![F.A. Davis Company
1915 Arch Street
Philadelphia
PA19103
www.fadavis.com
Copyright © 2015 by F.A. Davis Company
Copyright © 2009,2006,2003,2011,2013 by F.A.Davis Company.All rights reserved.This
book is protected by copyright. No part of it may be reproduced, stored in a retrieval
system,or transmitted in any form or by any means,electronic,mechanical,photocopying,
recording, or otherwise, without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Publisher: Lisa B. Houck
Art and Design Manager: Carolyn O’Brien
Content Project Manager II:Victoria White
Digital Publishing Project Manager: Sandra Glennie
As new scientific information becomes available through basic and clinical research, rec-
ommended treatments and drug therapies undergo changes.The authors and publisher
have done everything possible to make this book accurate,up to date,and in accord with
accepted standards at the time of publication.The authors, editors, and publisher are not
responsible for errors or omissions or for consequences from application of the book,
and make no warranty, expressed or implied, in regard to the contents of the book.Any
practice described in this book should be applied by the reader in accordance with profes-
sional standards of care used in regard to the unique circumstances that may apply in each
situation.The reader is advised always to check product information (package inserts) for
changes and new information regarding dose and contraindications before administering
any drug.Caution is especially urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Van Leeuwen,Anne M., author.
Davis’s comprehensive handbook of laboratory diagnostic tests with nursing implications/
Anne M.Van Leeuwen, Mickey Lynn Bladh.—6th edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-4405-2 -- ISBN 0-8036-4405-1
I. Bladh, Mickey Lynn, author. II. Title.
[DNLM: 1. Clinical Laboratory Techniques—Handbooks. 2. Clinical Laboratory
Techniques—Nurses’ Instruction. 3. Nursing Diagnosis—methods—Handbooks.
4. Nursing Diagnosis—methods—Nurses’ Instruction. QY 39]
RB38.2
616.07′5—dc23
2014025032
Authorization to photocopy items for internal or personal use,or the internal or personal
use of specific clients,is granted by F.A.Davis Company for users registered with the Copy-
right Clearance Center (CCC) Transactional Reporting Service, provided that the fee of
$.25 per copy is paid directly to CCC,222 Rosewood Drive,Danvers,MA 01923.For those
organizations that have been granted a photocopy license by CCC, a separate system of
payment has been arranged.The fee code for users of theTransactional Reporting Service
is:978–0–8036–4405–2/15 0 + $0.25
FM_i-xx.indd 4 19/11/14 1:04 PM](https://image.slidesharecdn.com/21801627-250524035643-2728eb82/85/Daviss-Comprehensive-Handbook-Of-Laboratory-And-Diagnostic-Tests-6e-February-3-20150803644051fa-Davispdf-Anne-M-Van-Leeuwen-8-320.jpg)
![Access additional resources at davisplus.fadavis.com
A
ACTH with an exaggerated and
prolonged response to stimula-
tion. Cortisol levels usually do
not reach 20 mcg/dL.
(The DST is useful in differentiat-
ing the causes of increased corti-
sol levels. Dexamethasone is a
synthetic glucocorticoid that is
significantly more potent than
cortisol. It works by negative
feedback. It suppresses the
release of ACTH in patients with a
normal hypothalamus. A cortisol
level less than 1.8 mcg/dL usually
excludes Cushing’s syndrome.
With the DST, a baseline morning
cortisol level is collected, and the
patient is given a 1-mg dose of
dexamethasone at bedtime. A sec-
ond specimen is collected the fol-
lowing morning. If cortisol levels
have not been suppressed, adre-
nal adenoma is suspected. The
DST also produces abnormal
results in the presence of certain
psychiatric illnesses [e.g., endog-
enous depression]).
The metyrapone stimulation
test is used to distinguish cortico-
tropin-dependent causes (pituitary
Cushing’s disease and ectopic
Cushing’s disease) from cortico-
tropin-independent causes (e.g.,
carcinoma of the lung or thyroid)
of increased cortisol levels.
Metyrapone inhibits the conver-
sion of 11-deoxycortisol to corti-
sol. Cortisol levels should decrease
to less than 3 mcg/dL if normal
pituitary stimulation by ACTH
occurs after an oral dose of metyr-
apone. Specimen collection and
administration of the medication
are performed as with the over-
night dexamethasone test.
Increased in
Overproduction of ACTH can
occur as a direct result of either
disease (e.g., primary or ectopic
tumor that secretes ACTH) or
stimulation by physical or emo-
tional stress, or it can be an indi-
rect response to abnormalities in
the complex feedback mecha-
nisms involving the pituitary
gland, hypothalamus, or adrenal
glands.
ACTH Increased in
•
• Addison’s disease (primary adre-
nocortical hypofunction)
•
• Carcinoid syndrome
•
• Congenital adrenal hyperplasia
•
• Cushing’s disease (pituitary-
dependent adrenal
hyperplasia)
•
• Cushing’s syndrome (ectopic
secretion of ACTH)
•
• Depression
•
• Ectopic ACTH-producing tumors
•
• Menstruation
•
• Nelson’s syndrome
(ACTH-producing pituitary
tumors)
•
• Non-insulin-dependent diabetes
•
• Pregnancy
•
• Sepsis
•
• Septic shock
Decreased in
Secondary adrenal insufficiency
due to hypopituitarism (inade-
quate production by the pitu-
itary) can result in decreased
levels of ACTH. Conditions that
result in overproduction or avail-
ability of high levels of cortisol
can also result in decreased levels
of ACTH.
ACTH Decreased in
•
• Adrenal adenoma
•
• Adrenal cancer
•
• Cushing’s syndrome
•
• Exogenous steroid therapy
Adrenocorticotropic Hormone (and Challenge Tests) 15
Monograph_A_001-023.indd 15 17/11/14 12:03 PM](https://image.slidesharecdn.com/21801627-250524035643-2728eb82/85/Daviss-Comprehensive-Handbook-Of-Laboratory-And-Diagnostic-Tests-6e-February-3-20150803644051fa-Davispdf-Anne-M-Van-Leeuwen-36-320.jpg)
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Alanine Aminotransferase 23
A
Patient Education:
➧
➧ Reinforce information given by the
patient’s HCP regarding further testing,
treatment, or referral to another HCP.
Recognize anxiety related to test results,
and answer any questions or address any
concerns voiced by the patient or family.
➧
➧ Provide teaching and information
regarding the clinical implications of the
test results, as appropriate.
➧
➧ Educate the patient regarding access
to counseling services. Provide contact
information, if desired, for the Centers
for Disease Control and Prevention
(www.cdc.gov/diseasesconditions).
➧
➧ Provide information regarding disease
process and proactive activities that the
patient can take in managing health.
➧
➧ Provide samples of dietary selections
that can support pancreatic and
liver health and that are culturally
appropriate.
Expected Patient Outcomes:
Knowledge
➧
➧ The patient and family verbalize
understanding of causative factors of
pancreatitis and liver disease.
➧
➧ The patient and family verbalize under-
standing that the disease can reoccur
if not adhering to positive actions to
change lifestyle.
Skills
➧
➧ The patient creates a diet plan that
supports liver and pancreatic health.
➧
➧ The patient takes medication as pre-
scribed to limit pancreatic secretions
and decrease pain.
Attitude
➧
➧ The patient agrees to seek counseling
for alcohol abstinence.
➧
➧ The patient agrees to control potential
behaviors that could trigger future
disease episodes.
RELATED MONOGRAPHS:
➧
➧ Related tests include acetaminophen,
ammonia, AST, bilirubin, biopsy liver,
cholangiography percutaneous transhe-
patic, electrolytes, GGT, hepatitis anti-
gens and antibodies, LDH, liver and
spleen scan, US abdomen, and US liver.
➧
➧ See the Hepatobiliary System table at
the end of the book for related tests by
body system.
➧
➧ Instruct the patient to cooperate fully
and to follow directions. Direct the
patient to breathe normally and to
avoid unnecessary movement.
➧
➧ Observe standard precautions, and fol-
low the general guidelines in Appendix A.
Positively identify the patient, and label
the appropriate specimen container
with the corresponding patient
demographics, initials of the person
collecting the specimen, date, and time
of collection. Perform a venipuncture.
➧
➧ Remove the needle, and apply direct
pressure with dry gauze to stop bleeding.
Observe/assess venipuncture site for
bleeding and hematoma formation and
secure gauze with adhesive bandage.
➧
➧ Promptly transport the specimen to the
laboratory for processing and analysis.
POST-TEST:
➧
➧ Inform the patient that a report of the
results will be made available to the
re
questing health-care provider (HCP), who
will discuss the results with the patient.
➧
➧ Nutritional Considerations: Increased ALT
levels may be associated with liver dis-
ease. Dietary recommendations may be
indicated and vary depending on the
severity of the condition. A low-protein
diet may be in order if the patient’s liver
has lost the ability to process the end
products of protein metabolism. A diet of
soft foods may be required if esophageal
varices have developed. Ammonia levels
may be used to determine whether pro-
tein should be added to or reduced from
the diet. Patients should be encouraged
to eat simple carbohydrates and emulsi-
fied fats (as in homogenized milk or
eggs) rather than complex carbohy-
drates (e.g., starch, fiber, and glycogen
[animal carbohydrates]) and complex
fats, which require additional bile to
emulsify them so that they can be used.
The cirrhotic patient should be carefully
observed for the development of ascites,
in which case fluid and electrolyte bal-
ance requires strict attention.
➧
➧ Depending on the results of this proce-
dure, additional testing may be performed
to evaluate or monitor progression of the
disease process and determine the need
for a change in therapy. Evaluate test
results in relation to the patient’s symp-
toms and other tests performed.
Monograph_A_001-023.indd 23 17/11/14 12:03 PM](https://image.slidesharecdn.com/21801627-250524035643-2728eb82/85/Daviss-Comprehensive-Handbook-Of-Laboratory-And-Diagnostic-Tests-6e-February-3-20150803644051fa-Davispdf-Anne-M-Van-Leeuwen-44-320.jpg)
![already explained. As a rule, the rising cost of food has been so
general as not to change greatly the relative economy of the
different types of food as compared with each other.
Cost and nutritive value.—The discussion of cost has dealt so
far with the cost of food materials as they are found in the market.
What we are really seeking to learn is the amount of nutritive
material to be obtained for a given sum of money, and in order to do
this, we must think of our purchases in terms of the foodstuffs and
their values. The accompanying table from a government bulletin[17]
gives an estimate of cost from this point of view in terms of protein
and fuel value. Notice that wheat bread is a cheap food, standing
first in the amount of building material and energy.
Amounts of Protein and Energy Obtained for 10 Cents Expended
For Bread and Other Foods at Certain Assumed Prices per Pound
FOOD
MATERIALS
PRICE
10 CENTS
WILL BUY
10 CENTS’ WORTH WILL
CONTAIN
PROTEIN
A FUEL VALUE
OF
Ounces Ounces Calories
Wheat bread
5 cents per
lb.
32.0 2.9 2400
Cheese
22 cents
per lb.
7.3 1.9 886
Beef, average
20 cents
per lb.
8.0 1.2 467
Porterhouse
steak
25 cents
per lb
6.4 1.3 444
Dried beef
25 cents
per lb.
6.4 .1 315](https://image.slidesharecdn.com/21801627-250524035643-2728eb82/85/Daviss-Comprehensive-Handbook-Of-Laboratory-And-Diagnostic-Tests-6e-February-3-20150803644051fa-Davispdf-Anne-M-Van-Leeuwen-63-320.jpg)
![CHAPTER XVIII
MENUS AND DIETARIES[18]
When we have learned to choose and cook wholesome and
appetizing food we have not solved the whole problem of successful
feeding. It is possible to make people sick with good food, if it is
badly selected and fed at wrong times or in unsuitable amounts.
Whether children grow to their full size and strength depends more
upon the choice of their food than upon any other one thing. The
effect of food is strikingly shown in the case of the white rats in Fig.
74. The two upper ones are the same age. Both had the same
mother, lived in the same kind of clean cages, and had plenty of
food, but the diet of the upper was good for growth, while that for
the middle one was not. It remained perfectly well, but became
stunted because of the character of its food. You can see that it
resembles the lowest one in the illustration, which is only one fourth
as old. In this chapter we shall consider how and when and in what
amounts to serve food so that every one may get from it the fullest
benefit in both health and happiness.](https://image.slidesharecdn.com/21801627-250524035643-2728eb82/85/Daviss-Comprehensive-Handbook-Of-Laboratory-And-Diagnostic-Tests-6e-February-3-20150803644051fa-Davispdf-Anne-M-Van-Leeuwen-75-320.jpg)
![obtained by a few well-selected dishes at each meal. If we do not
exhaust our resources on one meal, we shall be able to have a
greater range of foods in the course of a week. A hotel may have
fifty or sixty items on its bill of fare, but after a few days one feels as
if there were a great sameness, because all of them are impressed
on the mind at each meal and every day.
Dietaries.—A dietary, as we shall use the term here,[19] is a
statement of the food requirements of a person or group of persons
for a day or some other definite length of time, with a selection of
foods to satisfy this requirement.
The first part of a family dietary will have to be calculated
according to the age, weight, and occupation, as stated on pages
299-303. When complete, it will stand somewhat like this:
Food Requirements
Members of
Family
Age
Weight
Pounds
Total
Calories
Protein
Calories
Man 40 154 2680 268-402
Woman 38 120 2160 216-324
Girl 16 110 2200 220-330
Boy 12 75 2250 225-338
Boy 6 40 1600 160-240
Total requirements 10,890 1089-1634
In selecting food to satisfy these requirements it is a good plan
to make first a list of those foods that need to be included in the
day’s dietary, no matter what the particular menu may be. This will
include foods for growth where there are children, special dishes
needed if any one is sick, and those common foods which we are
accustomed to include in every day’s menu, such as bread and
butter.](https://image.slidesharecdn.com/21801627-250524035643-2728eb82/85/Daviss-Comprehensive-Handbook-Of-Laboratory-And-Diagnostic-Tests-6e-February-3-20150803644051fa-Davispdf-Anne-M-Van-Leeuwen-90-320.jpg)
Daviss Comprehensive Handbook Of Laboratory And Diagnostic Tests 6e February 3 20150803644051fa Davispdf Anne M Van Leeuwen
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- 5. Comprehensive Handbook of Laboratory & Diagnostic Tests Anne M. Van Leeuwen Mickey Lynn Bladh / /
- 6. FM_i-xx.indd 1 19/11/14 1:04 PM DAVIS'S Comprehensive Handbook of Laboratory & Diagnostic Tests with Nursing Implications 6TH EDITIO;"
- 7. F. A. DAVIS COMPANY • Philadelphia Anne M. Van Leeuwen Mickey Lynn Bladh FM_i-xx.indd 3 19/11/14 1:04 PM
- 8. F.A. Davis Company 1915 Arch Street Philadelphia PA19103 www.fadavis.com Copyright © 2015 by F.A. Davis Company Copyright © 2009,2006,2003,2011,2013 by F.A.Davis Company.All rights reserved.This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system,or transmitted in any form or by any means,electronic,mechanical,photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher: Lisa B. Houck Art and Design Manager: Carolyn O’Brien Content Project Manager II:Victoria White Digital Publishing Project Manager: Sandra Glennie As new scientific information becomes available through basic and clinical research, rec- ommended treatments and drug therapies undergo changes.The authors and publisher have done everything possible to make this book accurate,up to date,and in accord with accepted standards at the time of publication.The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book.Any practice described in this book should be applied by the reader in accordance with profes- sional standards of care used in regard to the unique circumstances that may apply in each situation.The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug.Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Van Leeuwen,Anne M., author. Davis’s comprehensive handbook of laboratory diagnostic tests with nursing implications/ Anne M.Van Leeuwen, Mickey Lynn Bladh.—6th edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8036-4405-2 -- ISBN 0-8036-4405-1 I. Bladh, Mickey Lynn, author. II. Title. [DNLM: 1. Clinical Laboratory Techniques—Handbooks. 2. Clinical Laboratory Techniques—Nurses’ Instruction. 3. Nursing Diagnosis—methods—Handbooks. 4. Nursing Diagnosis—methods—Nurses’ Instruction. QY 39] RB38.2 616.07′5—dc23 2014025032 Authorization to photocopy items for internal or personal use,or the internal or personal use of specific clients,is granted by F.A.Davis Company for users registered with the Copy- right Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC,222 Rosewood Drive,Danvers,MA 01923.For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged.The fee code for users of theTransactional Reporting Service is:978–0–8036–4405–2/15 0 + $0.25 FM_i-xx.indd 4 19/11/14 1:04 PM
- 9. Dedication Inspiration springs from Passion. … Passion is born from unconstrained love, commitment, and a vision no one else can own. Lynda—my best friend and extraordinarily gifted nurse—thank you, I could not have done this without your love, strong support, and belief in me. My gratitude to Mom, Dad,Adele, Gram . . . all my family and friends, for I am truly blessed by your humor and faith.A huge hug for my daughters, Sarah and Margaret—I love you very much.To my puppies, Maggie,Taylor, and Emma, for their endless and unconditional love. Many thanks to my friend and wonderful coauthor Mickey; to all the folks at F.A. Davis, especially Rob and Victoria for their guidance, support, and great ideas.And, very special thanks to Lisa Houck, publisher, for her friendship, excellent direction, and unwavering encouragement. Anne M. Van Leeuwen, MA, BS, MT (ASCP) Medical Laboratory Scientist & Independent Author Greater Seattle Area,Washington An eternity of searching would never have provided me with a man more loving and supportive than my husband, Eric. He is the sunshine in my soul, and I will be forever grateful for the blessing of his presence in my life. I am grateful to my five children, Eric,Anni, Phillip, Mari, and Melissa, for the privilege of being their mom; always remember that you are limited only by your imagination and willingness to try.To Anne, thanks so much for the opportunity to spread my wings, for your patience and guidance, and thanks to Lynda for the miracle of finding me.To all of those at F.A. Davis—Rob, Victoria, and Lisa—you are the best. Lastly, to my beloved parents, thanks with hugs and kisses. Mickey L. Bladh, RN, MSN Coordinator, Nursing Education PIH Health Hospital Whittier, California We are so grateful to all the people who have helped us make this book possible.We thank our readers for allowing us this important opportunity to touch their lives.We are also thankful for our association with the F.A. Davis Company.We value and appreciate the efforts of all the people associated with F.A. Davis because without their hard work this publication could not succeed.We recognize all the wonderful people in leadership, the editors, freelance consultants, designers, IT gurus, and digital applications developers, as well as those in sales & marketing, distribution, and finance.We have a deep appreciation for the Davis Educational Consultants.They are tasked with being our voice.Their exceptional ability to communicate is what actually brings our book to the market.We would like to give special v Dedication FM_i-xx.indd 5 19/11/14 1:04 PM
- 10. acknowledgement to the outstanding publishing professionals who were our core support team throughout the development of this edition: Lisa Houck Publisher Robert Allen Content Applications Developer Victoria White Content Project Manager II Cynthia Naughton Production Manager, Digital Solutions Sandra Glennie Project Manager, Digital Solutions Carolyn O’Brien Art & Design Manager Jaclyn Lux Marketing Manager Dan Clipner Production Manager vi Dedication FM_i-xx.indd 6 19/11/14 1:04 PM
- 11. vii About This Book About This Book This book is a reference for nurses, nursing students, and other health-care pro- fessionals.It is useful as a clinical tool as well as a supportive text to supplement clinical courses. It guides the nurse in planning what needs to be assessed, monitored, treated, and taught regarding pretest requirements, intratest proce- dures, and post-test care. It can be used by nursing students at all levels as a textbook in theory classes, integrating laboratory and diagnostic data as one aspect of nursing care;by practicing nurses to update information;and in clinical settings as a quick reference. Designed for use in academic and clinical settings, Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—With Nursing Implications provides a comprehensive reference that allows easy access to information about laboratory and diagnostic tests and procedures. WHAT’S NEW IN THE 6th EDITION? Two new monographs: • • Genetic Testing • • Bioterrorism and Public Health Safety Concerns: Testing for Toxins and Infectious Agents New or updated information for more than 50 different tests including further discussion of: • • Molecular testing and companion diagnostics • • Pediatric and geriatric considerations • • Specific contraindications and corresponding rationales • • Specific nursing problems,associated patient signs and symptoms,and poten- tial nursing interactions • • Specific complications with corresponding rationales and potential interventions • • Patient education, including references to Websites for information related to specific health conditions or disease management guidelines • • Expected patient outcomes expressed in terms of understanding, ability, and response. The expected patient outcomes are expressed in statements that reflect the patient’s understanding of their medical situation and what it will take to achieve the most positive outcome possible; their demonstrated ability to apply instructions, explanations, and education toward a goal; and their response to various aspects of Safe and Effective Nursing Care used in their situation • • Material regarding genetic markers forAlzheimer’s disease;tests used to diagnose gluten-sensitive enteropathies;immunosuppressant therapies used for organ trans- plant patients; genetic testing for drug resistance; description of the arterial brachial index; tests used to evaluate intermediate glycemic control; the use of pharmacogenetics to help explain why some patients don’t respond as expected to their medications;and the use of home test kits added in previous editions Evidence-based practice is reflected throughout in: • • Suggestions for patient teaching that reflect changes in standards of care, particularly with respect to current guidelines for cancer screening • • The most current Centers for Disease Control and Prevention (CDC) guide- lines for communicable diseases such as syphilis, tuberculosis, and HIV FM_i-xx.indd 7 19/11/14 1:04 PM
