Diagnostic Testing
- 2. Maintaining Consistency To ensure consistency and meet quality assurance standards, diagnostic evaluations performed in the CareNET clinics must conform to the methods outlined in this presentation. Additional information regarding each method can be found in the Clinic Training Manual.
- 3. Provider Presence Diagnostic tests that DO NOT require a provider to be present: Venipuncture Urine Specimen Collection X-Rays Height/Weight Measurement Nasal/Oral Function Test Visual Acuity Diagnostic tests that REQUIRE a provider to be present: Blood Pressure Readings Electrocardiogram (EKG) resting Stress Electrocardiogram (EKG) exercise-treadmill Doppler Test Pulmonary Function Test (PFT) Certain diagnostic procedures will require a provider to be present.
- 4. General Survey Diagnostic exams are performed to measure organ system function and detect any abnormalities that may be associated with a condition. However, even before any diagnostic exams are performed, a simple conversation with the patient can provide vital information on the patient’s condition, or otherwise give an early indication of systems that may need special attention. Take note of the following: Physical body features Wounds, scars Sweating, pallor, or flushing Neurological abnormalities State of consciousness and alertness Speech Body movements Nutritional status Behavior
- 5. Blood Pressure Measurement Blood pressure readings are required for the following examinations and claimed conditions: General Comprehensive Exam Diabetes Mellitus Hypertension Heart Condition Clinic policy is that three readings be taken while the patient maintains one position (sitting or standing). To ensure consistency, readings are to be taken on alternating arms (L/R/L or R/L/R).
- 6. Blood Pressure Measurement - Technique This technique requires a sphygmomanometer (BP cuff) and stethoscope. Have the client sit in a chair, with the arm raised and level with the heart. Place the cuff around the arm so that the bottom edge is 1 inch (2.5 cm) medial to the antecubital fossa (elbow). Place the stethoscope below the cuff on the anterior part of the arm to better hear the brachial artery. Close the valve on the inflation bulb by twisting the knob, and squeeze repeatedly to inflate the cuff and increase the pressure on the arm to 180mm Hg. Carefully twist the knob on the inflation bulb to release the pressure at a steady rate of -2 to - 3mmHg per second. Watch the gauge and note the point where the pulse is first heard (systole). Maintain the air release rate and note the point where no further sound is heard (diastole). Continue releasing air for an additional 10mm Hg to ensure that the endpoint is accurate. Use the valve to release the remaining air in the cuff, and record the findings in the format systolic diastolic on the Vital Signs section of the patient flow sheet. Repeat the examination on the other arm, for a total of three readings. Once all three blood pressure readings are received, do the following: Give all three blood pressure readings to the provider. Document that the results were given to the provider in the portal.
- 7. Blood Pressure Measurement - Results If all three blood pressures are less than 140/90 and Hypertension is a claimed condition, follow the guidelines listed below: If the Veteran is not taking blood pressure medication, the Veteran MUST return to the clinic for two additional blood pressure readings on two different days. If the Veteran can go to his/her Primary Care Physician (PCP) to have the two-day blood pressure readings performed, the clinic staff should work directly with the PCP/staff to obtain the results. If any of the three readings are equal to or greater than 140/90, follow the guidelines listed below: If the Veteran is taking medication for the blood pressure, do nothing else. If the Veteran is not taking medication, the Veteran MUST return to the clinic for two additional blood pressure readings on two different days. If the Veteran can go to his/her Primary Care Physician (PCP) to have the two-day blood pressure readings performed, the clinic staff should work directly with the PCP/staff to obtain the results. If the Veteran is unable to complete the three blood pressure readings within a reasonable time period the clinic staff shall notify the QR manager. Blood Pressure Levels Normal systolic: less than 120 mm Hg diastolic: less than 80mm Hg At risk (prehypertension) systolic: 120–139 mm Hg diastolic: 80–89 mm Hg High systolic: 140 mm Hg or higher diastolic: 90 mm Hg or higher
