  • Sequence: Temperature → Pulse Rate → Respiratory Rate → Blood Pressure.

Normal Ranges

  • Temperature: 36.5°C to 37.5°C.

  • Pulse Rate: 60 - 100 bpm.

  • Respiratory Rate: 12 - 20 cpm.

  • Blood Pressure: 90/60 mmHg to 120/80 mmHg.

Physical Assessment Techniques

  1. Inspection: Observational methods including using special equipment; involving various senses.

  2. Palpation: Thorough examination by touch.

  3. Percussion: Tapping for sound waves to assess various conditions.

  4. Auscultation: Listening with a stethoscope for internal sounds.