- 12. • • The most current guidelines for the prevention of cardiovascular disease (CVD) developed by the American College of Cardiology (ACA) and the American Heart Association (AHA) in conjunction with members of the National Heart, Lung, and Blood Institute’s (NHLBI) ATP IV Expert Panel Critical Findings sections now include: • • A sample statement that walks the nurse through the process for timely noti- fication and documentation of critical values • • Conventional and SI units • • Commonly reported pediatric and neonatal values The Reference Value heading in the laboratory monographs is now called Normal Findings to (a) use terminology that is easier to recognize and interpret and (b) use consistent terminology in laboratory and diagnostic monographs. We’ve included related information within the following monographs for this edition: • • Nasal cytology in Allergen-Specific Immunoglobulin E • • Digital subtraction in all the angiography monographs • • Post void residual in Cystometry • • Xenon enhanced CT in Computed Tomography, Brain • • Magnetic resonance cholangiopancreatography in Magnetic Resonance Imaging,Abdomen • • Bladder scan in Ultrasound, Bladder • • Digital rectal examination (DRE) in Ultrasound, Prostate Some monographs have been combined to consolidate similar tests, and a few less frequently used tests have been condensed into a mini-monograph for- mat that highlights abbreviated test-specific facts, with the full monographs for those tests now resident on the DavisPlusWeb site (http://davisplus.fadavis.com). The System Tables at the back of the book now indicate the individual stud- ies that contain information regarding genetic testing so the information, also in the index, can be located quickly. New: The Intersection of Nursing Care and Lab/Dx Testing We hear every day from students and instructors that they want a laboratory and diagnostic test reference that will help them“connect-the-dots”—that will show them how to integrate laboratory and diagnostic test results into safe,compassion- ate,comprehensive,and effective nursing care.So we have revised the 6th edition of the Handbook to be not only the comprehensive reference it was originally designed to be,but it now also presents carefully selected studies that have been enhanced to reflect aspects of Safe and Effective Nursing Care. The enhanced studies allow the reader to drill down further into the nursing implications.More than 80 studies have been expanded and examples include: • • Bilirubin • • Blood Gases • • Blood Groups and Antibodies • • Cerebrospinal Fluid Analysis • • Chlamydia Group Antibody • • Chloride, Sweat • • Complete Blood Count, Hemoglobin; Platelet Count; and WBC Count viii About This Book FM_i-xx.indd 8 19/11/14 1:04 PM
- 13. • • D-Dimer • • Glucose • • Glucose Tolerance Tests • • Newborn Screening • • Prostate Specific Antigen • • Prothrombin Time and INR • • Rheumatoid Factor • • Thyroid Stimulating Hormone • • Tuberculosis Testing WHAT’S NEW ONLINE? Davisplus The following additional information is available at the DavisPlus web site (http://davisplus.fadavis.com): • • Case studies in both instructor and student versions formatted to help the novice learn how to clinically reason by using the nursing process to problem solve. Cases are purposefully designed to promote discussion of situations that may occur in the clinical setting. Situations may be medical, ethical, family-related, patient-related, nurse-related,or any combination. • • Common potential nursing diagnoses associated with laboratory and diagnostic testing. • • Age-specific nursing care guidelines with suggested approaches to persons at various developmental stages to assist the provider in facilitating cooperation and understanding. • • Transfusion reactions, their signs and symptoms, associated laboratory find- ings, and potential nursing interventions. • • Introduction to CLIA (Clinical Laboratory Improvement Amendments) with an explanation of the different levels of testing complexity. • • Herbs and nutraceuticals associated with adverse clinical reactions or drug interactions related to the affected body system. • • Standard precautions. • • Interactive drag-and-drop,quiz-show,flash card,and multiple-choice exercises. • • A printable file of critical findings for laboratory and diagnostic tests. Instructor Guide and Student Guide • • Organized by nursing curriculum, presentations, and case studies with emphasis on laboratory and diagnostic test-related information and nursing implications have been developed for selected conditions and body systems, including sensory, obstetric, and nutrition coverage. • • Open-ended and NCLEX-type multiple-choice questions as well as suggested critical-thinking activities are provided. • • Updated with broadened age-related categories designed to enhance clinical communication. Each case study includes at least one test that appears in the 6e Handbook as an enhanced monograph.Information in the enhanced mono- graph can be referenced in the Handbook for the material that contains detailed nursing problems, complications, patient education, and expected patient outcomes for additional Safe and Effective Nursing Care teaching moments. • • PowerPoint presentation of laboratory and diagnostic pretest, intratest, and post-test concepts integrated with nursing process. About This Book ix FM_i-xx.indd 9 19/11/14 1:04 PM
- 14. Monograph Library • • A searchable library of mini-monographs for all the active tests included in the text. The mini-monograph gives each test’s full name, synonyms and acronyms, specimen type (laboratory tests) or area of application (diagnostic tests), reference ranges or contrast, and results. • • An archive of full monographs of retired tests that are referenced by mini- monographs in the text. WHAT WE KEPT FROM PREVIOUS EDITIONS System Tables Alphabetical listings of laboratory and diagnostic tests organized by related body systems.The tables have been revised to quickly identify individual tests in each table that contain information regarding genetic testing. Alphabetical Order The tests and procedures are presented in this book in alphabetical order by their complete name, allowing the user to locate information quickly without having to first place tests in a specific category or body system.Wherever pos- sible, information within the Indications, Potential Diagnosis, and Interfering Factors (drug lists) sections also has been organized alphabetically. Consistent Format The following information is provided for each laboratory and diagnostic tests: • • Each monograph is titled by the test name and given in its commonly used designation. • • Synonyms and Acronyms for each test are listed where appropriate. • • The Common Use section includes a brief description of the purpose for the study. • • The Specimen section includes the type of specimen usually collected and, where appropriate, the type of collection tube or container commonly rec- ommended.The amount of specimen collected for blood studies reflects the amount of serum, plasma, or whole blood required to perform the test and thus provides a way to project the total number of specimen containers required because patients usually have multiple laboratory tests requested for a single draw. Specimen requirements vary by laboratory. The amount of specimen collected is usually more than what is minimally required so that additional specimen is available, if needed, for repeat testing (quality-control failure, dilutions, or confirmation of unexpected results). In the case of diag- nostic tests, the type of procedure (e.g., nuclear medicine, x-ray) is given. • • Normal Findings for each monograph include age-specific, gender-specific, and ethnicity-specific variations, when indicated. It is important to consider the normal variation of laboratory values over the life span and across cul- tures;sometimes what might be considered an abnormal value in one circum- stance is actually what is expected in another. Normal findings for laboratory tests are given in conventional and standard international (SI) units.The factor used to convert conventional to SI units is also given. Because laboratory values can vary by method, each laboratory reference range is listed along with the associated methodology. • • The Description section includes the study’s purpose and insight into how and why the test results can affect health.Some test descriptions also provide x About This Book FM_i-xx.indd 10 19/11/14 1:04 PM
- 15. insight into how test results influence the development of national health guidelines. • • A separate Contraindications section has been created to differentiate cir- cumstances that might put the patient at risk if the procedure is performed from interfering factors that may indirectly affect patient care by adversely affecting the results of the study. • • Indications are a list of what the test is used for in terms of assessment, evaluation, monitoring, screening, identifying, or assisting in the diagnosis of a clinical condition. • • The Potential Diagnosis section presents a list of conditions in which values may be increased or decreased and, in some cases, an explanation of varia- tions that may be encountered. • • Critical Findings that may be life threatening or for which particular concern may be indicated are given in conventional and SI units, along with age span considerations where applicable.This section also includes signs and symp- toms associated with a critical value as well as possible nursing interventions and the nurse’s role in communication of critical findings to the appropriate health-care provider. • • Interfering Factors are substances or circumstances that may influence the results of the test, rendering the results invalid or unreliable. Knowledge of interfering factors is an important aspect of quality assurance and includes pharmaceuticals, foods, natural and additive therapies, timing of test in rela- tion to other tests or procedures, collection site, handling of specimen, and underlying patient conditions. • • The Pretest section addresses the need to: • • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. • • Provide an explanation to the patient, in the simplest terms possible, of the purpose of the study. • • Obtain pertinent clinical, laboratory, dietary, and therapeutic history of the patient, especially as it pertains to comparison of previous test results, preparation for the test, and identification of potentially interfering factors. • • Explain the requirements and restrictions related to the procedure as well as what to expect; provide the education necessary for the patient to be properly informed. • • Anticipate and allay patient and family concerns or anxieties with consider- ation of social and cultural issues during interactions. • • Provide for patient safety. Some monographs have an additional section for Nursing Problems at the beginning of the pretest section.The enhanced information presents problems the nurse might encounter relative to the study topic (e.g., glucose), signs and symptoms associated with abnormal study findings,and possible interventions. The additional information provides the reader with the opportunity to “drill” further down into the nursing implications.It is provided with the thought that incorporating laboratory and diagnostic data,on a day-to-day basis,by using the nursing process can be taught and reinforced using simple examples. • • The Intratest section can be used in a quality-control assessment or as a guide to the nurse who may be called on to participate in specimen collection or perform preparatory procedures. It provides: • • Specific directions for specimen collection and test performance About This Book xi FM_i-xx.indd 11 19/11/14 1:04 PM
- 16. • • Important information such as patient sensation and expected duration of the procedure • • Precautions to be taken by the nurse and patient Some monographs have an additional section for study specific complica- tions and rationales in the Intratest section. The additional information is another opportunity to “drill” further down into the nursing implications. It is provided as a reminder to anticipate the potential for procedural complications and be prepared to identify them across the age continuum. • • The Post-Test section provides guidelines regarding: • • Specific monitoring and therapeutic measures that should be performed after the procedure (e.g., maintaining bedrest, obtaining vital signs to com- pare with baseline values, signs and symptoms of complications) • • Specific instructions for the patient and family, such as when to resume usual diet, medications, and activity • • General nutritional guidelines related to excess or deficit as well as common food sources for dietary replacement • • Indications for interventions from public health representatives or for spe- cial counseling related to test outcomes • • Indications for follow-up testing that may be required within specific time frames • • An alphabetical listing of related laboratory and/or diagnostic tests that is intended to provoke a deeper and broader investigation of multiple pieces of information;the tests provide data that,when combined,can form a more complete picture of health or illness • • Reference to the specific body system tables of related laboratory and diag- nostic tests that might bear on a patient’s situation Some monographs have an additional section for specific patient education and expected patient outcomes in the post-test section. The additional informa- tion is another opportunity to“drill”further down into the nursing implications. It is provided as a reminder of the nurse’s role as educator and advocate. Color and Icons Design is used to facilitate locating critical information at a glance. On the inside front and back covers is a full-color chart describing tube tops used for various blood tests and their recommended order of draw. Nursing Process Within each phase of the testing procedure, we describe the nurse’s roles and responsibilities as defined by the nursing process. Appendices These include: • • A summary of guidelines for patient preparation with specimen collection procedures and materials which has been revised to reflect considerations for special patient populations. • • A listing of critical findings for laboratory studies. • • A listing of critical findings for diagnostic studies. xii About This Book FM_i-xx.indd 12 19/11/14 1:04 PM
- 17. Index Completely updated to reflect the addition of new tests, conditions, and other key words. Assumptions • • The authors recognize that preferences for the use of specific medical termi- nology may vary by institution. Much of the terminology used in this Handbook is sourced from Taber’s Cyclopedic Medical Dictionary. • • The definition, implementation, and interpretation of national guidelines for the treatment of various medical conditions changes as new information and new technology emerge.The publication of updated information may at times be contentious among the professional institutions that offer either support or dissent for the proposed changes.This can cause confusion when a patient asks questions about how their condition will be identified and managed.The authors believe that the most important discussion about health care occurs between the patient and their health-care provider(s). While the individual studies may point out various screening tests used to identify a disease, the authors often refer the reader to Websites maintained by nationally recog- nized authorities on a specific topic that reflect the most current information and recommendations for screening, diagnosis, and treatment. • • Most institutions have established policies, protocols, and interdisciplinary teams that provide for efficient and effective patient care within the appro- priate scope of practice.While it is not our intention that the actual duties a nurse may perform be misunderstood by way of misinterpreted inferences in writing style,the information prepared by the authors considers that specific limitations are understood by the licensed professionals and other team mem- bers involved in patient care activities and that the desired outcomes are achieved by order of the appropriate health-care provider. About This Book xiii FM_i-xx.indd 13 19/11/14 1:04 PM
- 18. xv Preface Preface Laboratory and diagnostic testing. The words themselves often conjure up cold and impersonal images of needles, specimens lined up in collection con- tainers, and high-tech electronic equipment. But they do not stand alone.They are tied to, bound with, and tell of health or disease in the blood and tissue of a person.Laboratory and diagnostic studies augment the health-care provider’s assessment of the quality of an individual’s physical being.Test results guide the plans and interventions geared toward strengthening life’s quality and endur- ance. Beyond the pounding noise of the MRI, the cold steel of the x-ray table, the sting of the needle, the invasive collection of fluids and tissue, and the probing and inspection is the gathering of evidence that supports the health- care provider’s ability to discern the course of a disease and the progression of its treatment.Laboratory and diagnostic data must be viewed with thought and compassion, however, as well as with microscopes and machines. We must remember that behind the specimen and test result is the person from whom it came,a person who is someone’s son,daughter,mother,father,husband,wife, or friend. This book is written to help health-care providers in their understanding and interpretation of laboratory and diagnostic procedures and their outcomes. Just as important,it is dedicated to all health-care professionals who experience the wonders in the science of laboratory and diagnostic testing,performed and interpreted in a caring and efficient manner. The authors have continued to enhance four areas in this new edition: pathophysiology that affects test results, patient safety, patient education, and integration of related laboratory and diagnostic testing. First, the Potential Diagnosis section includes an explanation of increased or decreased values, as many of you requested. We have added age-specific reference values for the neonatal, pediatric, and geriatric populations at the request of some of our readers.It should be mentioned that standardized infor- mation for the complexity of a geriatric population is difficult to document. Values may be increased or decreased in older adults due to the sole or com- bined effects of malnutrition, alcohol use, medications, and the presence of multiple chronic or acute diseases with or without muted symptoms. Second, the authors appreciate that nurses are the strongest patient advo- cates with a huge responsibility to protect the safety of their patients, and we have observed student nurses in clinical settings being interviewed by facility accreditation inspectors, so we have updated safety reminders, particularly with respect to positive patient identification, communication of critical infor- mation, proper timing of diagnostic procedures, rescheduling of specimen collection for therapeutic drug monitoring,use of evidence-based practices for prevention of surgical site infections, information regarding the move to track or limit exposure to radiation from CT studies for adults, and the Image Gently campaign for pediatric patients who undergo diagnostic studies that utilize radiation. The pretest section reminds the nurse to positively identify the patient before providing care, treatment, or services.The pretest section also addresses hand-off communication of critical information. The third area of emphasis coaches the student to focus on patient educa- tion and prepares the nurse to anticipate and respond to a patient’s questions or concerns: describing the purpose of the procedure, addressing concerns FM_i-xx.indd 15 19/11/14 1:04 PM
- 19. about pain, understanding the implications of the test results, and describing post-procedural care.Various related Websites for patient education are includ- ed throughout the book. And fourth, laboratory and diagnostic tests do not stand on their own—all the pieces fit together to form a picture.The section at the end of each mono- graph integrates both laboratory and diagnostic tests, providing a more com- plete picture of the studies that may be encountered in a patient’s health-care experience.The authors thought it useful for a nurse to know what other tests might be ordered together—and all the related tests are listed alphabetically for ease of use. Laboratory and diagnostic studies are essential components of a complete patient assessment. Examined in conjunction with an individual’s history and physical examination, laboratory studies and diagnostic data provide clues about health status. Nurses are increasingly expected to integrate an under- standing of laboratory and diagnostic procedures and expected outcomes in assessment, planning, implementation, and evaluation of nursing care.The data help develop and support nursing diagnoses, interventions, and outcomes. Nurses may interface with laboratory and diagnostic testing on several levels, including: • • Interacting with patients and families of patients undergoing diagnostic tests or procedures, and providing pretest, intratest, and posttest information and support • • Maintaining quality control to prevent or eliminate problems that may interfere with the accuracy and reliability of test results • • Providing education and emotional support at the point of care • • Ensuring completion of testing in a timely and accurate manner • • Collaborating with other health-care professionals in interpreting findings as they relate to planning and implementing total patient care • • Communicating significant alterations in test outcomes to appropriate health- care team members • • Coordinating interdisciplinary efforts Whether the nurse’s role at each level is direct or indirect, the underlying responsibility to the patient, family, and community remains the same. The authors hope that the changes and additions made to the book and its Web-based ancillaries will reward users with an expanded understanding of and appreciation for the place laboratory and diagnostic testing holds in the provision of high-quality nursing care and will make it easy for instructors to integrate this important content in their curricula.The authors would like to thank all the users of the previous editions for helping us identify what they like about this book as well as what might improve its value to them.We want to continue this dialogue.As writers, it is our desire to capture the interest of our readers, to provide essential information, and to continue to improve the presentation of the material in the book and ancillary products.We encourage our readers to provide feedback to the Website and to the publisher’s sales professionals. Your feedback helps us modify the material—to change with your changing needs. xvi Preface FM_i-xx.indd 16 19/11/14 1:04 PM