- 8. Pulse Measurement Pulse rate readings are required for all examinations. Clinic policy is that two readings be taken while the patient maintains one position (sitting or standing), and recordings be taken over at least 30 seconds. While there are many arterial sites that can be used to measure pulse, the most accessible and reliable are the carotid, brachial, and radial arteries. Carotid artery - palpated on the neck below the jaw and lateral to the larynx/trachea (i.e., mid-point between your earlobe and chin) Brachial artery - palpated on the anterior aspect of the elbow by gently pressing the artery against the underlying bone. Radial artery - palpated immediately above the wrist joint near the base of the thumb (common site), or in the anatomical snuff box (alternative site), by gently pressing the artery against the underlying bone
- 9. Pulse Measurement - Technique This technique requires a visible analog or digital clock that displays seconds. A stethoscope may be used, but is not necessary. Choose an accessible artery and palpate with the index and middle finger, gently pressing down until the pulse can be felt clearly. Do not use the thumb while palpating, your own pulse is felt strongly in the thumb and may give an erroneous reading. Monitor the patient’s pulse for 30 seconds and count the number of beats. A stethoscope may be placed on the artery site to hear the beats instead. Double the number of beats counted to obtain a beats-per-minute value. In some cases, a single pulse beat will be dicrotic – consisting of two beats in quick succession. If this is noticed, count each “pair” as one beat and note the abnormality. If the patient’s pulse is irregular, monitor for the full minute. Do not double this number. While recording the pulse, also be aware of regularity (time between each pulse) and volume (how strong the pulse is). Record any abnormality in either. Record the pulse in the format “___ beats per minute” on the Vital Signs section of the patient flow sheet.
- 10. Pulse Measurement - Results Normal pulse rates for an adult person at rest range from 60 to 100 beats per minute. Heightened resting heat rate may be caused by: Exercise Smoking Anxiety Dehydration Medications/drugs Disease Sepsis Myocardial infarction Lowered resting heart may be caused by: Physical fitness Medications/drugs Body relaxation A weak pulse may be caused by: Heart disease Reduced heart pumping capacity Dehydration Hemorrhagic shock
- 11. Respiratory Rate Respiratory rate readings are required for all examinations. Clinic policy is that the reading be taken while the patient maintains one position (sitting or standing), and recordings be taken over at least 30 seconds. As breathing rate is influenced by movement and conscious attention (manual breathing), it is best to be discreet when measuring a patient’s respiratory rate. People will often breathe slower and more deeply when they know that their breathing is being monitored – how does your breathing change after reading the sign to the left? It is suggested to perform the respiratory rate measurement immediately after performing a blood pressure and/or pulse measurement.
- 12. Respiratory Rate – Manual Technique This technique requires a visible analog or digital clock that displays seconds. A stethoscope may be used, but is not necessary. Distract the patient by continuing to hold the arm after a blood pressure measurement or other diagnostic evaluation. Monitor the patient’s chest for 30 seconds and count the number of breaths. A stethoscope may be placed on the upper chest or back to hear the breaths instead. One full breath consists of an inhalation (chest rise) and an exhalation (chest fall). Only count rises or falls, not both. Double the number of breaths noted to obtain a breaths-per- minute value. If the patient is breathing irregularly, monitor respiration for the full minute. Do not double this number. While performing the test, take note if the patient appears to have difficulty breathing or shows any other abnormal breathing patterns. If using a stethoscope, note unusual sounds such as rattling, wheezing, or gurgling. Record the breathing rate in the format “___ breaths per minute” on the Vital Signs section of the patient flow sheet.
- 13. Respiratory Rate - Results Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute. Abnormal respiration rates for an adult person at rest is <10 or >20 breaths per minute. It is shown that women typically have higher respiratory rates than men. Heightened respiratory rate may be caused by: Physical activity Medications/drugs Disease COPD Angina URTI Anxiety Smoking Lowered respiratory rate may be caused by; Physical fitness Medications/drugs Body relaxation
- 14. Temperature Measurement Depending on the type of VA examination, a temperature reading may be requested as part of the vital signs. While there are many multiple body sites that can be used to measure temperature, the most accessible and reliable are the oral and tympanic regions. Tympanic (the ear canal) Oral (underneath the tongue) Different thermometers are designed and calibrated for specific body sites. Using one type of thermometer in an incorrect location will not yield valid results.