- 20. xvii Reviewers Reviewers Nell Britton, MSN, RN, CNE Nursing Faculty Trident Technical College Nursing Division Charleston, South Carolina Cheryl Cassis, MSN, RN Professor of Nursing Belmont Technical College St. Clairsville, Ohio Pamela Ellis, RN, MSHCA, MSN Nursing Faculty Mohave Community College Bullhead City,Arizona Stephanie Franks, MSN, RN Professor of Nursing St.Louis Community College–Meramec St. Louis, Missouri Linda Lott, MSN AD Nursing Instructor Itawamba Community College Fulton, Mississippi Martha Olson, RN, BSN, MS Nursing Associate Professor Iowa Lakes Community College Emmetsburg, Iowa Barbara Thompson, RN, BScN, MScN Professor of Nursing Sault College Sault Ste. Marie, Ontario Edward C.Walton, MS, APN-C, NP-C Assistant Professor of Nursing Richard Stockton College of New Jersey Galloway, New Jersey Jean Ann Wilson, RN, BSN Coordinator Norton Annex Colby Community College Norton, Kansas FM_i-xx.indd 17 19/11/14 1:04 PM
- 21. xix Dedication v About This Book vii Preface xv Reviewers xvii Monographs 1 System Tables 1613 APPENDIX A Patient Preparation and Specimen Collection 1628 APPENDIX B Laboratory Critical Findings 1644 APPENDIX C Diagnostic Critical Findings 1654 Index 1656 Available on http://davisplus.fadavis.com: APPENDIX D: Potential Nursing Diagnoses Associated with Laboratory Diagnostic Testing APPENDIX E: Guidelines for Age-Specific Communication APPENDIX F:Transfusion Reactions: Laboratory Findings and Potential Nursing Interventions APPENDIX G: Introduction to CLIA APPENDIX H: Effects of Natural Products on Laboratory Values APPENDIX I: Standard and Universal Precautions Bibliography Contents Contents FM_i-xx.indd 19 19/11/14 1:04 PM
- 22. Adrenocorticotropic Hormone (and Challenge Tests) Adrenocorticotropic Hormone (and Challenge Tests) a 1 SYNONYM/ACRONYM: AChR (AChR-binding antibody, AChR-blocking antibody, and AChR-modulating antibody). COMMON USE: To assist in confirming the diagnosis of myasthenia gravis (MG). SPECIMEN: Serum (1 mL) collected in a red-top tube. NORMAL FINDINGS: (Method: Radioimmunoassay) AChR-binding antibody: Less than 0.4 nmol/L,AChR-blocking antibody: Less than 25% blocking, and AChR- modulating antibody: Less than 30% modulating. Acetylcholine Receptor Antibody DESCRIPTION: Normally when impulses travel down a nerve, the nerve ending releases a neu- rotransmitter called acetylcholine (ACh), which binds to receptor sites in the neuromuscular junc- tion, eventually resulting in muscle contraction. Once the neuromus- cular junction is polarized,ACh is rapidly metabolized by the enzyme acetylcholinesterase.When pres- ent,AChR-binding antibodies can activate complement and create a complex of ACh,AChR-binding antibodies, and complement.This complex renders ACh unavailable for muscle receptor sites. If AChR—binding antibodies are not detected, and myasthenia gravis (MG) is strongly suspected,AChR- blocking and AChR-modulating antibodies may be ordered.AChR- blocking antibodies impair or prevent ACh from attaching to receptor sites on the muscle mem- brane,resulting in poor muscle con- traction.AChR-modulating antibodies destroy AChR sites, interfering with neuromuscular transmission. The lack of ACh bound to muscle receptor sites results in muscle weakness.Antibodies to AChR sites are present in 90% of patients with generalized MG and in 55% to 70% of patients who either have ocular forms of MG or are in remission. Approximately 10% to 15% of people with confirmed MG do not demonstrate detectable levels of AChR-binding, -blocking, or -modulating antibodies. MG is an acquired autoimmune disorder that can occur at any age. Its exact cause is unknown, and it seems to strike women between ages 20 and 40 years; men appear to be affected later in life than women. It can affect any voluntary muscle, but muscles that control eye, eye- lid, facial movement, and swallow- ing are most frequently affected. Antibodies may not be detected in the first 6 to 12 months after the first appearance of symptoms. MG is a common complication associ- ated with thymoma.The relation- ship between the thymus gland and MG is not completely under- stood. It is believed that miscom- munication in the thymus gland directed at developing immune cells may trigger the development of autoantibodies responsible for MG. Remission after thymectomy is associated with a progressive decrease in antibody level. Other markers used in the study of MG include striational muscle antibod- ies, thyroglobulin, HLA-B8, and HLA-DR3.These antibodies are often undetectable in the early stages of MG. A Monograph_A_001-023.indd 1 17/11/14 12:03 PM
- 23. 2 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A This procedure is contraindicated for • • Patients who have received radioactive scans or radiation within 1 wk of the test. Results may be invalidated when radioimmuno- assay is the test method. Appropriate timing when schedul- ing multiple studies should be taken into consideration. INDICATIONS • • Confirm the presence but not the severity of MG • • Detect subclinical MG in the pres- ence of thymoma • • Monitor the effectiveness of immu- nosuppressive therapy for MG • • Monitor the remission stage of MG POTENTIAL DIAGNOSIS Increased in • • Autoimmune liver disease • • Generalized MG (Defective trans- mission of nerve impulses to muscles evidenced by muscle weakness. It occurs when normal communication between the nerve and muscle is interrupted at the neuromuscular junction. It is believed that miscommunica- tion in the thymus gland directed at developing immune cells may trigger the development of autoantibodies responsible for MG.) • • Lambert-Eaton myasthenic syndrome • • Primary lung cancer • • Thymoma associated with MG (Defective transmission of nerve impulses to muscles evi- denced by muscle weakness. It occurs when normal communi- cation between the nerve and muscle is interrupted at the neuromuscular junction. It is believed that miscommunication in the thymus gland directed at developing immune cells may trigger the development of auto- antibodies responsible for MG.) Decreased in • • Postthymectomy (The thymus gland produces the T lymphocytes responsible for cell-mediated immunity. T cells also help control B-cell development for the produc- tion of antibodies. T-cell response is directed at cells in the body that have been infected by bacte- ria, viruses, parasites, fungi, or protozoans. T cells also provide immune surveillance for cancer- ous cells. Removal of the thymus gland is strongly associated with a decrease in AChR antibody levels.) CRITICAL FINDINGS: N/A INTERFERING FACTORS • • Drugs that may increase AChR levels include penicillamine (long-term use may cause a reversible syndrome that produces clinical, serological, and electro- physiological findings indistinguish- able from MG). • • Biological false-positive results may be associated with amyotrophic lat- eral sclerosis, autoimmune hepatitis, Lambert-Eaton myasthenic syn- drome, primary biliary cirrhosis, and encephalomyeloneuropathies associated with carcinoma of the lung. • • Immunosuppressive therapy is the recommended treatment for MG; prior immunosuppressive drug administration may result in nega- tive test results. • • Recent radioactive scans or radiation within 1 wk of the test can interfere with test results when radioimmuno- assay is the test method. Monograph_A_001-023.indd 2 17/11/14 12:03 PM
- 24. Access additional resources at davisplus.fadavis.com Acetylcholine Receptor Antibody 3 A N U R S I N G I M P L I C A T I O N S A N D P R O C E D U R E Problem Signs & Symptoms Interventions Urination (Related to neurogenic bladder; spastic bladder; associated with disease process) Urinary retention; urinary frequency; urinary urgency; pain and abdominal distention; urinary dribbling Assess amount of fluid intake as it may be necessary to limit fluids to control incontinence; assess risk of urinary tract infection with limiting oral intake; begin bladder training program; teach catheterization techniques to family and patient self-catheterization Self-care (Related to spasticity; altered level of conscious ness; paresis; increasing weakness; paralysis) Difficulty fastening clothing; difficulty performing personal hygiene; inability to maintain appropriate appearance; difficulty with independent mobility; declining physical function Reinforce self-care techniques as taught by occupational therapy; ensure the patient has adequate time to perform self-care; encourage use of assistive devices to maintain independence; assess ability to perform ADLs; provide care assistance appropriate to degree of disability while maintaining as much independence as possible Mobility (Related to weakness; tremors; spasticity) Unsteady gait; lack of coordination; difficult purposeful movement; inadequate range of motion Assess gait; assess muscle strength; assess weakness and coordination; assess physical endurance and level of fatigue; assess ability to perform independent ADLs; assess ability for safe, independent movement; identify need for assistive device; encourage safe self-care Pain (Related to motor and sensory nerve damage associated with disease process) Self-report of pain; emotional symptoms of distress; crying; agitation; facial grimace; moaning; verbalization of pain; rocking motions; irritability; disturbed sleep; diaphoresis; altered blood pressure and heart rate; nausea; vomiting Keep the immediate environment cool to decrease aggravating MG symptoms; use passive or active range of motion to decrease muscle tightness; administer analgesics, tranquilizers, antispasmodics, and neuropathic pain medication, as ordered Potential Nursing Problems: Monograph_A_001-023.indd 3 17/11/14 12:03 PM
- 25. 4 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A ➧ ➧ Remove the needle and apply direct pressure with dry gauze to stop bleed- ing. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. ➧ ➧ Promptly transport the specimen to the laboratory for processing and analysis. POST-TEST: ➧ ➧ Inform the patient that a report of the results will be made available to the requesting health-care provider (HCP), who will discuss the results with the patient. ➧ ➧ Recognize anxiety related to test results, and be supportive of activity challenges related to lack of neuromus- cular control, anticipated loss of inde- pendence, and fear of death. It is important to note that a diagnosis of MG should be based on abnormal find- ings from two different diagnostic tests. These tests include AChR antibody assay, anti-MuSK antibody assay (an antibody which is produced in 40% to 70% of the remaining 15% who have MG but test negative for AChR anti- body), edrophonium test (which involves injection of edrophonium or tensilon, a medication that temporarily blocks the degradation of acetylcholine, allowing normal measurable neuromuscular transmission that dissipates as the effects of the injection wear off), repeti- tive nerve stimulation (small pulses of electricity are repeatedly sent to specific muscles by way of electrodes to mea- sure a decrease in response due to muscle weakening), and single-fiber electromyography (see EMG mono- graph for more detailed information). Discuss the implications of positive test results on the patient’s lifestyle. Positive test results may lead to testing for other conditions associated with MG. Thyrotoxicosis may occur in conjunction with MG; related thyroid testing may be indicated. MG patients may also pro- duce antibodies, such as antinuclear antibody and rheumatoid factor, not pri- marily associated with MG that demon- strate measurable reactivity. ➧ ➧ Evaluate test results in relation to future general anesthesia, especially regarding therapeutic management of MG with cholinesterase inhibitors. PRETEST: ➧ ➧ Positively identify the patient using at least two unique identifiers before pro- viding care, treatment, or services. ➧ ➧ Patient Teaching: Inform the patient that the test is used to identify antibodies responsible for decreased neuromus- cular transmission and associated muscle weakness. ➧ ➧ Obtain a history of the patient’s com- plaints, including a list of known aller- gens, especially allergies or sensitivities to latex, and any prior complications with general anesthesia. ➧ ➧ Obtain a history of the patient’s musculo- skeletal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures. ➧ ➧ Note any recent procedures that can interfere with test results. ➧ ➧ Obtain a list of the patient’s current medications, including herbs, nutri- tional supplements, and nutraceuticals (see Appendix H online at DavisPlus). ➧ ➧ Review the procedure with the patient. Inform the patient that specimen col- lection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some dis- comfort during the venipuncture. ➧ ➧ Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. ➧ ➧ Note that there are no food, fluid, or medication restrictions unless by medi- cal direction. INTRATEST: Potential Complications: N/A ➧ ➧ Avoid the use of equipment containing latex if the patient has a history of aller- gic reaction to latex. ➧ ➧ Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. ➧ ➧ Observe standard precautions, and fol- low the general guidelines in Appendix A. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demo- graphics, initials of the person collect- ing the specimen, date, and time of collection. Perform a venipuncture. Monograph_A_001-023.indd 4 17/11/14 12:03 PM
- 26. Access additional resources at davisplus.fadavis.com Acid Phosphatase, Prostatic 5 A ➧ ➧ Teach the family and patient that assistive devices can improve quality of life and decrease injury risk. Expected Patient Outcomes: Knowledge ➧ ➧ The patient and family verbalize understanding that spasms can be decreased by adhering to recommended physical therapy. ➧ ➧ The patient and family describe the necessity to promote independent self-care while seeking assistance as necessary to prevent injury. Skills ➧ ➧ The patient and family demonstrate the ability to perform passive and active range of motion activities. ➧ ➧ The patient and family demonstrate how to apply splints to hands to help control hand spasms. Attitude ➧ ➧ The patient and family set personal goals regarding performance of self-care activities that are in realistic proportion to disease progression. ➧ ➧ The patient and family accept the physical limitations related to the disease process. RELATED MONOGRAPHS: ➧ ➧ Related tests include ANA, antithyroglob- ulin and antithyroid peroxidase antibodies, CT chest, myoglobin, pseudocholines- terase, RF, TSH, and total T4. ➧ ➧ Refer to the Musculoskeletal System table at the end of the book for related tests by body system. Succinylcholine-sensitive patients may be unable to metabolize the anesthetic quickly, resulting in prolonged or unrecoverable apnea. ➧ ➧ Provide contact information, if desired, for the Myasthenia Gravis Foundation of America (www.myasthenia.org) and the Muscular Dystrophy Association (www.mdausa.org). ➧ ➧ Depending on the results of this procedure, additional testing may be performed to evaluate or monitor pro- gression of the disease process and determine the need for a change in therapy. If a diagnosis of MG is made, a computed tomography (CT) scan of the chest should be performed to rule out thymoma. Evaluate test results in relation to the patient’s symptoms and other tests performed. Patient Education: ➧ ➧ Discuss the implications of positive test results on the patient’s lifestyle. ➧ ➧ Provide teaching and information regarding the clinical implications of the test results, as appropriate. ➧ ➧ Educate the patient regarding access to counseling services. ➧ ➧ Reinforce information given by the patient’s health-care provider (HCP) regarding further testing, treatment, or referral to another HCP. ➧ ➧ Answer any questions or address any concerns voiced by the patient or family. ➧ ➧ Teach family to place self-care items within the patients reach to promote as much independence in care as possible. Access additional resources at davisplus.fadavis.com Acid Phosphatase, Prostatic SYNONYM/ACRONYM: Prostatic acid phosphatase,o-phosphoric monoester phos- phohydrolase, PAcP PAP. COMMON USE: To assist in staging prostate cancer and document evidence of sexual intercourse through semen identification in alleged cases of rape and sexual abuse. SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Place separated serum into a standard transport tube within 2 hr of collection. Monograph_A_001-023.indd 5 17/11/14 12:03 PM
- 27. 6 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A A swab with vaginal secretions may be submitted in the appropriate trans- fer container. Other material such as clothing may be submitted for analysis. Consult the laboratory or emergency services department for the proper specimen collection instructions and containers. NORMAL FINDINGS: (Method: Immunochemiluminometric) Conventional & SI Units Less than 3.5 ng/mL Values are elevated at birth, decrease by 6 mo, increase at approximately 10 yr through puberty, level off through adulthood, and may increase in advancing age. This procedure is contraindicated for: N/A POTENTIAL DIAGNOSIS Increased in PAcP is released from any dam- aged cell in which it is stored, so diseases of the bone, prostate, and liver that cause cellular destruc- tion demonstrate elevated PAcP levels. Conditions that result in abnormal elevations of cells that contain PAcP (e.g., leukemia, thrombocytosis) or conditions that result in rapid cellular destruction (sickle cell crisis) also reflect increased levels. • • Acute myelogenous leukemia • • After prostate surgery or biopsy • • Benign prostatic hypertrophy • • Liver disease • • Lysosomal storage diseases (Gaucher’s disease and Niemann-Pick disease) (PAcP is stored in the lysosomes of blood cells, and increased levels are present in lysosomal storage diseases) • • Metastatic bone cancer • • Paget’s disease • • Prostatic cancer • • Prostatic infarct • • Prostatitis • • Sickle cell crisis • • Thrombocytosis Decreased in: N/A CRITICAL FINDINGS: N/A Find and print out the full monograph at DavisPlus (http://davisplus.fadavis .com, keyword Van Leeuwen). Adrenal Gland Scan SYNONYM/ACRONYM: Adrenal scintiscan. COMMON USE: To assist in the diagnosis of Cushing’s syndrome and differentiate between adrenal gland cancer and infection. AREA OF APPLICATION: Adrenal gland. CONTRAST: Intravenous radioactive NP-59 (iodomethyl-19-norcholesterol) or metaiodobenzylguanidine (MIBG). Monograph_A_001-023.indd 6 17/11/14 12:03 PM
- 28. Access additional resources at davisplus.fadavis.com Adrenal Gland Scan 7 A • • Conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reac- tion is not to iodine; in fact, an actual iodine allergy would be very problematic because iodine is required for the production of thy- roid hormones. In the case of shell- fish, the reaction is to a muscle pro- tein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from pre- medication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if avail- able, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium. INDICATIONS • • Aid in the diagnosis of Cushing’s syndrome and aldosteronism • • Aid in the diagnosis of gland tissue destruction caused by infection, infarction, neoplasm, or suppression • • Aid in locating adrenergic tumors • • Determine adrenal suppressibility with prescan administration of cor- ticosteroid to diagnose and localize adrenal adenoma, aldosteronomas, androgen excess, and low-renin hypertension • • Differentiate between asymmetric hyperplasia and asymmetry from aldosteronism with dexamethasone suppression test DESCRIPTION: This nuclear medi- cine study evaluates the function of the adrenal glands.The secre- tory function of the adrenal glands is controlled primarily by the anterior pituitary, which produces adrenocorticotropic hormone (ACTH).ACTH stimulates the adre- nal cortex to produce cortisone and secrete aldosterone.Adrenal imaging is most useful in differen- tiation of hyperplasia from adeno- ma in primary aldosteronism when computed tomography (CT) and magnetic resonance imaging (MRI) findings are equivocal. High concentrations of cholesterol (the precursor in the synthesis of adrenocorticoste- roids, including aldosterone) are stored in the adrenal cortex and this allows the radionuclide, which attaches to the cholesterol, to be used in identifying patholo- gy in the secretory function of the adrenal cortex.The uptake of the radionuclide occurs gradually over time and imaging is per- formed within 24 to 48 hr of radionuclide injection and contin- ued daily for 3 to 5 days. Imaging can reveal increased uptake, unilateral or bilateral uptake, or absence of uptake in the detec- tion of pathological processes. Following prescanning treatment with corticosteroids, suppression studies can also be done to differ- entiate the presence of tumor from hyperplasia of the glands. This procedure is contraindicated for • • Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far out- weigh the risk of radiation expo- sure to the fetus and mother. Monograph_A_001-023.indd 7 17/11/14 12:03 PM
- 29. 8 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A Safety in Pediatric Imaging (www.pedrad.org/associations/ 5364/ig/). • • Risks associated with radiation overexposure can result from fre- quent x-ray or radionuclide proce- dures. Personnel working in the examination area should wear badges to record their radiation exposure level. POTENTIAL DIAGNOSIS Normal findings in • • No evidence of tumors, infection, infarction, or suppression • • Normal bilateral uptake of radionu- clide and secretory function of adrenal cortex • • Normal salivary glands and urinary bladder; vague shape of the liver and spleen sometimes seen Abnormal findings in • • Adrenal gland suppression • • Adrenal infarction • • Adrenal tumor • • Hyperplasia • • Infection • • Pheochromocytoma CRITICAL FINDINGS: N/A INTERFERING FACTORS Factors that may impair clear imaging • • Retained barium from a previous radiological procedure. • • Inability of the patient to cooperate or remain still during the proce- dure because of age, significant pain, or mental status. Other considerations • • Improper injection of the radionu- clide may allow the tracer to seep deep into the muscle tissue, pro- ducing erroneous hot spots. • • Consultation with a health-care pro- vider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactat- ing. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radia- tion dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation N U R S I N G I M P L I C A T I O N S A N D P R O C E D U R E PRETEST: ➧ ➧ Positively identify the patient using at least two unique identifiers before pro- viding care, treatment, or services. ➧ ➧ Patient Teaching: Inform the patient this procedure can visualize and assess the function of the adrenal gland, which is located near the kidney. ➧ ➧ Obtain a history of the patient’s com- plaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anes- thetics, contrast medium, or sedatives. ➧ ➧ Obtain a history of the patient’s endo- crine system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures. ➧ ➧ Perform all adrenal blood tests before doing this test. ➧ ➧ Record the date of last menstrual period and determine the possibility of pregnancy in perimenopausal women. ➧ ➧ Obtain a list of the patient’s current medications, including herbs, nutri- tional supplements, and nutraceuticals (see Appendix H online at DavisPlus). ➧ ➧ If iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non–insulin-dependent (type 2) diabe- tes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side Monograph_A_001-023.indd 8 17/11/14 12:03 PM
- 30. Access additional resources at davisplus.fadavis.com Adrenal Gland Scan 9 A ➧ ➧ Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex. ➧ ➧ Observe standard precautions, and follow the general guidelines in Appendix A. Positively identify the patient. ➧ ➧ Ensure that the patient has removed external metallic objects from the area to be examined prior to the procedure. ➧ ➧ Have emergency equipment readily available. ➧ ➧ Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided. ➧ ➧ Insert an IV line, and inject the radionu- clide IV on day 1; images are taken on days 1, 2, and 3. Imaging is done from the urinary bladder to the base of the skull to scan for a primary tumor. Each image takes 20 min, and total imaging time is 1 to 2 hr per day. ➧ ➧ Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement pro- duces unreliable results. POST-TEST: ➧ ➧ Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient. ➧ ➧ Advise the patient to drink increased amounts of fluids for 24 to 48 hrs to eliminate the radionuclide from the body, unless contraindicated. Inform the patient that radionuclide is elimi- nated from the body within 24 to 48 hr. ➧ ➧ Do not schedule other radionuclide tests 24 to 48 hr after this procedure. ➧ ➧ Observe/assess the needle site for bleeding, hematoma formation, and inflammation. ➧ ➧ Instruct the patient in the care and assessment of the injection site. ➧ ➧ Instruct the patient to apply cold com- presses to the puncture site as needed to reduce discomfort or edema. ➧ ➧ If a woman who is breast-feeding must have a nuclear scan, she should not breast-feed the infant until the radio- nuclide has been eliminated. This could take as long as 3 days. Instruct her to express the milk and discard it effect of metformin (related to renal impairment that does not support sufficient excretion of metformin). ➧ ➧ Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Inform the patient that the procedure is usually performed in a nuclear medicine department by a nuclear medicine technologist with sup- port staff, and it takes approximately 1 to 2 hr each day. Inform the patient the test usually involves a prolonged scan- ning schedule over a period of days. ➧ ➧ Administer saturated solution of potassium iodide (SSKI or Lugol iodine solution) 24 hr before the study to prevent thyroid uptake of the free radioactive iodine. ➧ ➧ Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. ➧ ➧ Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, contrast medium, or emergency medications. ➧ ➧ Note that there are no food, fluid, or medication restrictions unless by medi- cal direction. ➧ ➧ Instruct the patient to remove jewelry and other metallic objects from the area to be examined. ➧ ➧ Make sure a written and informed consent has been signed prior to the procedure and before administering any medications. INTRATEST: Potential Complications: Injection of the contrast is an invasive procedure. Complications are rare but do include risk for: allergic reaction (related to contrast reaction), hema- toma (related to blood leakage into the tissue following needle insertion), bleeding from the puncture site (related to a bleeding disorder, or the effects of natural products and medi- cations known to act as blood thin- ners), or infection (which might occur if bacteria from the skin surface is introduced at the puncture site). Monograph_A_001-023.indd 9 17/11/14 12:03 PM
- 31. 10 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A 10 days after the injection of the radionuclide. Answer any questions or address any concerns voiced by the patient or family. ➧ ➧ Depending on the results of this pro- cedure, additional testing may be needed to evaluate or monitor pro- gression of the disease process and determine the need for a change in therapy. Evaluate test results in rela- tion to the patient’s symptoms and other tests performed. RELATED MONOGRAPHS: ➧ ➧ Related tests include ACTH and chal- lenge tests, aldosterone, angiography adrenal, catecholamines, CT abdomen, cortisol and challenge tests, HVA, MRI abdomen, metanephrines, potassium, renin, sodium, and VMA. ➧ ➧ Refer to the Endocrine System table at the end of the book for related tests by body system. during the 3-day period to prevent cessation of milk production. ➧ ➧ Instruct the patient to immediately flush the toilet and to meticulously wash hands with soap and water after each voiding for 48 hrs after the procedure. ➧ ➧ Instruct all caregivers to wear gloves when discarding urine for 48 hrs after the procedure. Wash gloved hands with soap and water before removing gloves. Then wash ungloved hands after the gloves are removed. ➧ ➧ Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and informa- tion regarding the clinical implications of the test results, as appropriate. ➧ ➧ Reinforce information given by the patient’s HCP regarding further test- ing, treatment, or referral to another HCP. Advise the patient that SSKI (120 mg/day) will be administered for Adrenocorticotropic Hormone (and Challenge Tests) SYNONYM/ACRONYM: Corticotropin,ACTH. COMMON USE: To assist in the investigation of adrenocortical dysfunction using ACTH and cortisol levels in diagnosing disorders such as Addison’s disease, Cushing’s disease, and Cushing’s syndrome. SPECIMEN: Plasma (2 mL) from a lavender-top (EDTA) tube for adrenocorti- cotropic hormone (ACTH) and serum (1 mL) from a red-top tube for cortisol and 11-deoxycortisol. Collect specimens in a prechilled lavender- and red- top tubes. Gold-tiger- and green-top (heparin) tubes are also acceptable for cortisol, but take care to use the same type of collection container for serial measurements.Immediately transport specimen,tightly capped and in an ice slurry, to the laboratory. The specimens should be immediately processed. Plasma for ACTH analysis should be transferred to a plastic container. Monograph_A_001-023.indd 10 17/11/14 12:03 PM
- 32. Access additional resources at davisplus.fadavis.com A Adrenocorticotropic Hormone (and Challenge Tests) 11 Procedure Indications Medication Administered, Adult Dosage Recommended Collection Times ACTH stimulation, rapid test Suspect adrenal insufficiency (Addison’s disease) or congenital adrenal hyperplasia 1 mcg (low-dose physiologic protocol) cosyntropin IM or IV; 250 mcg (standard pharmaco l ogic protocol) cosyntropin IM or IV Three cortisol levels: baseline immediately before bolus, 30 min after bolus, and 60 min (optional) after bolus. Baseline and 30 min levels are adequate for accurate diagnosis using either dosage; low dose protocol sensitivity is most accurate for 30 min level only Corticotropin- releasing hormone (CRH) stimulation Differential diagnosis between ACTH- dependent conditions such as Cushing’s disease (pituitary source) or Cushing’s syndrome (ectopic source) and ACTH- independent conditions such as Cushing’s syndrome (adrenal source) IV dose of 1 mcg/kg human CRH Eight cortisol and eight ACTH levels: baseline collected 15 min before injection, 0 min before injection, and then 5, 15, 30, 60, 120, and 180 min after injection Dexameth asone suppression (overnight) Differential diagnosis between ACTH- dependent conditions such as Cushing’s disease (pituitary source) or Cushing’s syndrome (ectopic source) and ACTH- independent conditions such as Cushing’s syndrome (adrenal source) Oral dose of 1 mg dexameth a sone (Decadron) at 11 p.m. Collect cortisol at 8 a.m. on the morning after the dexamethasone dose Metyrapone stimulation (overnight) Suspect hypothalamic/pituitary disease such as adrenal insufficiency, ACTH-dependent conditions such as Cushing’s disease (pituitary source) or Cushing’s syndrome (ectopic source), and ACTH-independent conditions such as Cushing’s syndrome (adrenal source) Oral dose of 30 mg/kg metyrapone with snack at midnight Collect cortisol, 11-deoxycortisol, and ACTH at 8 a.m. on the morning after the metyrapone dose IM = intramuscular, IV = intravenous. Monograph_A_001-023.indd 11 17/11/14 12:03 PM
- 33. 12 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A NORMAL FINDINGS: (Method: Immunochemiluminescent assay for ACTH and cortisol; HPLC/MS-MS for 11-deoxycortisol) ACTH Age Conventional Units SI Units (Conventional Units × 0.22) Cord blood 50–570 pg/mL 11–125 pmol/L Newborn 10–185 pg/mL 2–41 pmol/L 1 wk–9 yr 5–46 pg/mL 1.1–10.1 pmol/L 10–18 yr 6–55 pg/mL 1.3–12.1 pmol/L 19 yr–Adult Male supine (specimen collected in morning) 7–69 pg/mL 1.5–15.2 pmol/L Female supine (specimen collected in morning) 6–58 pg/mL 1.3–12.8 pmol/L Values may be unchanged or slightly elevated in healthy older adults. Long-term use of corticosteroids, to treat arthritis and autoimmune diseases, may suppress secretion of ACTH. ACTH Challenge Tests ACTH (Cosyntropin) Stimulated, Rapid Test Conventional Units SI Units (Conventional Units × 27.6) Baseline Cortisol greater than 5 mcg/dL Greater than 138 nmol/L 30- or 60-min response Cortisol 18–20 mcg/dL or incremental increase of 7 mcg/dL over baseline value 497–552 nmol/L or incremental increase of 193.2 nmol/L over baseline value Corticotropin- Releasing Hormone Stimulated Conventional Units SI Units (Conventional Units × 27.6) Cortisol peaks at greater than 20 mcg/dL within 30–60 min Greater than 552 nmol/L SI Units (Conventional Units × 0.22) ACTH increases twofold to fourfold within 30–60 min Twofold to fourfold increase within 30–60 min Monograph_A_001-023.indd 12 17/11/14 12:03 PM
- 34. Access additional resources at davisplus.fadavis.com A Dexamethasone Suppressed Overnight Test Conventional Units SI Units (Conventional Units × 27.6) Cortisol less than 1.8 mcg/dL next day Less than 49.7 nmol/L Metyrapone Stimulated Overnight Test Conventional Units SI Units (Conventional Units × 27.6) Cortisol less than 3 mcg/dL next day Less than 83 nmol/L SI Units (Conventional Units × 0.22) ACTH greater than 75 pg/mL Greater than 16.5 pmol/L SI Units (Conventional Units × 28.9) 11-deoxycortisol greater than 7 mcg/dL Greater than 202 nmol/L DESCRIPTION: Hypothalamic- releasing factor stimulates the release of ACTH from the anteri- or pituitary gland.ACTH stimu- lates adrenal cortex secretion of glucocorticoids, androgens, and, to a lesser degree, mineralocorti- coids. Cortisol is the major gluco- corticoid secreted by the adrenal cortex.ACTH and cortisol test results are evaluated together because a change in one normal- ly causes a change in the other. ACTH secretion is stimulated by insulin, metyrapone, and vaso- pressin. It is decreased by dexa- methasone. Cortisol excess from any source is termed Cushing’s syndrome. Cortisol excess result- ing from ACTH excess produced by the pituitary is termed Cushing’s disease.ACTH levels exhibit a diurnal variation, peak- ing between 6 and 8 a.m. and reaching the lowest point between 6 and 11 p.m. Evening levels are generally one-half to two-thirds lower than morning levels. Cortisol levels also vary diurnally, with the peak values occurring during between 6 and 8 a.m. in the morning and reach- ing the lowest levels between 8 p.m. and midnight in the eve- ning. Specimens are typically col- lected at 8 a.m. and 4 p.m.This pattern may be reversed in indi- viduals who sleep during day- time hours and are active during nighttime hours. Salivary cortisol levels are known to parallel blood levels and can be used to screen for Cushing’s disease and Cushing’s syndrome. Adrenocorticotropic Hormone (and Challenge Tests) 13 Monograph_A_001-023.indd 13 17/11/14 12:03 PM
- 35. 14 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A This procedure is contraindicated for • • Patients with suspected adre- nal insufficiency because it may induce an acute adrenal crisis, a life threatening condition, in patients whose adrenal function is already compromised. INDICATIONS • • Determine adequacy of replace- ment therapy in congenital adrenal hyperplasia • • Determine adrenocortical dysfunction • • Differentiate between increased ACTH release with decreased cor- tisol levels and decreased ACTH release with increased cortisol levels POTENTIAL DIAGNOSIS ACTH Result Because ACTH and cortisol secre- tion exhibit diurnal variation with values being highest in the morning, a lack of change in val- ues from morning to evening is clinically significant. Decreased concentrations of hormones secreted by the pituitary gland and its target organs are observed in hypopituitarism. In primary adrenal insufficiency (Addison’s disease), because of adrenal gland destruction by tumor, infec- tious process, or immune reac- tion, ACTH levels are elevated while cortisol levels are decreased. Both ACTH and cortisol levels are decreased in secondary adrenal insufficiency (i.e., secondary to pituitary insufficiency). Excess ACTH can be produced ectopically by various lung cancers such as oat-cell carcinoma and large- cell carcinoma of the lung and by benign bronchial carcinoid tumor. Challenge Tests and Results The ACTH (cosyntropin) stimulated rapid test directly evaluates adre- nal gland function and indirectly evaluates pituitary gland and hypothala mus function. Cosyntro pin is a synthetic form of ACTH. A baseline cortisol level is collected before the injection of cosyntropin. Specimens are subsequently col- lected at 30- and 60-min intervals. If the adrenal glands function nor- mally, cortisol levels rise signifi- cantly after administration of cosyntropin. The CRH stimulation test works as well as the dexamethasone sup- pression test (DST) in distinguishing Cushing’s disease from conditions in which ACTH is secreted ectopi- cally (e.g., tumors not located in the pituitary gland that secrete ACTH). Patients with pituitary tumors tend to respond to CRH stimulation, whereas those with ectopic tumors do not. Patients with adrenal insufficiency dem- onstrate one of three patterns depending on the underlying cause: • • Primary adrenal insufficiency— high baseline ACTH (in response to IV-administered ACTH) and low cortisol levels pre- and post- IV ACTH. • • Secondary adrenal insufficiency (pituitary)—low baseline ACTH that does not respond to ACTH stimulation. Cortisol levels do not increase after stimulation. • • Tertiary adrenal insufficiency (hypothalamic)—low baseline Monograph_A_001-023.indd 14 17/11/14 12:03 PM
- 36. Access additional resources at davisplus.fadavis.com A ACTH with an exaggerated and prolonged response to stimula- tion. Cortisol levels usually do not reach 20 mcg/dL. (The DST is useful in differentiat- ing the causes of increased corti- sol levels. Dexamethasone is a synthetic glucocorticoid that is significantly more potent than cortisol. It works by negative feedback. It suppresses the release of ACTH in patients with a normal hypothalamus. A cortisol level less than 1.8 mcg/dL usually excludes Cushing’s syndrome. With the DST, a baseline morning cortisol level is collected, and the patient is given a 1-mg dose of dexamethasone at bedtime. A sec- ond specimen is collected the fol- lowing morning. If cortisol levels have not been suppressed, adre- nal adenoma is suspected. The DST also produces abnormal results in the presence of certain psychiatric illnesses [e.g., endog- enous depression]). The metyrapone stimulation test is used to distinguish cortico- tropin-dependent causes (pituitary Cushing’s disease and ectopic Cushing’s disease) from cortico- tropin-independent causes (e.g., carcinoma of the lung or thyroid) of increased cortisol levels. Metyrapone inhibits the conver- sion of 11-deoxycortisol to corti- sol. Cortisol levels should decrease to less than 3 mcg/dL if normal pituitary stimulation by ACTH occurs after an oral dose of metyr- apone. Specimen collection and administration of the medication are performed as with the over- night dexamethasone test. Increased in Overproduction of ACTH can occur as a direct result of either disease (e.g., primary or ectopic tumor that secretes ACTH) or stimulation by physical or emo- tional stress, or it can be an indi- rect response to abnormalities in the complex feedback mecha- nisms involving the pituitary gland, hypothalamus, or adrenal glands. ACTH Increased in • • Addison’s disease (primary adre- nocortical hypofunction) • • Carcinoid syndrome • • Congenital adrenal hyperplasia • • Cushing’s disease (pituitary- dependent adrenal hyperplasia) • • Cushing’s syndrome (ectopic secretion of ACTH) • • Depression • • Ectopic ACTH-producing tumors • • Menstruation • • Nelson’s syndrome (ACTH-producing pituitary tumors) • • Non-insulin-dependent diabetes • • Pregnancy • • Sepsis • • Septic shock Decreased in Secondary adrenal insufficiency due to hypopituitarism (inade- quate production by the pitu- itary) can result in decreased levels of ACTH. Conditions that result in overproduction or avail- ability of high levels of cortisol can also result in decreased levels of ACTH. ACTH Decreased in • • Adrenal adenoma • • Adrenal cancer • • Cushing’s syndrome • • Exogenous steroid therapy Adrenocorticotropic Hormone (and Challenge Tests) 15 Monograph_A_001-023.indd 15 17/11/14 12:03 PM
- 37. 16 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A CRITICAL FINDINGS: N/A INTERFERING FACTORS • • Drugs that may increase ACTH lev- els include insulin, metoclopramide, metyrapone, mifepristone (RU 486), and vasopressin. • • Drugs that may decrease ACTH lev- els include corticosteroids (e.g., dexamethasone) and pravastatin. • • Test results are affected by the time the test is done because ACTH lev- els vary diurnally, with the highest values occurring between 6 and 8 a.m. and the lowest values occur- ring at night. Samples should be collected at the same time of day, between 6 and 8 a.m. Summary of the Relationship Between Cortisol and ACTH Levels in Conditions Affecting the Adrenal and Pituitary Glands Disease Cortisol Level ACTH Level Addison’s disease (adrenal insufficiency) Decreased Increased Cushing’s disease (pituitary adenoma) Increased Increased Cushing’s syndrome related to ectopic source of ACTH Increased Increased Cushing’s syndrome (ACTH independent; adrenal cancer or adenoma) Increased Decreased Congenital adrenal hyperplasia Decreased Increased • • Excessive physical activity can produce elevated levels. • • Metyrapone may cause gastrointes- tinal distress and/or confusion. Administer oral dose of metyrapone with milk and snack. • • Rapid clearance of metyrapone, resulting in falsely increased corti- sol levels, may occur if the patient is taking drugs that enhance steroid metabolism (e.g., phenytoin, rifampin, pheno- barbital, mitotane, and corticoste- roids).The requesting health-care provider (HCP) should be consult- ed prior to a metyrapone stimula- tion test regarding a decision to withhold these medications. N U R S I N G I M P L I C A T I O N S A N D P R O C E D U R E Potential Nursing Problems: Problem Signs & Symptoms Interventions Fluid volume (Related to loss of water secondary to vomiting; diarrhea) Deficient: hypotension; decreased cardiac output; decreased urinary output; dry skin/mucous membranes; poor skin turgor; sunken eyeballs; increased urine specific gravity; hemoconcentration Monitor intake and output; assess for symptoms of dehydration (dry skin, dry mucous membranes, poor skin turgor, sunken eyeballs); monitor and trend vital signs; monitor for symptoms of poor cardiac output (rapid, weak, thready pulse); monitor and trend daily weight; collaborate with physician with administration of IV Monograph_A_001-023.indd 16 17/11/14 12:03 PM
- 38. Access additional resources at davisplus.fadavis.com A Problem Signs & Symptoms Interventions fluids to support hydration; monitor laboratory values that reflect alterations in fluid status (potassium, blood urea nitrogen, creatinine, calcium, hemoglobin, and hematocrit, sodium); manage underlying cause of fluid alteration; monitor urine characteristics and respiratory status; establish baseline assessment data; collaborate with physician to adjust oral and IV fluids to provide optimal hydration status; administer replacement electrolytes, as ordered; adjust diuretics, as appropriate Infection risk (Related to impaired immune response secondary to elevated cortisol level) Delayed wound healing; inhibited collagen formation; impaired blood flow to edematous tissues; symptoms of infection (temperature; increased heart rate; increased blood pressure; shaking; chills; mottled skin; lethargy; fatigue; swelling; edema; pain; localized pressure; diaphoresis; night sweats; confusion; vomiting; nausea; headache) Decrease exposure to environment by placing the patient in a private room; monitor and trend vital signs; monitor and trend laboratory values that would indicate an infection (WBC, CRP); promote good hygiene; assist with hygiene, as needed; administer prescribed antibiotics, antipyretics; use cooling measures; administer prescribed IV fluids; monitor vital signs and trend temperatures; encourage oral fluids; adhere to standard or universal precautions; isolate as appropriate; obtain cultures, as ordered; encourage lightweight clothing and bedding Injury risk (Related to poor wound healing; decreased bone density; capillary fragility) Easy bruising; blood in stool; skin breakdown; fracture; poor wound healing Assess for bruising; assess stool for occult blood; assess for skin breakdown; assess wound for healing progress; facilitate ordered bone density screening PRETEST: ➧ ➧ Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. ➧ ➧ Patient Teaching: Inform the patient this test can assist in evaluating the amount of hormone produced by the pituitary gland located at the base of the brain. Adrenocorticotropic Hormone (and Challenge Tests) 17 Monograph_A_001-023.indd 17 17/11/14 12:03 PM