- 15. Temperature Measurement – Technique (Tympanic) This technique requires a tympanic thermometer and a disposable probe cover. Using gloves, attach the probe cover to the probe on the thermometer. Instruct the client to hold their head still as the probe is inserted into the ear. Place the covered tip no more than 0.5 inches (1 cm) into the opening of the ear canal, and wait 2 to 5 seconds after you press the scan button for the temperature display. To obtain an accurate reading from a tympanic thermometer, it is important to place the probe at the proper angle for sealing the ear canal. Remove the thermometer and use the automatic probe cover ejector to detach and discard the disposable probe cover. Record the temperature in the Vital Signs section of the patient flow sheet and discard the used thermometer.
- 16. Temperature Measurement – Technique (Oral) This technique requires a disposable oral thermometer (Tempa•DOT™) and a clock. Tear off one thermometer from the strip. As you peel the package away, be careful to hold the thermometer by its handle, rather than the dotted section. Instruct the client to place the thermometer underneath the tongue as far back as possible. It does not matter whether the dots are facing up or down. Close the mouth and leave the thermometer in for 60 seconds. After 60 seconds, remove the thermometer and let it sit for ten seconds. Read the temperature by looking at the blue dots. The last blue dot shows the temperature. Ignore any unchanged dots. Record the temperature in the Vital Signs section of the patient flow sheet and discard the used thermometer.
- 17. Temperature Measurement - Results Temperature may also be influenced by the following factors: Emotional status Time of day Air temperature (environment) Injury to hypothalamus Infection/ illness (increases temperature) Physical activity (increases temperature) Menstrual cycle (higher at time of ovulation) Eating and drinking (oral temp) Smoking (oral temp) Oral Tympanic Axilla Men 35.7 – 37.7*C 35.5 – 37.5*C 35.5 – 37.8*C Women 33.2 – 38.1*C 35.7 – 37.5*C 35.5 – 37.8*C Overall 33.2 – 38.2*C 35.4 – 37.8*C 35.5 – 37.0*C Normal temperature ranges: Convert degrees F to degrees C by subtracting 32 and then dividing by 1.8 Convert degrees C to degrees F by multiplying by 1.8 and then adding 32.
- 18. Weight Measurement Weight readings are required for all examinations. Clinic policy is that the reading be taken without additional medical equipment (such as braces). It is suggested to perform the height and weight measurements together if the scale used has an integrated height rod. Self-reported weights are not acceptable measurements.
- 19. Weight Measurement – Beam Scale Technique This technique requires a beam scale. Calibrate the scale by placing both the large and small weights at the zero (0) markings. The balance bar should be floating in the center of the balance window. If not, the scale is not calibrated properly and should not be used. If the client is wearing a brace, have them remove the brace on their own. If the client is unable or unwilling to remove the brace, document in the flow sheet that the weight was measured with the brace on. Instruct the client to take their shoes should be off and stand on the scale, with their feet together and arms by their side. Starting with the large weight, adjust the weights on the beam until the balance bar is floating in the center of the balance window. If the balance bar is touching the top of the window, you need to move the weights toward 0 If the balance bar is touching the bottom of the window, you need to move the weights away from 0. Once the bar is balanced, record the weight. To calculate the total weight add the weight displayed by the large weight indicator on the bottom bar to the weight displayed by the small weight indicator on the top bar. The lower bar markings increase in increments of 50 lbs. The upper bar numbers increase in increments of 2 lbs. The long bold lines on the upper bar are whole numbers The medium and short lines behind the whole numbers measure fractional weights; the first line is ¼, the second line is ½, and the third line is ¾. Record the weight in the appropriate section of the patient flow sheet.