- 39. 18 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A pain, headache, dizziness, sedation, allergic rash, decreased white blood cell (WBC) count, and bone marrow depres- sion. Signs and symptoms of overdose or acute adrenocortical insufficiency include cardiac arrhythmias, hypoten- sion, dehydration, anxiety, confusion, weakness, impairment of conscious- ness, N/V, epigastric pain, diarrhea, hyponatremia, and hyperkalemia. ➧ ➧ Ensure that strenuous exercise was avoided for 12 hr before the test and that 1 hr of bed rest was taken imme- diately before the test. Samples should be collected between 6 and 8 a.m. ➧ ➧ Have emergency equipment readily available in case of adverse reaction to metyrapone. ➧ ➧ Avoid the use of equipment containing latex if the patient has a history of aller- gic reaction to latex. ➧ ➧ Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. ➧ ➧ Observe standard precautions, and follow the general guidelines in Appendix A. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of col- lection. Perform a venipuncture; collect the specimen in prechilled collection containers as listed under the “Specimen” subheading. ➧ ➧ Remove the needle and apply direct pressure with dry gauze to stop bleed- ing. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. ➧ ➧ Promptly transport the specimen to the laboratory for processing and analysis. The tightly capped sample should be placed in an ice slurry immediately after collection. Information on the specimen label should be protected from water in the ice slurry by first placing the speci- men in a protective plastic bag. POST-TEST: ➧ ➧ Inform the patient that a report of the results will be made available to the requesting health-care provider (HCP), who will discuss the results with the patient. ➧ ➧ Recognize anxiety related to test results, and offer support. ➧ ➧ Obtain a history of the patient’s com- plaints, including a list of known allergens, especially allergies or sensitivities to latex. ➧ ➧ Obtain a history of the patient’s endocrine system, symptoms, and results of previ- ously performed laboratory tests and diagnostic and surgical procedures. ➧ ➧ Note any recent procedures that can interfere with test results. ➧ ➧ Obtain a list of the patient’s current medications, especially drugs that enhance steroid metabolism, including herbs, nutritional supplements, and nutraceuticals (see Appendix H online at DavisPlus). ➧ ➧ Weigh patient and report weight to pharmacy for dosing of metyrapone (30 mg/kg body weight). ➧ ➧ Review the procedure with the patient. When ACTH hypersecretion is sus- pected, a second sample may be requested between 6 and 8 p.m. to determine if changes are the result of diurnal variation in ACTH levels. Inform the patient that more than one sample may be necessary to ensure accurate results, and samples are obtained at spe- cific times to determine high and low lev- els of ACTH. Inform the patient that each specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture. ➧ ➧ Sensitivity to social and cultural issues, as well as concern for modesty, is impor- tant in providing psychological support before, during, and after the procedure. ➧ ➧ Note that there are no food, fluid, or medication restrictions unless by medical direction. ➧ ➧ Drugs that enhance steroid metabolism may be withheld by medical direction prior to metyrapone stimulation testing. ➧ ➧ Instruct the patient to refrain from strenuous exercise for 12 hr before the test and to remain in bed or at rest for 1 hr immediately before the test. Avoid smoking and alcohol use. ➧ ➧ Prepare an ice slurry in a cup or plastic bag to have on hand for immediate trans- port of the specimen to the laboratory. INTRATEST: Potential Complications: Adverse reactions to metyrapone include nausea and vomiting (N/V), abdominal Monograph_A_001-023.indd 18 17/11/14 12:03 PM
- 40. Access additional resources at davisplus.fadavis.com Alanine Aminotransferase 19 A testing, treatment, or referral to another HCP. ➧ ➧ Answer any questions or address any concerns voiced by the patient or family. ➧ ➧ Teach the patient and family the effects of the disease process and associated treatments Expected Patient Outcomes: Knowledge ➧ ➧ States the importance of compliance with the recommended therapeutic regime to health maintenance ➧ ➧ States understanding of the necessity of altering the medication regime dur- ing times of illness and stress Skills ➧ ➧ Demonstrates proficiency in the self- administration of prescribed steroids ➧ ➧ Adheres to the request to stand slowly to prevent orthostatic hypotension Attitude ➧ ➧ Complies with the HCP’s request to wear a medic alert bracelet indicating adrenal insufficiency and steroid use ➧ ➧ Complies with the HCP’s request to increase oral fluid intake with a diet high in sodium and low in potassium (Addison’s disease) RELATED MONOGRAPHS: ➧ ➧ Related tests include cortisol and chal- lenge tests, CT abdomen, CT pituitary, MRI abdomen, MRI pituitary, TSH, thyroxine, and US abdomen. ➧ ➧ See the Endocrine System table at the end of the book for related tests by body system. ➧ ➧ Observe/assess the patient who has been administered metyrapone for signs and symptoms of an acute adrenal (addisonian) crisis which may include abdominal pain, nausea, vomiting, hypotension, tachycardia, tachypnia, dehydration, excessively increased per- spiration of the face and hands, sudden and significant fatigue or weakness, confusion, loss of consciousness, shock, coma. Potential interventions include immediate corticosteroid replacement (IV or IM), airway protection and mainte- nance, administration of dextrose for hypoglycemia, correction of electrolyte imbalance, and rehydration with IV fluids. ➧ ➧ Depending on the results of this proce- dure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. If a diagnosis of Cushing’s disease is made, pituitary com- puted tomography (CT) or magnetic reso- nance imaging (MRI) may be indicated prior to surgery. If a diagnosis of ectopic corticotropin syndrome is made, abdomi- nal CT or MRI may be indicated prior to surgery. Evaluate test results in relation to the patient’s symptoms and other tests performed. Patient Education: ➧ ➧ Instruct the patient to resume normal activity as directed by the HCP. ➧ ➧ Provide contact information, if desired, for the Cushing’s Support and Research Foundation (www.csrf.net). ➧ ➧ Reinforce information given by the patient’s HCP regarding further Alanine Aminotransferase SYNONYM/ACRONYM: Serum glutamic pyruvic transaminase (SGPT),ALT. COMMON USE: To assess liver function related to liver disease and/or damage. SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma (1 mL) collected in a green-top (heparin) tube is also acceptable. NORMAL FINDINGS: (Method: Spectrophotometry) Access additional resources at davisplus.fadavis.com Monograph_A_001-023.indd 19 17/11/14 12:03 PM
- 41. 20 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A Age Conventional & SI Units Newborn–12 mo 13–45 units/L 13 mo–60 yr Male 10–40 units/L Female 7–35 units/L 61–90 yr Male 13–40 units/L Female 10–28 units/L Greater than 90 yr Male 6–38 units/L Female 5–24 units/L DESCRIPTION: Alanine aminotransfer- ase (ALT),formerly known as serum glutamic pyruvic transaminase (SGPT), is an enzyme produced by the liver.The highest concentration of ALT is found in liver cells;mod- erate amounts are found in kidney cells;and smaller amounts are found in heart, pancreas, spleen, skeletal muscle, and red blood cells.When liver damage occurs, serum levels of ALT may increase as much as 50 times normal, making this a sensitive test for evaluating liver function.ALT is part of a group of tests known as LFTs or liver func- tion tests used to evaluate liver function:ALT,Albumin,Alkaline phosphatase,Aspartate amino- transferase (AST), Bilirubin, direct, Bilirubin, total, and Protein, total indicated by gradually declining levels POTENTIAL DIAGNOSIS Increased in Related to release of ALT from damaged liver, kidney, heart, pan- creas, red blood cells, or skeletal muscle cells. • • Acute pancreatitis • • AIDS (related to hepatitis B co-infection) • • Biliary tract obstruction • • Burns (severe) • • Chronic alcohol abuse • • Cirrhosis • • Fatty liver • • Hepatic carcinoma • • Hepatitis • • Infectious mononucleosis • • Muscle injury from intramuscular injections, trauma, infection, and seizures (recent) • • Muscular dystrophy • • Myocardial infarction • • Myositis • • Pancreatitis • • Pre-eclampsia • • Shock (severe) Decreased in • • Pyridoxal phosphate deficiency (related to a deficiency of pyri- doxal phosphate that results in decreased production of ALT) CRITICAL FINDINGS: N/A INTERFERING FACTORS • • Drugs that may increase ALT levels by causing cholestasis include ana- bolic steroids, dapsone, estrogens, ethionamide, icterogenin, mepazine, methandriol, oral contraceptives, oxymetholone, propoxyphene, sulfonylureas, and zidovudine. • • Drugs that may increase ALT levels by causing hepatocellular damage include acetaminophen (toxic),ace- tylsalicylic acid,anticonvulsants, asparaginase,carbutamide,cephalo- sporins,chloramphenicol,clofibrate, Values may be slightly elevated in older adults due to the effects of medications and the presence of multiple chronic or acute diseases with or without muted symptoms. This procedure is contraindicated for: N/A INDICATIONS • • Compare serially with aspartate aminotransferase (AST) levels to track the course of liver disease • • Monitor liver damage resulting from hepatotoxic drugs • • Monitor response to treatment of liver disease, with tissue repair Monograph_A_001-023.indd 20 17/11/14 12:03 PM
- 42. Access additional resources at davisplus.fadavis.com Alanine Aminotransferase 21 A cytarabine,danazol,dinitrophenol, enflurane,erythromycin,ethambutol, ethionamide,ethotoin,florantyrone, foscarnet,gentamicin,gold salts, halothane,ibufenac,indomethacin, interleukin-2,isoniazid,lincomycin, low-molecular-weight heparin,meta- hexamide,metaxalone,methoxsalen, methyldopa,methylthiouracil, naproxen,nitrofurans,oral contra- ceptives,probenecid,procainamide, and tetracyclines. • • Drugs that may decrease ALT levels include cyclosporine, interferons, metronidazole (affects enzymatic test methods), and ursodiol. Problem Signs & Symptoms Interventions Pain (Related to organ inflam mation and surrounding tissues; excessive alcohol intake; infection) Emotional symptoms of distress; crying; agitation; facial grimace; moaning; verbalization of pain; rocking motions; irritability; disturbed sleep; diaphoresis; altered blood pressure and heart rate; nausea; vomiting; self-report of pain; upper abdominal and gastric pain after eating fatty foods or alcohol intake with acute pancreatic disease; pain, which may be decreased or absent in chronic pancreatic disease Collaborate with the patient and physician to identify the best pain management modality to provide relief; refrain from activities that may aggravate pain; use the application of heat or cold to the best effect in managing pain; monitor pain severity Fluid volume (Related to vomiting; decreased intake; compromised renal function; overly aggressive fluid resuscitation; overly aggressive diuresis) Overload: Edema, shortness of breath, increased weight, ascites, rales, rhonchi, and diluted laboratory values. Deficient: decreased urinary output, fatigue, and sunken eyes, dark urine, decreased blood pressure, increased heart rate, and altered mental status Complete a daily weight with monitoring of trends; accurate intake and output; collaborate with physician with administration of IV fluids to support hydration; monitor laboratory values that reflect alterations in fluid status (potassium, blood urea nitrogen, creatinine, calcium, hemoglobin, and hematocrit); manage underlying cause of fluid alteration; monitor urine characteristics and respiratory status; establish baseline assessment data; collaborate N U R S I N G I M P L I C A T I O N S A N D P R O C E D U R E Potential Nursing Problems: (table continues on page 22) Monograph_A_001-023.indd 21 17/11/14 12:03 PM
- 43. 22 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A N U R S I N G I M P L I C A T I O N S A N D P R O C E D U R E Problem Signs & Symptoms Interventions with physician to adjust oral and intravenous fluids to provide optimal hydration status; administer replacement electrolytes, as ordered Nutrition (Related to metabolic imbalances) Increased liver function tests; hyperglycemia with polyuria, weight loss, weakness, nausea, vomiting; hypocalcemia with confusion, intestinal cramping, diarrhea; hypertriglyceridemia; altered thiamine with weakness, confusion Administer enteral nutrition; administer parenteral nutrition; monitor laboratory values and collaborate with physician on replacement strategies; correlate laboratory values with IV fluid infusion and collaborate with the physician and pharmacist to adjust to patient needs; ensure adequate pain control; monitor vital sings for alterations associated metabolic imbalances Gastrointestinal problems (Related to altered motility; irritation of the GI tract; taste alterations; pancreatic and gastric secretions) Nausea; vomiting; abdominal distention; unexplained weight loss; steatorrhea; diarrhea; visible abdominal distention; ascites; diminished or absent bowel sounds Perform nasogastric intubation (NGT) to remove gastric secretions and decrease pancreatic secretions which may result in autodigestion; monitor NGT for patency and amount of drainage; assess hydration status; assess bowel sounds frequently; measure abdominal girth to monitor degree of abdominal distention PRETEST: ➧ ➧ Positively identify the patient using at least two unique identifiers before pro- viding care, treatment, or services. ➧ ➧ Patient Teaching: Inform the patient this test can assist with evaluation of liver function and help identify disease. ➧ ➧ Obtain a history of the patient’s com- plaints, including a list of known allergens, especially allergies or sensitivities to latex. ➧ ➧ Obtain a history of the patient’s hepa- tobiliary system, symptoms, and results of previously performed labora- tory tests and diagnostic and surgical procedures. ➧ ➧ Obtain a list of the patient’s current medications including herbs, nutritional supplements, and nutraceuticals (see Appendix H online at DavisPlus). ➧ ➧ Review the procedure with the patient. Inform the patient that specimen collec- tion takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some dis- comfort during the venipuncture. ➧ ➧ Sensitivity to social and cultural issues, as well as concern for modesty, is impor- tant in providing psychological support before, during, and after the procedure. ➧ ➧ Note that there are no food, fluid, or medication restrictions unless by medi- cal direction. INTRATEST: Potential Complications: N/A ➧ ➧ Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex. Monograph_A_001-023.indd 22 17/11/14 12:03 PM
- 44. Access additional resources at davisplus.fadavis.com Alanine Aminotransferase 23 A Patient Education: ➧ ➧ Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Recognize anxiety related to test results, and answer any questions or address any concerns voiced by the patient or family. ➧ ➧ Provide teaching and information regarding the clinical implications of the test results, as appropriate. ➧ ➧ Educate the patient regarding access to counseling services. Provide contact information, if desired, for the Centers for Disease Control and Prevention (www.cdc.gov/diseasesconditions). ➧ ➧ Provide information regarding disease process and proactive activities that the patient can take in managing health. ➧ ➧ Provide samples of dietary selections that can support pancreatic and liver health and that are culturally appropriate. Expected Patient Outcomes: Knowledge ➧ ➧ The patient and family verbalize understanding of causative factors of pancreatitis and liver disease. ➧ ➧ The patient and family verbalize under- standing that the disease can reoccur if not adhering to positive actions to change lifestyle. Skills ➧ ➧ The patient creates a diet plan that supports liver and pancreatic health. ➧ ➧ The patient takes medication as pre- scribed to limit pancreatic secretions and decrease pain. Attitude ➧ ➧ The patient agrees to seek counseling for alcohol abstinence. ➧ ➧ The patient agrees to control potential behaviors that could trigger future disease episodes. RELATED MONOGRAPHS: ➧ ➧ Related tests include acetaminophen, ammonia, AST, bilirubin, biopsy liver, cholangiography percutaneous transhe- patic, electrolytes, GGT, hepatitis anti- gens and antibodies, LDH, liver and spleen scan, US abdomen, and US liver. ➧ ➧ See the Hepatobiliary System table at the end of the book for related tests by body system. ➧ ➧ Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. ➧ ➧ Observe standard precautions, and fol- low the general guidelines in Appendix A. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection. Perform a venipuncture. ➧ ➧ Remove the needle, and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding and hematoma formation and secure gauze with adhesive bandage. ➧ ➧ Promptly transport the specimen to the laboratory for processing and analysis. POST-TEST: ➧ ➧ Inform the patient that a report of the results will be made available to the re questing health-care provider (HCP), who will discuss the results with the patient. ➧ ➧ Nutritional Considerations: Increased ALT levels may be associated with liver dis- ease. Dietary recommendations may be indicated and vary depending on the severity of the condition. A low-protein diet may be in order if the patient’s liver has lost the ability to process the end products of protein metabolism. A diet of soft foods may be required if esophageal varices have developed. Ammonia levels may be used to determine whether pro- tein should be added to or reduced from the diet. Patients should be encouraged to eat simple carbohydrates and emulsi- fied fats (as in homogenized milk or eggs) rather than complex carbohy- drates (e.g., starch, fiber, and glycogen [animal carbohydrates]) and complex fats, which require additional bile to emulsify them so that they can be used. The cirrhotic patient should be carefully observed for the development of ascites, in which case fluid and electrolyte bal- ance requires strict attention. ➧ ➧ Depending on the results of this proce- dure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symp- toms and other tests performed. Monograph_A_001-023.indd 23 17/11/14 12:03 PM
- 45. 24 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A SYNONYM/ACRONYM: Alb,A/G ratio. COMMON USE: To assess liver or kidney function and nutritional status. SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma (1 mL) collected in a green-top (heparin) tube is also acceptable. NORMAL FINDINGS: (Method:Spectrophotometry) Normally the albumin/globulin (A/G) ratio is greater than 1. Albumin and Albumin/Globulin Ratio Age Conventional Units SI Units (Conventional Units × 10) Cord 2.8–4.3 g/dL 28–43 g/L Newborn–7 d 2.6–3.6 g/dL 26–36 g/L 8–30 d 2–4.5 g/dL 20–45 g/L 1–3 mo 2–4.8 g/dL 20–48 g/L 4–6 mo 2.1–4.9 g/dL 21–49 g/L 7–12 mo 2.1–4.7 g/dL 21–47 g/L 1–3 yr 3.4–4.2 g/dL 34–42 g/L 4–6 yr 3.5–5.2 g/dL 35–52 g/L 7–19 yr 3.7–5.6 g/dL 37–56 g/L 20–40 yr 3.7–5.1 g/dL 37–51 g/L 41–60 yr 3.4–4.8 g/dL 34–48 g/L 61–90 yr 3.2–4.6 g/dL 32–46 g/L Greater than 90 yr 2.9–4.5 g/dL 29–45 g/L DESCRIPTION: Most of the body’s total protein is a combination of albumin and globulins.Albumin,the protein present in the highest con- centrations,is the main transport protein in the body for hormones, therapeutic drugs,calcium,magne- sium,heme,and waste products such as bilirubin.Albumin also sig- nificantly affects plasma oncotic pressure,which regulates the distri- bution of body fluid between blood vessels,tissues,and cells.Albumin is synthesized in the liver.Low levels of albumin may be the result of either inadequate intake,inade- quate production,or excessive loss. Albumin levels are more useful as an indicator of chronic deficiency than of short-term deficiency. Hypoalbuminemia or low serum albumin,a level less than 3.4 g/dL, can stem from many causes and may be a useful predictor of mortal- ity.Normally albumin is not excret- ed in urine.However,in cases of kidney damage some albumin may be lost due to decreased kidney function as seen in nephrotic syn- drome,and in pregnant women with pre-eclampsia and eclampsia. Albumin levels are affected by posture.Results from specimens collected in an upright posture are higher than results from specimens collected in a supine position. A Monograph_A_024-046.indd 24 17/11/14 12:03 PM
- 46. Access additional resources at davisplus.fadavis.com Albumin and Albumin/Globulin Ratio 25 A This procedure is contraindicated for: N/A INDICATIONS • • Assess nutritional status of hospital- ized patients, especially geriatric patients • • Evaluate chronic illness • • Evaluate liver disease POTENTIAL DIAGNOSIS Increased in Any condition that results in a decrease of plasma water (e.g., dehy- dration); look for increase in hemo- globin and hematocrit. Decreases in the volume of intravascular liquid automatically result in concentration of the components present in the remaining liquid, as reflected by an elevated albumin level. • • Hyperinfusion of albumin Decreased in • • Insufficient intake: Malabsorption (related to lack of amino acids available for protein synthesis) Malnutrition (related to insufficient dietary source of amino acids required for protein synthesis) The albumin/globulin (A/G) ratio is useful in the evaluation of liver and kidney disease.The ratio is calculated using the following formula: albumin/(total protein – albumin) where globulin is the difference between the total protein value and the albumin value. For exam- ple, with a total protein of 7 g/dL and albumin of 4 g/dL, the A/G ratio is calculated as 4/(7 – 4) or 4/3 = 1.33.A reversal in the ratio, where globulin exceeds albumin (i.e., ratio less than 1.0), is clini- cally significant. • • Decreased synthesis by the liver: Acute and chronic liver disease (e.g., alcoholism, cirrhosis, hepatitis) (evidenced by a decrease in normal liver function; the liver is the body’s site of protein synthesis) Genetic analbuminemia (related to genetic inability of liver to synthesize albumin) • • Inflammation and chronic dis- eases result in production of acute-phase reactant and other globulin proteins; the increase in globulins causes a corresponding relative decrease in albumin: Amyloidosis Bacterial infections Monoclonal gammopathies (e.g., multiple myeloma, Waldenström’s macroglobulinemia) Neoplasm Parasitic infestations Peptic ulcer Prolonged immobilization Rheumatic diseases Severe skin disease • • Increased loss over body surface: Burns (evidenced by loss of interstitial fluid albumin) Enteropathies (e.g., gluten sensitivity, Crohn’s disease, ulcerative colitis, Whipple’s disease) (evidenced by sensitivity to ingested substances or related to inadequate absorption from intestinal loss) Fistula (gastrointestinal or lymphatic) (related to loss of sequestered albumin from general circulation) Hemorrhage (related to fluid loss) Kidney disease (related to loss from damaged renal tubules) Pre-eclampsia (evidenced by excessive renal loss) Rapid hydration or overhydration (evidenced by dilution effect) Repeated thoracentesis or paracentesis (related to removal of albumin in accumulated third-space fluid) • • Increased catabolism: Cushing’s disease (related to excessive cortisol induced protein metabolism) Thyroid dysfunction (related to overproduction of albumin binding thyroid hormones) Monograph_A_024-046.indd 25 17/11/14 12:03 PM
- 47. 26 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A ➧ ➧ Obtain a list of the patient’s current medications including herbs, nutritional supplements, and nutraceuticals (see Appendix H online at DavisPlus). ➧ ➧ Review the procedure with the patient. Inform the patient that specimen col- lection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some dis- comfort during the venipuncture. ➧ ➧ Sensitivity to social and cultural issues, as well as concern for modesty, is impor- tant in providing psychological support before, during, and after the procedure. ➧ ➧ Note that there are no food, fluid, or medication restrictions unless by medical direction. INTRATEST: Potential Complications: N/A ➧ ➧ Avoid the use of equipment containing latex if the patient has a history of aller- gic reaction to latex. ➧ ➧ Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. ➧ ➧ Observe standard precautions, and fol- low the general guidelines in Appendix A. Positively identify the patient, and label the appropriate specimen con- tainer with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection. Perform a venipuncture. ➧ ➧ Remove the needle and apply direct pressure with dry gauze to stop bleed- ing. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. ➧ ➧ Promptly transport the specimen to the laboratory for processing and analysis. POST-TEST: ➧ ➧ Inform the patient that a report of the results will be made available to the requesting health-care provider (HCP), who will discuss the results with the patient. ➧ ➧ Nutritional Considerations: Dietary recom- mendations may be indicated and will vary depending on the severity of the condition. Ammonia levels may be used to determine whether protein • • Increased blood volume (hypervolemia): Congestive heart failure (evidenced by dilution effect) Pre-eclampsia (related to fluid retention) Pregnancy (evidenced by increased circulatory volume from placenta and fetus) CRITICAL FINDINGS: N/A INTERFERING FACTORS • • Drugs that may increase albumin levels include carbamazepine, furosemide, phenobarbital, and prednisolone. • • Drugs that may decrease albumin levels include acetaminophen (poi- soning), amiodarone, asparaginase, dextran, estrogens, ibuprofen, inter- leukin-2, methotrexate, methyldopa, niacin, nitrofurantoin, oral contra- ceptives, phenytoin, prednisone, and valproic acid. • • Availability of administered drugs is affected by variations in albumin levels. N U R S I N G I M P L I C A T I O N S A N D P R O C E D U R E PRETEST: ➧ ➧ Positively identify the patient using at least two unique identifiers before pro- viding care, treatment, or services. ➧ ➧ Patient Teaching: Inform the patient this test can assist with evaluation of liver and kidney function, as well as chronic disease. ➧ ➧ Obtain a history of the patient’s com- plaints, including a list of known aller- gens, especially allergies or sensitivities to latex. The patient should be assessed for signs of edema or ascites. ➧ ➧ Obtain a history of the patient’s gastro- intestinal, genitourinary, and hepatobili- ary systems; symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures. Monograph_A_024-046.indd 26 17/11/14 12:03 PM
- 48. Access additional resources at davisplus.fadavis.com Aldolase 27 A order to prevent development of toxic drug concentrations. Evaluate test results in relation to the patient’s symp- toms and other tests performed. RELATED MONOGRAPHS: ➧ ➧ Related tests include ALT, ALP, ammonia, anti–smooth muscle antibodies, AST, bilirubin, biopsy liver, CBC hematocrit, CBC hemoglobin, CT biliary tract and liver, GGT, hepatitis antibodies and anti- gens, KUB studies, laparoscopy abdom- inal, liver scan, MRI abdomen, osmolality, potassium, prealbumin, protein total and fractions, radiofrequency ablation liver, sodium, US abdomen, and US liver. ➧ ➧ See the Gastrointestinal, Genitourinary, and Hepatobiliary systems tables at the end of the book for related tests by body system. should be added to or reduced from the diet. ➧ ➧ Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Recognize anxiety related to test results and answer any questions or address any concerns voiced by the patient or family. ➧ ➧ Depending on the results of this procedure, additional testing may be performed to evaluate or monitor pro- gression of the disease process and determine the need for a change in ther- apy. Availability of administered drugs is affected by variations in albumin lev- els. Patients receiving therapeutic drug treatments should have their drug levels monitored when levels of the transport protein, albumin, are decreased in Aldolase SYNONYM/ACRONYM: ALD. COMMON USE: To assist in the diagnosis of muscle-wasting diseases such as muscular dystrophy or other diseases that cause muscle and cellular damage such as hepatitis and cirrhosis of the liver. SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. NORMAL FINDINGS: (Method: Spectrophotometry) Age Conventional & SI Units Newborn–30 d 6–32 units/L 1 mo–2 yr 3.4–11.8 units/L 3–6 yr 2.7–8.8 units/L 7–17 yr 3.3–9.7 units/L Adult Less than 8.1 units/L This procedure is contraindicated for: N/A POTENTIAL DIAGNOSIS Increased in ALD is released from any damaged cell in which it is stored, so diseases of skeletal muscle, cardiac muscle, pancreas, red blood cells, and liver that cause cellular destruction demonstrate elevated ALD levels. • • Carcinoma (lung, breast, and genito- urinary tract and metastasis to liver) • • Dermatomyositis • • Duchenne’s muscular dystrophy Monograph_A_024-046.indd 27 17/11/14 12:03 PM
- 49. 28 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A Decreased in • • Hereditary fructose intolerance (evidenced by hereditary defi- ciency of the aldolase B enzyme) • • Late stages of muscle-wasting diseases in which muscle mass has significantly diminished CRITICAL FINDINGS: N/A • • Hepatitis (acute viral or toxic) • • Limb girdle muscular dystrophy • • Myocardial infarction • • Pancreatitis (acute) • • Polymyositis • • Severe crush injuries • • Tetanus • • Trichinosis (related to myositis) Find and print out the full monograph at DavisPlus (http://davisplus.fadavis .com, keyword Van Leeuwen). Aldosterone SYNONYM/ACRONYM: N/A. COMMON USE: To assist in the diagnosis of primary hyperaldosteronism disor- ders such as Conn’s syndrome and Addison’s disease. Blood levels fluctuate with dehydration and fluid overload. This test can be used in evaluation of hypertension. SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma (1 mL) collected in a green-top (heparin) or lavender-top (EDTA) tube is also acceptable. NORMAL FINDINGS: (Method: Radioimmunoassay) Age Conventional Units SI Units (Conventional Units × 0.0277) Cord blood 40–200 ng/dL 1.11–5.54 nmol/L 3 days–1 wk 7–184 ng/dL 0.19–5.09 nmol/L 1 mo–1 yr 5–90 ng/dL 0.14–2.49 nmol/L 13–23 mo 7–54 ng/dL 0.19–1.49 nmol/L 2–10 yr Supine 3–35 ng/dL 0.08–0.97 nmol/L Upright 5–80 ng/dL 0.14–2.22 nmol/L 11–15 yr Supine 2–22 ng/dL 0.06–0.61 nmol/L Upright 4–48 ng/dL 0.11–1.33 nmol/L Adult Supine 3–16 ng/dL 0.08–0.44 nmol/L Upright 7–30 ng/dL 0.19–0.83 nmol/L Older Adult Levels decline with age These values reflect a normal-sodium diet. Values for a low-sodium diet are three to five times higher. Monograph_A_024-046.indd 28 17/11/14 12:03 PM
- 50. Access additional resources at davisplus.fadavis.com A DESCRIPTION: Aldosterone is a mineralocorticoid secreted by the zona glomerulosa of the adrenal cortex and is regulated by the renin-angiotensin system. Changes in renal blood flow trigger or sup- press release of renin from the glomeruli.The presence of circu- lating renin stimulates the liver to produce angiotensin I.Angiotensin I is converted by the lung and kidneys into angiotensin II, a potent trigger for the release of aldosterone.Aldosterone and the renin-angiotensin system work together to regulate sodium and potassium levels.Aldosterone acts to increase sodium reabsorption in the renal tubules.This results in excretion of potassium, increased water retention, increased blood volume, and increased blood pres- sure.This test is of little diagnostic value in differentiating primary and secondary aldosteronism unless plasma renin activity is measured simultaneously (see monograph titled “Renin”). A vari- ety of factors influence serum aldosterone levels, including sodi- um intake, certain medications, and activity. Secretion of aldoste- rone is also affected by ACTH, a pituitary hormone that primarily stimulates secretion of glucocorti- coids and minimally affects secre- tion of mineralocorticosteroids. Patients with serum potassium less than 3.6 mEq/L and 24-hour urine potassium greater than 40 mEq/L fit the general criteria to test for aldosteronism. Renin is low in primary aldosteronism and high in secondary aldosteronism. A ratio of plasma aldosterone to plasma renin activity greater than 50 is significant. Ratios greater than 20 obtained after unchal- lenged screening may indicate the need for further evaluation with a sodium-loading protocol. A captopril protocol can be sub- stituted for patients who may not tolerate the sodium-loading protocol. This procedure is contraindicated for: N/A INDICATIONS • • Evaluate hypertension of unknown cause, especially with hypokalemia not induced by diuretics • • Investigate suspected hyperaldoste- ronism,as indicated by elevated levels • • Investigate suspected hypoaldosteron- ism,as indicated by decreased levels POTENTIAL DIAGNOSIS Increased in Increased With Decreased Renin Levels Primary hyperaldosteronism (evidenced by overproduction related to abnormal adrenal gland function): • • Adenomas (Conn’s syndrome) • • Bilateral hyperplasia of the aldosterone-secreting zona glomerulosa cells Increased With Increased Renin Levels Secondary hyperaldosteronism (related to conditions that increase renin levels, which then stimulate aldosterone secretion): • • Bartter’s syndrome (related to excessive loss of potassium by the kidneys, leading to release of renin and subsequent release of aldosterone) • • Cardiac failure (related to diluted concentration of sodium by increased blood volume) • • Chronic obstructive pulmonary disease Aldosterone 29 Monograph_A_024-046.indd 29 17/11/14 12:03 PM
- 51. 30 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A • • Excess secretion of deoxycortico- sterone (related to suppression of ACTH production by cortisol, which in turn affects aldosterone secretion) • • Turner’s syndrome (25% of cases) (related to congenital adrenal hyperplasia resulting in under- production of aldosterone and overproduction of androgens) CRITICAL FINDINGS: N/A INTERFERING FACTORS • • Drugs that may increase aldoste- rone levels include amiloride, ammonium chloride, angiotensin, angiotensin II, dobutamine, dopa- mine, endralazine, fenoldopam, hydralazine, hydrochlorothiazide, laxatives (abuse), metoclopramide, nifedipine, opiates, potassium, spi- ronolactone, and zacopride. • • Drugs that may decrease aldoste- rone levels include atenolol, capto- pril, carvedilol, cilazapril, enalapril, fadrozole, glycyrrhiza (licorice), ibopamine, indomethacin, lisino- pril, nicardipine, NSAIDs, perindo- pril, ranitidine, saline, sinorphan, and verapamil. Prolonged heparin therapy also decreases aldosterone levels. • • Upright body posture, stress, strenu- ous exercise, and late pregnancy can lead to increased levels. • • Recent radioactive scans or radiation within 1 wk before the test can inter- fere with test results when radioim- munoassay is the test method. • • Diet can significantly affect results. A low-sodium diet can increase serum aldosterone, whereas a high- sodium diet can decrease levels. Decreased serum sodium and ele- vated serum potassium increase aldosterone secretion. Elevated serum sodium and decreased serum potassium suppress aldoste- rone secretion. • • Cirrhosis with ascites formation (related to diluted concentration of sodium by increased blood volume) • • Diuretic abuse (related to direct stimulation of aldosterone secretion) • • Hypovolemia (secondary to hem- orrhage and transudation) • • Laxative abuse (related to direct stimulation of aldosterone secretion) • • Nephrotic syndrome (related to excessive renal protein loss, development of decreased oncotic pressure, fluid reten- tion, and diluted concentration of sodium) • • Starvation (after 10 days) (related to diluted concentration of sodium by development of edema) • • Thermal stress (related to direct stimulation of aldosterone secretion) • • Toxemia of pregnancy (related to diluted concentration of sodium by increased blood volume evi- denced by edema; placental corticotropin-releasing hormone stimulates production of mater- nal adrenal hormones that can also contribute to edema) Decreased in Without Hypertension • • Addison’s disease (related to lack of function in the adrenal cortex) • • Hypoaldosteronism (secondary to renin deficiency) • • Isolated aldosterone deficiency With Hypertension • • Acute alcohol intoxication (related to toxic effects of alcohol on adrenal gland function and there- fore secretion of aldosterone) • • Diabetes (related to impaired conversion of prerenin to renin by damaged kidneys, resulting in decreased aldosterone) Monograph_A_024-046.indd 30 17/11/14 12:03 PM
- 52. Access additional resources at davisplus.fadavis.com A Aldosterone 31 N U R S I N G I M P L I C A T I O N S A N D P R O C E D U R E Potential Nursing Problems: Problem Signs & Symptoms Interventions Fluid volume (Related to hypovolemia associated with adrenal insufficiency; cortisol insufficiency; hyponatremia, vomiting, diarrhea) Deficient: hypotension; decreased cardiac output; decreased urinary output; dry skin/mucous membranes; poor skin turgor; sunken eyeballs; increased urine specific gravity; hemoconcentration; weakness, lethargy, dizziness, tachycardia, low sodium, elevated potassium, hypoglycemia Monitor intake and output; assess for symptoms of dehydration (dry skin, dry mucous membranes, poor skin turgor, sunken eyeballs), monitor and trend vital signs; monitor for symptoms of poor cardiac output (rapid, weak, thready pulse); monitor daily weight with monitoring of trends; collaborate with physician with administration of IV fluids to support hydration; monitor laboratory values that reflect alterations in fluid status (potassium, blood urea nitrogen, creatinine, calcium, hemoglobin, and hematocrit, sodium); manage underlying cause of fluid alteration; monitor urine characteristics and respiratory status; establish baseline assessment data; collaborate with physician to adjust oral and IV fluids to provide optimal hydration status; administer replacement electrolytes, as ordered; adjust diuretics, as appropriate, monitor and trend blood glucose Tissue perfusion (Related to inadequate fluid volume; decreased cortisol levels) Hypotension; dizziness; cool extremities; pallor; capillary refill greater than 3 sec in fingers and toes; weak pedal pulses; altered level of consciousness; altered sensation; urinary output less than 30 mL/hr Monitor blood pressure; assess for dizziness; assess extremities for skin temperature, color, warmth; assess capillary refill; assess pedal pulses; monitor for numbness, tingling, hyperesthesia, hypoesthesia; monitor for DVT; carefully use heat and cold on affected areas; use foot cradle to keep pressure off of affected body parts; provide oxygen as required (table continues on page 32) Monograph_A_024-046.indd 31 17/11/14 12:03 PM
- 53. 32 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications A Problem Signs & Symptoms Interventions Self-care (Related to dizziness, fatigue, weakness, vomiting, diarrhea, anorexia) Difficulty fastening clothing; difficulty performing personal hygiene; inability to maintain appropriate appearance; difficulty with independent mobility Reinforce self-care techniques as taught by occupational therapy; ensure that the patient has adequate time to perform self- care; encourage use of assistive devices to maintain independence; ask if there is any interference with lifestyle activities; assess the ability to engage in activities of daily living Mobility (Related to dizziness, fatigue, weakness secondary to adrenal insufficiency and decreased cortisol levels) Weakness, muscle wasting, pain in muscles and joints, decreased endurance, activity intolerance, difficult purposeful movement, reluctance to attempt to engage in activity Provide assistance with mobility with encouraged use of assistive devices; assess emotional response to limited mobility; assess willingness to participate in activity; assess environment of safety concerns; assess the ability to engage in activities of daily living; encourage early mobility to retain as much independent function as possible; allow sufficient time to perform tasks without being rushed; assess nutritional intake PRETEST: ➧ ➧ Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. ➧ ➧ Patient Teaching: Inform the patient this test evaluates dehydration and can assist in identification of the causes of muscle weakness or high blood pressure. ➧ ➧ Obtain a history of the patient’s com- plaints, including a list of known aller- gens, especially allergies or sensitivities to latex. ➧ ➧ Obtain a history of known or sus- pected fluid or electrolyte imbalance, hypertension, renal function, or stage of pregnancy. Note the amount of sodium ingested in the diet over the past 2 wk. ➧ ➧ Obtain a history of the patient’s endocrine and genitourinary systems, symptoms, and results of previously performed laboratory tests and diag- nostic and surgical procedures. ➧ ➧ Note any recent procedures that can interfere with test results. ➧ ➧ Obtain a list of the patient’s current medications, including herbs, nutri- tional supplements, and nutraceuticals (see Appendix H online at DavisPlus). ➧ ➧ Review the procedure with the patient. Inform the patient that specimen collec- tion takes approximately 5 to 10 min. Inform the patient that multiple speci- mens may be required. Address con- cerns about pain and explain that there may be some discomfort during the venipuncture. Aldosterone levels may also be collected directly from the left and right adrenal veins. This procedure is performed by a radiologist via cathe- terization and takes approximately 1 hr. ➧ ➧ Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. ➧ ➧ Inform the patient that the required position, supine/lying down or upright/ sitting up, must be maintained for 2 hr before specimen collection. Monograph_A_024-046.indd 32 17/11/14 12:03 PM
- 54. Access additional resources at davisplus.fadavis.com Aldosterone 33 A site for bleeding or hematoma formation and secure gauze with adhesive bandage. ➧ ➧ Promptly transport the specimen on ice to the laboratory for processing and analysis. POST-TEST: ➧ ➧ Inform the patient that a report of the results will be made available to the requesting health-care provider (HCP), who will discuss the results with the patient. ➧ ➧ Instruct the patient to resume usual diet, medication, and activity as directed by the HCP. ➧ ➧ Instruct the patient to notify the HCP of any signs and symptoms of dehydra- tion or fluid overload related to elevated aldosterone levels or compromised sodium regulatory mechanisms. ➧ ➧ Nutritional Considerations: Aldosterone levels are involved in the regulation of body fluid volume. Educate patients about the importance of proper water balance. Tap water may also contain other nutrients. Water-softening sys- tems replace minerals (e.g., calcium, magnesium, iron) with sodium, so cau- tion should be used if a low-sodium diet is prescribed. ➧ ➧ Nutritional Considerations: Because aldo- sterone levels affect sodium levels, some consideration may be given to dietary adjustment if sodium allow- ances need to be regulated. Educate patients with low sodium levels that the major source of dietary sodium is table salt. Many foods, such as milk and other dairy products, are also good sources of dietary sodium. Most other dietary sodium is available through consumption of processed foods. Patients who need to follow low- sodium diets should avoid beverages such as colas, ginger ale, Gatorade, lemon-lime sodas, and root beer. Many over-the-counter medications, includ- ing antacids, laxatives, analgesics, sedatives, and antitussives, contain significant amounts of sodium. The best advice is to emphasize the impor- tance of reading all food, beverage, and medicine labels. Potassium is present in all plant and animal cells, ➧ ➧ Prescribe the patient a normal-sodium diet (1 to 2 g of sodium per day) 2 to 4 wk before the test. Protocols may vary among facilities. ➧ ➧ Under medical direction, the patient should avoid diuretics, antihypertensive drugs and herbals, and cyclic proges- togens and estrogens for 2 to 4 wk before the test. The patient should also be advised to avoid consuming any- thing that contains licorice for 2 wk before the test. Licorice inhibits short- chain dehydrogenase/reductase enzymes. These enzymes normally prevent cortisol from binding to aldo- sterone receptor sites in the kidney. In the absence of these enzymes, cortisol acts on the kidney and triggers the same effects as aldosterone, which include increased potassium excretion, sodium retention, and water retention. Aldosterone levels are not affected by licorice ingestion, but the simultaneous measurements of electrolytes may pro- vide misleading results. INTRATEST: Potential Complications: N/A ➧ ➧ Ensure that the patient has complied with dietary, medication, and pretesting preparations regarding activity. ➧ ➧ Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex. ➧ ➧ Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. ➧ ➧ Observe standard precautions, and fol- low the general guidelines in Appendix A. Positively identify the patient, and label the appropriate tubes with the corre- sponding patient demographics, date, time of collection, patient position (upright or supine), and exact source of specimen (peripheral versus arterial). Perform a venipuncture after the patient has been in the upright (sitting or standing) position for 2 hr. If a supine specimen is requested on an inpatient, the specimen should be collected early in the morning before rising. ➧ ➧ Remove the needle, and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture Monograph_A_024-046.indd 33 17/11/14 12:03 PM
- 55. Another Random Document on Scribd Without Any Related Topics
- 56. first time with the guest of honor. It is not a matter of great importance, provided no one has to wait long. Two waitresses make the service quicker. The guests of honor sit at the right of the host and hostess. The number of courses.—Two or three courses are enough for everyday comfort and health. In formal serving, it is good taste not to have too many. A first course of grapefruit or perhaps oyster cocktail, a soup, a fish course, or some light substitute for it,—the main course with meat, a salad, dessert, coffee—make a quite sufficient meal. The “entrée” is a light dish, say sweetbreads in cases, after the fish course, but it is quite unnecessary. Many people are becoming very weary of the long-drawn-out dinners and banquets, which are certainly far from hygienic. Carving.—This is an art that used to be taught as an accomplishment to girls, and it is not an easy matter to master. If not done at the table, it must nevertheless be well done. Watch a good carver, and practice when you have a chance. A few simple directions can be given, but a demonstration is really necessary. First and foremost, have a sharp, strong knife, and a strong fork. The next essential is a platter large enough to hold the meat, without having it slip off. The fork must be firmly placed in the meat, and the meat held down. Notice the shape of the cut of meat. Meat must be cut across the grain. Loosen from the bone, notice the grain, and cut evenly and firmly. With fowl, discover the joints, pierce with the end of the knife, disjoint, and lay at the side, and then slice the breast across the grain. If carving at the table, learn the preference of those served, whether they wish light or dark meat, meat well done or underdone. Have a spoon for dish gravy and stuffing.