- 20. Weight Measurement – Floor Scale Technique This technique requires a floor scale. Ensure that the scale is calibrated correctly; the display should read 0 when nothing is resting on it. If not, the scale may be recalibrated with a dial on the bottom or sides. If the client is wearing a brace, have them remove the brace on their own. If the client is unable or unwilling to remove the brace, document in the flow sheet that the weight was measured with the brace on. Instruct the client to take their shoes should be off and stand on the scale, with their feet together and arms by their side. Record the weight in the appropriate section of the patient flow sheet.
- 21. Height Measurement Height readings are required for all examinations. Clinic policy is that the reading be taken twice. If there is a deviation of 3mm or more between the readings, a third must be taken until consistent results are obtained. It is suggested to perform the height and weight measurements together if the scale used has an integrated height rod. If the client is unable to stand, or has spinal conditions that would interfere with a correct reading (kyphosis, lordosis), arm span measurements can be used. Self-reported heights are not acceptable measurements.
- 22. Height Measurement – Height Rod Technique This technique requires a stadiometer or weight scale with integrated height rod. Instruct the client to step onto the center of the weight scale or align the body against the wall mounted stadiometer (height rod) Instruct the client to stand straight and tall with their back toward the height rod. Heels, buttocks and upper back should be in contact with the height rod. Position the client’s head so that they are looking straight forward Be prepared to assist the veteran should they become dizzy, stumble or have any trouble getting on or off the scale. Extend the rod to its maximum height and ensure that the rod head is perpendicular to the rod. Slide the rod downward until the rod head touches the crown of the client’s head with sufficient pressure to press hair. Ensure the height bar is level on top of the client’s head to get an accurate reading. Use the step stool if necessary to determine if the height bar is level on the top of the client’s head to ensure an accurate reading. Note the direction the height values on the rod are increasing in to determine if fractional values are less or greater than the nearest whole number value. Record the height in the appropriate section of the patient flow sheet.
- 23. Height Measurement – Wall-Mount Technique This technique requires a wall-mounted height ruler. Ensure that the measurement device is properly attached to the wall and oriented correctly. Instruct the client to stand straight and tall with their back toward the wall. Heels, buttocks and upper back should be in contact with the wall. Position the client’s head so that they are looking straight forward Be prepared to assist the veteran should they become dizzy, stumble. Slide the ruler head down until the rod head touches the crown of the client’s head with sufficient pressure to press hair. Ensure the horizontal bar is level on top of the client’s head to get an accurate reading. Use the step stool if necessary to determine if the height bar is level on the top of the client’s head to ensure an accurate reading. The height will be displayed in a window or electronic display on the ruler head. Record the height in the appropriate section of the patient flow sheet.
- 24. Height Measurement – Arm Span This technique is used if the client is unable to stand, or has a spinal condition that would give an erroneous standing height reading. This technique requires a measurement tape. Instruct the client to spread both arms horizontally in the frontal plane with the palms facing forward. The client’s height is equal to the distance from the tips of the middle fingers. If the client is unable to lift both arms, support one arm and measure the distance from the middle finger tip to the sternum. The client’s height is double the recorded value. Record the height in the appropriate section of the patient flow sheet.
- 25. Height and Weight Measurement - Results Once height and weight measurements are obtained, the BMI chart can be used to determine the client’s BMI. BMI values outside of the green “healthy” range may be at risk for various conditions ranging from malnutrition to diabetes.
- 26. Nasal and Oral Function Study Nasal and oral function studies are performed in varying circumstances; the ability to detect smoke, fumes, or natural gas may be necessary in certain fields.