- 57. EXERCISES 1. Plan the order of work for the following menus: (a) Cooked cereal and cream, stewed prunes, poached egg on toast, popovers, coffee. (b) Tomato bisque, lamb chops with peas and mashed potatoes, plain lettuce with French dressing, Brown Betty with foamy sauce, black coffee. 2. What are the important points in serving each dish? Give some simple garnishes. 3. Obtain price lists and estimate the cost of table furnishings. 4. What do you consider good taste in china and silver? 5. What are the important points in table setting? 6. Make a list of dishes to be used for the menus given above, or other menus. 7. What are the fundamentals in waiting on the table? 8. How may the home service be made comfortable? 9. Discuss different methods in formal service. 10. How may the guest be made most comfortable?
- 58. CHAPTER XVII THE COST AND PURCHASING OF FOOD This is at all times an important matter, but the notable increase in food prices, during the last decade, has made it a matter of interest to all. The cost of food is one item only in the whole cost of living, and this is affected by many conditions in manufacture and commerce and the business of the nations. Economists and others interested in social questions are studying the problem, but as yet they do not agree upon the cause, or causes, of the increased cost of living. We cannot hope, therefore, to understand the situation fully; but we must be determined to spend money as wisely as we can, and to learn what we may about food prices in relation to food values. There are a few causes of the difference in price between one food and another that are more or less unchanging. The cost of food may be considered from several points of view. The question of the cost for each individual a day and relation of cost and nutritive value are studied in Chapter XVIII. The proportion of the income to be spent for food is taken up in Chapter XIX.
- 59. Labor and prices.—The amount of labor involved in producing a food material affects its price. Meats cost more than staple vegetable foods, like corn, wheat, or beans, because we must raise the corn first to feed the animals. Meat is as cheap as vegetable foods only when the animal can find its own food, as in the pioneer days of any country, when only a small part of the land is under cultivation. To the Pilgrim Fathers, meat was cheaper than corn, in terms of labor, with deer at hand in the forest and corn raised with difficulty in small clearings. Meat production is now an industry, and the product an expensive one, especially as the wide cattle ranges of our West, where the animals have formerly found natural food, are now used more and more for other purposes. Transportation.—Carrying food from place to place increases its cost. In one sense this is another form of labor. Each person who handles the food material from producer to consumer adds something to what the consumer pays. We have heard much discussion of late of the “middleman,” and the effort to bring the producer and consumer closer together. This simply means doing away with some person who handles the product after it leaves the producer and before it reaches the consumer and who must have something for his labor. In transportation there is another element involved, the original cost of the means of conveyance; and the natural wear and tear on the product are items that increase the final cost. The modern farmer who carries his produce to market in an auto truck must have a return for the original cost of the truck and the keeping of it in repair. The long-distance railway furnishes cold-storage cars, and the cost of these and their maintenance affect freight rates. A peach from South Africa costs from fifty to sixty cents in the Boston market. It is probably true, in this case, that a fancy price is asked because African fruit is a novelty here; but the difficulty and expense of long-distance transportation naturally make it costly.
- 60. Demand and supply.—The relation of demand to supply affects the price of food in a way not difficult to understand. Where the supply is permanently small and the demand widespread, the price of the particular food material will be high, and vice versa. Olive oil is a good example of the permanently high-priced food. California olive oil brings a high price not only because it is pure and well flavored, but because many people want it, and the industry is a small one. Many years are needed to establish an olive grove, and olive raising is not a popular way of making money, because it is slow. One enterprising American firm has bought an olive grove in Spain, and is using new methods there, but the product, though delicious, is no cheaper. Although the manufacture of olive oil will doubtless remain a rather small industry, the use of olive oil is increasing, in this country, at least. It does not seem likely, therefore, to become a cheap form of fat. We find nearly the opposite of this in cottonseed oil, a large supply and a relatively smaller demand making a low price. The seed (a by-product of the cotton industry) contains a large quantity of oil, and it is not all used as food. Therefore, it is permanently a low- priced fat, as contrasted with the permanently high-priced fat, olive oil. Agricultural conditions.—There are two things of which the farmer can never feel sure, the kind of weather to expect and the general character of the season. Of course, the season affects the quality and the amount of any crop, and this, again, influences the price. Another aspect of the effect of season on food is this: that a food is in its own locality cheaper when it is in season than at other times of year, when it has to be brought from a distance. Insect pests and plant diseases not infrequently spoil a crop, and the market price goes up with the smaller supply. This is what happened not long since to the potato crop and potato prices, when
- 61. potatoes were affected by the potato blight. Moreover, if the farmer succeeds in keeping his crop free from a particular pest, it means a more or less permanent increase in his expenses, for in fighting insects and fungi there is an outlay for machinery and chemicals, and much labor is expended. Unfortunately, injurious insects and plant diseases are on the increase, and this may mean a permanent rise in the cost of certain foods. Another fact has to be reckoned with in comparing the prices of different foods. Some vegetables are more difficult to raise than others, even when the season is favorable, and the insects at least partly conquered. Some plants have more vitality than others, and grow under almost any condition of soil and moisture. Animal diseases must also affect the price of food. If a large number of cattle are found to have tuberculosis, and are condemned as food, healthy cattle bring a higher price, because, again, the supply is small in relation to the demand. Quality of food.—Poor food always costs less money than good food, but it may not be economy to buy it. There may be more usable material in one good apple at five cents than in three wormy ones for five. Form and place in which food is sold.—Food in the package costs more than in bulk, and each fancy label adds a fraction to the cost. Plate-glass windows and ribbon decorations in a shop and the large expense of rent on a fashionable street are all paid for by the consumer. Relative cost of home and shop products.—When prepared food of any kind is purchased, one pays for raw material plus the cost of fuel and the labor involved in the cooking and the cleaning of apparatus and kitchen. For example, canned soup sold by one of the best manufacturers brings a good price because so much time and labor are used in a careful inspection of all material, and in keeping up a high standard of cleanliness. Remember, too, that whenever
- 62. cooked food appears on the table, these two items, fuel and labor, are in reality added to the cost of the raw material. We may not pay cash always for the labor, but it must be accounted for in time and energy. The woman who says, “My time doesn’t count,” has a poor opinion of herself. Whether or not it is better to buy cooked food or to prepare food at home is discussed on page 292. Other elements in food prices.—So far we have considered those causes of food prices that are what may be called “natural,” always to be taken into account, and only partly under our control. There are others that have to do with big business methods and interests and that have great influence at some one period in a nation’s life, and less at others. They are more or less under our control if we have the wisdom and courage to act. A discussion of these causes is part of the study of economics proper, and we can only stop by the way to think of them for a moment. Transportation must always increase cost, as we have learned, but bad methods, involving the handling of food by many people, increase it unnecessarily. Our present methods of marketing food are clumsy, and not economical, especially in large cities. The subject is being seriously studied with a view to improvement, possibly by the establishment of public markets. At present we have a bewildering state of things, but the housekeeper who sincerely desires, can learn to buy and prepare the less costly foods in an appetizing way, and leave nothing for the garbage pail but the parts that are actually not eatable. Comparative costs.—It would be useless to print here a list of actual prices, since they vary in different localities, and are constantly changing. This list can be made by yourselves in your notebooks for your own home town, and for the current year. The table on page 318 is a guide, however, for in spite of fluctuations in prices there are certain foods that are permanently more economical than others; for example, grain products than meats, for reasons
- 63. already explained. As a rule, the rising cost of food has been so general as not to change greatly the relative economy of the different types of food as compared with each other. Cost and nutritive value.—The discussion of cost has dealt so far with the cost of food materials as they are found in the market. What we are really seeking to learn is the amount of nutritive material to be obtained for a given sum of money, and in order to do this, we must think of our purchases in terms of the foodstuffs and their values. The accompanying table from a government bulletin[17] gives an estimate of cost from this point of view in terms of protein and fuel value. Notice that wheat bread is a cheap food, standing first in the amount of building material and energy. Amounts of Protein and Energy Obtained for 10 Cents Expended For Bread and Other Foods at Certain Assumed Prices per Pound FOOD MATERIALS PRICE 10 CENTS WILL BUY 10 CENTS’ WORTH WILL CONTAIN PROTEIN A FUEL VALUE OF Ounces Ounces Calories Wheat bread 5 cents per lb. 32.0 2.9 2400 Cheese 22 cents per lb. 7.3 1.9 886 Beef, average 20 cents per lb. 8.0 1.2 467 Porterhouse steak 25 cents per lb 6.4 1.3 444 Dried beef 25 cents per lb. 6.4 .1 315
- 64. Eggs 24 cents per lb. 10.0 1.3 198 Milk 9 cents per qt. 38.3 1.2 736 Potatoes 60 cents per bu. 160.0 — 2950 Apples 11⁄2 cents per lb. 106.7 — 1270 The price quoted for eggs is low, and even less could be obtained for ten cents at prevailing prices in 1913-1914. This kind of estimate is a help in making menus and dietaries. (See Chapter XVIII.) Another method of estimating economy for this purpose is by calculating the cost of 100-Calorie portions of various food materials. A table giving such a comparison will be found in the next chapter. Purchasing Food In addition to the general principles of buying discussed in Chapter XXI there are some details to be studied in purchasing food. Personal attention in buying food.—It is absolutely necessary to visit the market and the grocery where food is purchased. The purchaser would not fail to visit a shop before deciding to patronize it regularly, but frequent calls are necessary if buying is to be economical. Select the grocery, market, and bakery with a view to their cleanliness. Notice if the doors and windows are screened, and if proper effort is made to catch flies that may have entered. Refuse to buy food that is exposed upon the sidewalk, and if it is within doors, see that it is protected from dust and flies. The
- 65. best markets now have tiled walls and floors, which help to insure cleanliness. The difference in odor is marked between a market that is properly cleaned daily, and one where the proprietor uses uncleanly methods. Meat and vegetables, in particular, should be personally selected whenever this is possible. The butcher must understand that the purchaser is familiar with the different cuts of meat and that honest service is demanded in regard to the quality, trimming, and weight of the meat. One does not want to be too suspicious, but it is well for the butcher to know that the purchaser has a set of standard scales at home by which to prove the accuracy of his weighing. It is also important to inspect fruit and vegetables for quality and cost. Quantities in which to purchase food.—The amount that one purchases of a certain food depends on its keeping qualities, and upon the storage space available at home. A general rule may be stated: Buy perishable foods in small quantities; non-perishable foods in large. The reason for buying in larger quantity is that the cost is somewhat less, although sometimes it seems but little less. Some one has remarked that no one is a good buyer who does not consider a quarter of a cent. In a modern house or apartment where there is not room for a barrel of flour or sugar, then the quantity must be gauged by the space. The same is true of canned goods as of flour and sugar. Buying by the dozen saves a little on each can if you have shelf room for piling the cans. Foods may be classed in this connection as perishable, semi- perishable, and non-perishable. This depends somewhat for any one housekeeper upon the size of her refrigerator, and upon an available place where food may be cool, even if not so cold as in the refrigerator. Those foods classed here as perishable are those which readily “spoil,” that is, those that are affected by mold and bacteria on account of the moisture that they contain, and also those that lose flavor and freshness quickly. Those most easily affected should be kept the coldest; those in the semi-perishable group do not
- 66. deteriorate so rapidly, although a low temperature is desirable with all of these. Under the non-perishable foods are classed those that are not subject to bacteria or mold in ordinary circumstances. These should be kept dry, however, and never in a heated place. In a sense, no food material is non-perishable. Insects sometimes develop in the cereal products, for instance, and the material is thus rendered unfit for food. The food adjuncts do not spoil except as they lose flavor if kept too long. Perishable.—Milk, cream, uncooked meat, uncooked fish, shellfish, berries, fruits with delicate skins, lettuce, and vegetables that wilt easily. Semi-perishable.—Butter, eggs, cooked meat and fish, root vegetables, cooked vegetables, left overs in general, skin fruits like apples, bananas, oranges, and lemons, dried fruits, scalded milk and cream, smoked and salted fish and meats, open molasses and sirup. Non-perishable.—Flour, meals and cereals, sugar, salt, and other condiments and flavorings, jellies, preserves and canned goods, coffee, tea, cocoa, and chocolate. Suggestions for buying.—Milk and cream must be delivered daily. The average amount used by the family is the regular order. Fresh meat should be delivered on the day wanted unless the refrigerator is large with a space for hanging meat. Even then, it should not be kept more than twenty-four hours. Meat should not be placed directly on the ice. Fresh berries and delicate vegetables should be delivered on the day wanted. Butter and eggs may be purchased once a week; other semi-perishables in quantities depending on storage space. It is economical to buy a box of lemons, and the root vegetables in large quantities. Flour and sugar are purchased by the bag or barrel; lump sugar, in boxes. Breakfast cereals are best bought in packages, and it is wise not to buy a large number at one time. It is better to purchase oftener and have fresher material. Coffee may be bought in pound cans, but it is
- 67. economy to purchase it in five or ten pound quantities, unground. Tea comes in closely sealed packages, in 1⁄4, 1⁄2, and 1 lb. and larger. Cocoa is bought in 1⁄2 lb. cans, but it is economy to buy in large cans if it is frequently used. Macaroni is bought by the package, and the number at one time must depend on how much it is used in the menu. Rice, tapioca, and sago may be bought in bulk and kept in tin or glass jars. Salt by the bag or box. Spices, ground, in tight boxes; whole in bulk, to be kept in tightly closed cans. Molasses comes by the gallon or in cans. If in bulk, it is usually acid; in the can it is not. Vinegar comes by the gallon, or in bottles. Canned and preserved goods, singly, by the dozen, or case. Bakery products, when bought at all, should be purchased daily, or every other day. Do not buy so much that stale bread accumulates. Weights, measures, and packages.—The buyer is at a disadvantage here in regard to quantities, for the baskets in which fruits and vegetables are sold do not always conform to the standard dry measures, and dishonest dealers evade the law in regard to the use of standard scales. Even if they have the standard, they resort to tricks that give the customer short weights. Here the Bureau of Weights and Measures, with its Commissioner and corps of inspectors, comes to the aid of the purchaser. Effective work has been done in our cities in enforcing the laws, and this work continues. Selling fruit, vegetables, and even eggs by weight would simplify matters in many ways, and this is the custom in some parts of the United States with vegetables and fruit, although it is not yet a common practice; with eggs it seems more convenient to sell by the dozen, but grading according to size is a step toward standardization. The alluring packages in which so many articles are offered are quite uneven as to the quantities they contain. They certainly do away with some handling of food, and they keep out dust.
- 68. Unfortunately, an attractive package does not guarantee a clean factory or clean handling in the packing. Dried figs, for example, in pretty baskets are sometimes packed in uncleanly places. Moreover, small packages are poor economy, since the box adds to the cost of the food material, and sometimes there seems even more package than food. If the family consumes many biscuits or “crackers,” it costs considerably more to buy them in packages. Yet, these are convenient, and should be cleanly, and are justified for these reasons, provided the housekeeper does not buy many small packages. The quantities in canned goods are variable and sometimes below measure when purchased from a second-rate dealer. In September, 1914, the net weight amendment to the National Food Law will go into effect, after which, in general, foods sold in packages must be labeled to show net weight or measure or numerical count. As already suggested, you should own standard scales for testing the purchases made by weight, even baker’s bread. Buy fruit and vegetables by the quart, peck, and bushel, rather than by the basket of uncertain measure. Examine baskets containing small fruits to see if they have false bottoms. If you discover small measure, report at once to the dealer, and to whatever authority has charge of such matters in your town. Quality.—Modern methods of manufacture, transportation, and storage make it difficult to determine the history and quality of food we purchase in the markets. Yet the consumer has a natural right to know if the food offered for sale is the best of its kind; fresh eggs, clean milk, meat from healthy animals, untainted and free from harmful preservatives, sound vegetables and fruit, manufactured and preserved foodstuffs unspoiled by the manufacturing processes, free from harmful preservatives, and of good flavor. Many people must be in danger of forgetting the flavor of a fresh-laid egg. The familiar
- 69. signs in many small shops, “Fresh eggs,” “Strictly fresh eggs,” “Fancy eggs,” are amusing, but they bespeak an unnatural state of things. As our business methods have created conditions beyond the control of the individual consumer it follows that we must take concerted action, and make and enforce whatever laws are necessary. This is done partly through the Federal government, and partly through state laws and municipal ordinances. Thus, while we may not know the actual conditions in which food is produced, we may through legislation seek to insure that the food we buy shall be (1) what it purports to be in kind and amount, (2) free from deterioration or unwholesome conditions, (3) possessed of full nutritive value. The Federal Food and Drugs Act of June 30, 1906, commonly known as “The Pure Food Law,” and on which subsequent legislation by most of the states has been largely based, defines the main types of adulteration and misbranding, but, except in the case of confectionery and of habit-forming drugs, does not name the specific substances which are to be prohibited or restricted in use, nor does the law itself contain standards of composition for foods. According to this law a food is deemed adulterated: (1) If any substance has been mixed or packed with it so as to reduce or lower or injuriously affect its quality or strength. (2) If any substance has been substituted, wholly or in part. (3) If any valuable constituent has been wholly or in part abstracted. (4) If it be mixed, colored, coated, powdered, or stained in a manner whereby damage or inferiority is concealed.
- 70. (5) If it contain any added poisonous or other added deleterious ingredient which may render such article injurious to health. (6) If it consists in whole or in part of a filthy, decomposed, or putrid animal or vegetable substance, or any portion of an animal unfit for food, or if it be the product of a diseased animal, or one that has died otherwise than by slaughter. And a food is deemed to be misbranded: (1) If it be an imitation of or offered for sale under the distinctive name of another article. (2) If it be labeled or branded so as to deceive or mislead the purchaser, or purport to be a foreign product when not so, or if the contents shall have been substituted in whole or in part, or if it fail to bear a statement on the label of the quantity or proportion of any narcotic or habit-forming drug which it contains. (3) If it bear an incorrect statement of weight or measure. (4) If the package containing it or its label shall bear any statement, design, or device which is false or misleading in any particular. For a fuller discussion of the basis of pure food legislation and the essential features of the United States laws see Sherman’s “Food Products,” from which a part of the summary here given is drawn. The modern cold storage plant is of immense service in keeping food from the season of abundance to that of scarcity, but it may prove worse than useless if improperly managed. State and federal laws must control the management, and government inspection must be thorough. Cold storage would be a benefit to all under proper conditions of management, and the prices of many foods would be evenly adjusted by the maintenance of a steady supply. Many states now have laws regulating cold storage plants and there
- 71. is every reason to hope that the abuses which have sometimes existed will be eliminated and the usefulness of cold storage extended. We may feel that the progress of the pure food movement has been most satisfactory, even though much more remains to be done. The states generally have either enacted new food laws, or revised their laws following the national law. Under the national law over 2000 prosecutions have already (1913) been decided in favor of the government. Congress has passed an even more stringent law for meat inspection supplementary to the Pure Food Law with ample appropriation for its enforcement. Moreover, in 1913, the Secretary of Agriculture appointed outside experts to inspect meat-packing establishments throughout the country. This inspection is to check up the regular work being done by the Bureau of Animal Industry. The enforcing of federal and state laws has already largely stopped the misbranding of package foods as to weight or measure, cheap substitutions, the removal of valuable ingredients, and the sale of decomposed or tainted food derived from diseased animals. Remember that abuses can be kept down to any extent that we are willing to pay for. Taxpayers must appropriate money to pay for inspection, for laws, no matter how good, will not insure pure food unless carried out faithfully by an adequate number of specially trained inspectors. In the face of all these difficulties we must not be frightened into that state of mind where danger seems to lurk in every mouthful. We must use caution and common sense in our buying, and earnestly support every good movement for bettering conditions. There is a certain difference in quality even at a first class dealer’s that one must learn to distinguish. One can of peaches will
- 72. cost more than another, because the peaches are larger. If it is only this, and there is only a slight difference in flavor in favor of the more costly, buy the cheaper by all means. A fancy brand of imported preserves brings a fancy price which it is not worth while to pay. We have to learn to distinguish between poor and good quality, on the one hand, and between good and what may be called “fancy,” on the other. We should demand the good, but most of us cannot afford the “fancy.” Ready-cooked foods.—More and more cooked food, canned or otherwise, is taking its place in the market. When canned goods were first manufactured on a large scale they comprised fruits, vegetables, meats, and fish, but we are now accustomed to a miscellaneous variety, including soups, baked beans, puddings, and pudding sauces, spaghetti, hashed meat, and shellfish. Bakery products have a larger sale than ever, and are found in small towns, and even in country districts carried there by bakers’ wagons. In our large cities we find the “delicatessen shop” very common, where small portions of cooked meats and fowl may be purchased after the custom of Europe, and these stores are open even on Sunday. How shall we decide what is best for us in our buying? We must not condemn entirely the buying of cooked food without a careful study of the situation. The custom has grown with changes in our mode of living, especially in cities, where the small apartment is common, and where gas is the fuel. Under these conditions it is difficult to prepare foods that need long and slow cooking, and these processes are more expensive when gas is used. The long slow cooking of soup and beans, the even baking of bread, are difficult to accomplish. The odors from these processes fill the small apartment, and scent it for some time, and this is unpleasant at all seasons. Take another example, the canning and preserving of fruits. The first cost of the fruit is usually high in the city, and this plus the sugar and the gas, and the labor and the lack of storage space make
- 73. it seem impracticable in these conditions, and many people decide in favor of buying goods already canned. Such housekeeping is simplified by buying cooked products to some extent. The fireless cooker helps here, but not for all processes. Counting in fuel, the cost is not so much greater as we might suppose; and comfort and convenience are increased. Under other conditions, even in the city, a different conclusion is reached. If coal is the fuel, and a steady fire is kept, perhaps in winter for heating purposes, then it is economy to cook most food materials at home. In the country and small village different conditions prevail. Here the abundance of certain fruits in season makes it economical to can and dry, even counting fuel and labor. In some sections many people can their own vegetables also. However, even in the country in the summer, it is a decided relief to the farmer’s wife, probably short of “help,” to win a little leisure by buying staple bakery products. Here if strict economy is not necessary, is it not better to save strength rather than money? Each housekeeper must work out these problems for herself. EXERCISES 1. What are the more permanent factors in the cost of food material? 2. Why is vegetable food usually cheaper than animal food? 3. Explain the effect of season upon the cost. 4. Why does transportation affect the cost of food? 5. Why is clean milk more costly than unclean? 6. How do business conditions affect the cost?
- 74. 7. Why is wheat bread a truly cheap food? 8. How can we estimate the cost of the actual nutrients in food? 9. Describe the working of the pure food law. 10. Why are such laws necessary? 11. How may we all aid in the passage and enforcement of pure food laws?
- 75. CHAPTER XVIII MENUS AND DIETARIES[18] When we have learned to choose and cook wholesome and appetizing food we have not solved the whole problem of successful feeding. It is possible to make people sick with good food, if it is badly selected and fed at wrong times or in unsuitable amounts. Whether children grow to their full size and strength depends more upon the choice of their food than upon any other one thing. The effect of food is strikingly shown in the case of the white rats in Fig. 74. The two upper ones are the same age. Both had the same mother, lived in the same kind of clean cages, and had plenty of food, but the diet of the upper was good for growth, while that for the middle one was not. It remained perfectly well, but became stunted because of the character of its food. You can see that it resembles the lowest one in the illustration, which is only one fourth as old. In this chapter we shall consider how and when and in what amounts to serve food so that every one may get from it the fullest benefit in both health and happiness.
- 76. Fig. 74.—The effect of food on growth. Reprinted from publication of the Carnegie Institution. Courtesy Professor Lafayette B. Mendel. In Chapter I we learned that the body is a working machine whose first requirement is fuel. Hence the first consideration in the diet is to have the proper amount of fuel for each day, to provide energy for the constant internal work that keeps the body alive, and for the variable external work which may be so light as to consist of the few movements that one makes lying in bed, or sitting quietly;
- 77. or so hard as to exercise many muscles, as playing tennis, bicycling, or swimming. Fig. 75.—Respiration calorimeter, open. From the “Journal of Biological Chemistry.” Courtesy of Professor Graham Lusk. Energy requirements of adults.—We have also learned something about the foods which supply this energy; we must now find out how much fuel (in the form of food) it takes to do different amounts of work, just as the owner of an automobile wants to know how much gasoline per mile or per hour is required to run his machine under different conditions. Very careful experiments have
- 78. been made on many men in different ways to measure their energy output, the most accurate and interesting being those made in a respiration calorimeter, a device so delicate as to be able to measure the extra heat given off when one changes from lying perfectly quiet to sitting up equally still, thus adding the work of holding the upper part of the body upright. A respiration calorimeter large enough to hold a child is shown in Figs. 75 and 76. You can see that it consists of a chamber with thick walls to prevent loss of heat. In Fig. 75 the door is open. When an experiment is going on the door is closed, as in Fig. 76, air being furnished through special tubes. The walls are fitted with delicate thermometers and every device which will help to get the exact amount of heat given off from the body is employed.
- 79. Fig. 76.—Respiration calorimeter, closed. From the “Journal of Biological Chemistry.” Courtesy of Professor Graham Lusk. Just as it takes more fuel to run a big machine than a little one, so it takes more energy for a large person than a small one; therefore we must know the weight of the one whose food requirements we wish to calculate, as well as the amount of energy required to do different kinds and amounts of work. The following table will help in calculating the approximate fuel requirements of any grown person. The food needs of children and young people under twenty-five will be discussed later. Approximate Energy Requirements of Average-sized Man Occupation Calories per pound per hour Sleeping 0.4 Sitting quietly 0.6 At light muscular exercise 1.0 At active muscular exercise 2.0 At severe muscular exercise 3.0 Light exercise may be understood to include work equivalent to standing and working with the hands, as at a desk in chemistry or cookery; or work involving the feet like walking or running a sewing machine. Many persons, as students, stenographers, seamstresses, bookkeepers, teachers, and tailors do little or no work heavier than this. Active exercise involves more muscles, as in bicycling compared with walking, or exercise with dumb-bells as compared with typewriting. Carpenters, general houseworkers, and mail carriers do about this grade of work while on duty.
- 80. Severe exercise not only involves a good many muscles, but causes enough strain to harden and enlarge them. Bicycling up grade, swimming, and other active sports would be included in this kind of exercise. Lumbermen, excavators, and a few others do even heavier work than this. Knowing the weight of a grown man or woman, and something of the daily occupation, as in the case of a professional man, we can estimate the probable energy requirement somewhat as follows: Sleeping, 8 hours; 8 × 0.4 Calories = 3.2 Calories per pound. Sitting quietly (at meals, reading, etc.), 8 hours; 8 × 0.6 Calories = 4.8 per pound. At light muscular exercise (dressing, standing, walking, etc.), 6 × 1.0 Calories = 6.0 Calories per pound. At active muscular exercise 2 hours, 2 × 2.0 Calories = 4 Calories per pound. Total Calories per pound for 24 hours, 18; 18 × 154 pounds (the weight of the average man) = 2772, or approximately 2680, Calories per day required. Calculate in this way the energy requirement for various grown persons whom you know. Energy requirements during growth.—In estimating food requirements of those who are under twenty-five years old, we must bear in mind that the same materials which serve for fuel serve in part for building material. Protein is used for muscle building as well as for supplying energy, and the larger one grows, the greater the reserves of carbohydrate and fat which he can carry. Furthermore, internal activity is greater in the young than the middle aged or very old, and external activity is apt also to be greater. Think, for instance, how much running children do compared with their parents. For all these reasons, we cannot use the table for adults in
- 81. calculating the energy requirement of young people. In the following table an attempt has been made to take account of their greater needs, but the estimates include only moderate exercise; with hard work more will be required. Notice that the highest allowance per pound of body weight is for the youngest children. Energy Requirements during Growth Age in Years Calories per pound per day Under 1 45 1-2 45-40 2-5 40-36 6-9 36-30 10-13 30-27 14-17 27-20 17-25 not less than 18 With these two tables for calculating energy requirement we can determine about how much will be needed by each member of the family. A group consisting of a professional man, his wife, and three children under 16 will require about 10,000 Calories per day; a workingman’s family with the same number of children from 12,000 to 14,000, because of the harder work which both parents and possibly the children will do. Protein requirement.—Since few of our foods consist of a single foodstuff, and we are not likely to make even a single meal on pure fat, or pure protein, or pure carbohydrate alone, we are sure to get some building material in any diet, but we must see to it that we are getting amounts which furnish the best possible conditions for growth and repair.
- 82. As we have already seen, nitrogen in the form of protein is necessary to the life of every cell in the body. From protein, too, muscle is built, though we cannot build good muscle merely by feeding protein; a diet moderate in its amount of protein, but with plenty of fuel for healthy exercise is best for muscle building. Under all ordinary conditions, if ten to fifteen Calories in every hundred (10 to 15 per cent of the total Calories) are from protein, the need for this kind of building material will be met. Thus a family requiring 10,000 Calories per day should have from 1000 to 1500 of these as protein Calories. The following table gives the protein Calories in the 100-Calorie portions of some common food materials. Table Showing Distribution of Calories in 100-calorie Portions of Common Food Materials Food Material Weight Distribution of Calories OuncesProteinFatCarbohydrate Almonds, shelled 0.5 13 77 10 Apples, fresh 7.5 2 6 92 Bacon 0.5 6 94 — Bananas 5.5 5 6 89 Beans, dried 1.0 26 5 69 Beef, lean round 2.5 54 46 — Bread 1.4 14 4 82 Butter 0.5 1 99 — Cabbage 13.3 21 7 72 Carrots 10.1 10 5 85 Cheese, American 0.8 27 73 — Cod, salt (boneless) 3.1 98 2 — Cornmeal 1.0 10 5 85 Eggs, whole 2.7 36 64 — Flour, white 1.0 12 3 85
- 83. Lamb chops 1.3 23 77 — Lentils 1.0 29 4 67 Macaroni 1.0 15 2 83 Milk, whole 5.1 19 52 29 Milk, skimmed 9.6 37 7 56 Oats, rolled 0.9 17 16 67 Peanuts, shelled 0.6 19 63 18 Peas, canned 6.4 26 3 71 Peas, dried 1.0 27 3 70 Salmon, canned 2.4 54 46 — Veal 3.2 70 30 — Walnuts, shelled 0.5 10 82 8 Notice that some foods, like bread, have about the right proportion of protein calories; others, like beef, beans, and peas are very high in protein calories. By combining some foods high in protein with others containing little or none, we can get the right proportion. Thus, 100 Calories of beef combined with 400 each of bread and butter will give 900 Calories of which 114, or 12.7 per cent, are from protein. PROTEIN CALORIES TOTAL CALORIES Beef 54 100 Bread 56 400 Butter 4 400 Totals 114 900 (114 ÷ 900 = 0.127 or 12.7%) It is interesting to work out other combinations which give these good proportions. Ash requirement.—We are also assured of ash in any ordinary diet, but some attention should be paid to kind and amount, especially as many common foods have lost the parts richest in ash.
- 84. Patent flour, for instance, made from the inner part of the grain, is not so rich in ash as whole or cracked wheat. Valuable salts are also lost in cooking vegetables when the water in which they were cooked is thrown away. If not desired with the vegetable, this should be saved for gravy or soup. It is not necessary to calculate a definite amount of ash for the diet, if ash-bearing foods are freely used. By reference to the table on page 384 you can see what foods are valuable for supplying the important kinds of ash. Milk is particularly rich in calcium and hence is required when the bones are growing. Eggs have iron and phosphorus in forms well suited to growth. But if eggs are too expensive, the vegetables and fruits generally will supply these same substances. Diet for growth.—Diets made in the chemical laboratory from mixtures of pure (isolated) protein, fat, carbohydrate, and ash to satisfy all the requirements which we have so far mentioned, do not behave alike when fed to animals. The kind of protein is important as well as the amount. This is shown by experiments in which only one protein is fed at a time. On some, the animals will not thrive. On others, adult animals do very well, but the young ones become stunted like the one shown on page 295. Milk has been found to contain proteins on which young animals can thrive. But even in diets containing the protein from milk, young animals do not develop normally unless the salts of milk are added too. No perfect substitute for milk has ever been found. During the first year of life, a child lives on it almost exclusively; for the first five years it should be considered the most important article in the diet; and throughout the period of growth it should be freely used if children are to become vigorous men and women. If not liked as a beverage, it can be used in cocoa, or cereal coffee, in soups, puddings, and other dishes. Considering what milk may save in the way of more expensive protein foods, such as eggs and meat, and of ash- supplying foods like fruits and vegetables, it is to be regarded as a cheap food. It is possible to get the proper amounts of fuel and
- 85. protein from white bread and meat, but such a diet is poorly balanced as to ash constituents and especially lacks calcium. It would need to be balanced by adding some fruit or vegetable and even then would not contain as much calcium as is best for growing people. A diet of bread and milk, on the other hand, is so nearly perfectly balanced (supplying fuel, protein, and ash constituents in suitable amounts) that it can be taken exclusively for a long time. Whole wheat bread and milk would be even better, because the whole wheat would supply more iron, in which white bread and milk are not rich. The addition of fruits and vegetables to the bread and milk diet would also be an advantage—partly for the same reason. Other foods especially valuable for growth are eggs and cereals from whole grains. Children should acquire the habit of eating fruits and green vegetables of all kinds, for when they are older and likely to take less milk and cereals, the fruits and vegetables supply important ash constituents and also help to prevent constipation. The foods good for children are also good for adults, but the latter can keep their bodies in good repair with less protein and ash in proportion to body weight than are required during growth, and many kinds of protein serve for repair. If there are not enough milk and eggs to go around, adults can take meat, nuts, peas, beans and bread for protein, and trust to these and fruit and vegetables for ash. When the body has been wasted by sickness, however, a return to the foods of growth, especially a diet of milk and eggs, is best for building it up again. The number of meals in a day.—Knowing how much and what kinds of food are best for each member of the family, we must next find out how to divide the total food for the day into meals. Few of us could take our required fuel in one meal, and if we could, we should probably be hungry before the time for the next meal. Some persons get along very well with two meals a day, but usually their fuel requirement is not high. Most people are more comfortable and
- 86. more likely to eat a suitable amount in a deliberate fashion if they have three meals a day. When large amounts of fuel have to be taken, four or five meals may be better than three; babies who have to eat in proportion to their size, often 21⁄2 times as much as their mothers, take 21⁄2 times as many meals, i.e. 7 or 8 in a day. The amount of food for each meal.—While the number of meals depends largely on the amount to be eaten in the whole day, and the appetite of the subject, the amount at each meal is most influenced by the nature of the daily occupation. The baby with nothing to do but eat and sleep has meals uniform in kind and amount. The business man who works very hard through the middle of the day, and has not time to take an elaborate meal, nor time to rest after it so that it may digest easily, takes a light luncheon and makes up for it at breakfast and dinner. The outdoor worker who has a long hard day and expends much energy, takes an hour at noon for a substantial dinner, in addition to a hearty breakfast and supper and sometimes a mid-forenoon or mid-afternoon lunch. Regularity of meals.—More important than the number of meals is regularity as to time of eating and amount of food. Training for the digestive tract is just as important as training the eye or the hand or the brain. We cannot expect good digestions if we have a hearty luncheon to-day, none at all to-morrow, and perhaps a scanty and hasty late one the next day. To take food into the stomach between meals is to demoralize the digestive system. Foods that are excellent as part of a meal provoke headaches and bad complexions, and many symptoms of a protesting stomach, when taken between meals. The younger the person, the more important is regularity. Little children soon suffer if their meals are not “on the minute.” Adults have more difficulty in controlling their time, but if they have to be late to meals, they should be more careful than usual to eat slowly and to choose plain simple food that will digest easily.
- 87. Mental attitude toward meals.—Good food may be provided at the proper time and yet the members of a family may fail to keep well and happy unless they come to meals in the right condition. Haste, chill, exhaustion, anxiety, excitement, fretfulness, or anger may interfere with the digestion of the most digestible of meals. Orderly table service, good manners, and cheerful conversation are very important factors in the success of a meal. Peace and joy as well as “calories” are watchwords of good nutrition. Balanced meals.—Having determined how many meals to serve in the day and what their hours shall be, the next question is how to choose and distribute the constituents of the day’s ration so as to promote digestibility and satisfaction. A meal of pure protein, or fat, or carbohydrate would not be relished, and would have some physiological disadvantages. Digestion is likely to be more complete on a mixed diet. A meal of carbohydrate alone leaves the stomach more quickly than any other kind, and one would feel hungry before the next meal, though one might have had plenty of fuel; a meal of fat alone would leave the stomach very slowly, and one would not have so good an appetite for the next meal; a meal of pure protein would stimulate heat production without any particular advantages, except possibly in very cold weather: it would be decidedly undesirable in hot weather. For these and other reasons it is best to have the different foodstuffs represented in each meal, and to see that no one contains an excess of fat, which tends to retard all digestion. This is what is usually meant by a balanced meal, but it may also include care that about the same proportion of fuel is served at the same meal each day. A meal does not need to be “balanced” in quite the same sense as a day’s ration. The latter must have a definite amount of fuel, a suitable proportion of protein, ash well represented, some food for bulk, the whole selected with regard for the physical condition, tastes, habits, and pocketbooks of those to be fed.
- 88. Menus.—Food taken at a stated time constitutes a meal. It may consist of a single food material, as bread, or a single dish, as soup; or it may contain many kinds of food and many dishes. When the day’s ration consists of a single food, there is no trouble in arranging the bill of fare, for all meals are alike. But as soon as we have two foods, we may consider whether they will digest better if eaten together or separately, and which way they will please the palate better. Balanced diets do not necessarily afford attractive menus. Macaroni and oatmeal would make a fairly well balanced meal except as regards ash constituents, but no one would call such a combination pleasing. By the substitution of a little cheese and an orange for the oatmeal, a meal containing about the same fuel value and proportion of protein could be arranged, and it would certainly appeal more to the appetite, and furnish better proportions of ash constituents. In the construction of the menu for the day or meal, we must consider not only food values and time of day and combinations which shall be digestible, but flavor, color, texture, and temperature of our foods. The study of digestible combinations belongs to the science of nutrition. The harmonious blending of tastes, odors, colors, and the like is an art. Just as there are pleasing combinations of sound, so there are harmonies of flavor; certain dishes seem naturally to “go together.” Habit has a great deal to do with food combinations. A Chinaman would not eat sugar on rice; a Japanese would not cook beans with molasses as the Bostonian does. It is interesting to experiment with new combinations, and study to find out why old ones are pleasing. Why do we like crackers with soup? Butter on bread? Toast with eggs? Peas with lamb chops? Digestible menus.—Some of our eating habits are worth preserving and cultivating. Fresh fruit for breakfast stimulates the appetite and helps to prevent or overcome constipation. A mild- flavored food like cereal is better relished before we have had meats or other highly flavored food. Soup at the beginning of a meal puts
- 89. the stomach in better condition to digest the food that follows. Ice cream at the end of a meal is less likely to chill the stomach than at the beginning. Bread and butter afford a good combination of fat and carbohydrate. Crackers help in the breaking up of cheese into particles easy to digest. Not all of our eating habits are good, however. Griddlecakes, melted butter, and maple sirup taste good, but the cakes make a pasty mass difficult for digestive juices to penetrate. The sirup is likely to ferment, and the butter coating the whole delays digestion greatly. Chicken salad is popular, but combinations of protein with much fat (as in the mayonnaise dressing) always digest very slowly. Simple dishes, without rich sauces or gravies, and not excessively high in fat, are easiest of digestion. Pastries, fried foods, meats with much fat, like pork and sausage, are always more or less difficult and should be attempted only by the strong, or when the body is free from physical or nervous weariness, and not about to undertake mental work. Attention to the art of menu making not only helps to make the diet easier to digest, but also better balanced. Foods which are similar in color, flavor, and texture, like potatoes and rice, are not artistic in combination, and it is better to substitute for one of them a green vegetable, or meat or butter, in which case we get a better balance, as more ash, protein, or fat would then be included with the starch of the rice or potato. In making the bill of fare it is a great mistake to consider each meal by itself alone. If we do so, some days are likely to be very high in fuel, while others may be very low. Then, too, the impression left from one meal carries over to the next. We do not care to see on the dinner table the same foods that we saw at luncheon. Our love of variety is one of nature’s ways of seeing to it that we get different kinds of foodstuffs in our diet. Variety stimulates appetite, but this does not mean a great variety at one meal. The truest variety is
- 90. obtained by a few well-selected dishes at each meal. If we do not exhaust our resources on one meal, we shall be able to have a greater range of foods in the course of a week. A hotel may have fifty or sixty items on its bill of fare, but after a few days one feels as if there were a great sameness, because all of them are impressed on the mind at each meal and every day. Dietaries.—A dietary, as we shall use the term here,[19] is a statement of the food requirements of a person or group of persons for a day or some other definite length of time, with a selection of foods to satisfy this requirement. The first part of a family dietary will have to be calculated according to the age, weight, and occupation, as stated on pages 299-303. When complete, it will stand somewhat like this: Food Requirements Members of Family Age Weight Pounds Total Calories Protein Calories Man 40 154 2680 268-402 Woman 38 120 2160 216-324 Girl 16 110 2200 220-330 Boy 12 75 2250 225-338 Boy 6 40 1600 160-240 Total requirements 10,890 1089-1634 In selecting food to satisfy these requirements it is a good plan to make first a list of those foods that need to be included in the day’s dietary, no matter what the particular menu may be. This will include foods for growth where there are children, special dishes needed if any one is sick, and those common foods which we are accustomed to include in every day’s menu, such as bread and butter.
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