- 27. Nasal Function Study - Technique This technique requires a blindfold or other optical occlusion device and four samples: hot coffee, a 1:3 soap:water mix, lemon oil (or fresh lemon) and tea. Explain the procedure to the client – they will be asked to identify the unknown substances by smell. Cover the client’s eyes and have them cover one nostril with a finger. Hold the first substance under the open nostril and ask the claimant to inhale. Have the veteran smell each item one minute apart. Repeat for the right nostril and note the number of incorrect detections. Record the results in the appropriate section of the patient flow sheet. Normal: all items identified correctly Partial loss of smell: some items identified correctly Complete loss of smell: no items identified correctly
- 28. Oral Function Study - Technique This technique requires a blindfold or other optical occlusion device, a disposable spoon, and four samples: salt, vinegar, lemon juice, and sugar. Explain the procedure to the client – they will be asked to identify the unknown substances by taste. Serve the client the first sample and have them attempt to identify it. Serve the remaining items each five minutes apart. Note the number of incorrect detections and dispose of the spoon appropriately. Record the results in the appropriate section of the patient flow sheet. Normal: all items identified correctly Partial loss of taste: some items identified correctly Complete loss of taste: no items identified correctly
- 29. Visual Acuity Measurement Visual acuity tests are performed in varying circumstances; some businesses may require employees to have a certain vision level, for instance. Three types of visual acuity tests may be performed depending on the client’s age and literacy. If the client is unable to perform any of the three available tests, a fourth qualitative test may be performed.
- 30. Visual Acuity Measurement – Snellen Chart This test requires a Snellen chart, a well-lit area with at least 20 feet of space, a plain occluder, a pinhole occluder, and alcohol wipes for cleaning the occluders after use. Secure the chart to a wall at eye level and mark a spot 20 feet from the wall where the chart is placed. Instruct the client to align the heels of their feet at the 20-foot marker. Ask client if they wear corrective glasses or contact lenses. If the client wears corrective glasses, the visual acuity test s are performed twice – once with the glasses and once without. If the client does not wear glasses, or their glasses are unavailable, the test is performed once. Cover one eye with the plain occluder and instruct the client to identify the letters they are able to distinguish, starting from the largest at the top and working down, left-to-right. Note the level at which the client is unable to correctly identify half of the letters in the row. The client’s vision score is determined by the last row they were able to successfully identify over half of the presented letters in. The score associated with each row is printed alongside it (e.g. 20/30 for row #6). If the client’s score is 20/40 or poorer, the tests are repeated with the pinhole occluder covering the testing eye. Results follow the format “20 / ___”. Summarize the test results in the corresponding section on the patient flow sheet. Example: Right VA= 20/40 without glasses, 20/20 with pinhole and Left VA= 20/40.
- 31. Visual Acuity Measurement – Tumbling E Chart This test requires a Tumbling E chart, a well-lit area with at least 20 feet of space, a plain occluder, a pinhole occluder, and alcohol wipes for cleaning the occluders after use. This chart is used if the client is unable to distinguish between different letters. Secure the chart to a wall at eye level and mark a spot 20 feet from the wall where the chart is placed. Instruct the client to align the heels of their feet at the 20-foot marker. Ask client if they wear corrective glasses or contact lenses. If the client wears corrective glasses, the visual acuity tests are performed twice – once with the glasses and once without. If the client does not wear glasses, or their glasses are unavailable, the test is performed once. Cover one eye with the pinhole occluder and instruct the client to identify the direction the letters are facing, starting from the largest at the top and working down, left-to-right. Note the level at which the client is unable to correctly identify half of the directions in the row. The top E in the chart shown is facing right. The client’s vision score is determined by the last row they were able to successfully identify over half of the presented letters in. The score associated with each row is printed alongside it (e.g. 20/30 for row #6). If the client’s score is 20/40 or poorer, the test is repeated with the pinhole occluder covering the testing eye. Results follow the format “20 / ___”. Summarize the test results in the corresponding section on the patient flow sheet. Example: Right VA= 20/40 without lenses, 20/20 with pinhole and Left VA= 20/40.
- 32. Visual Acuity Measurement – Lea Chart This test requires a Lea chart, a well-lit area with at least 20 feet of space, a plain occluder, a pinhole occluder, and alcohol wipes for cleaning the occluders after use. This chart is used if the client is unable to recognize letters. Secure the chart to a wall at eye level and mark a spot 20 feet from the wall where the chart is placed. Instruct the client to align the heels of their feet at the 20-foot marker. Ask client if they wear corrective glasses or contact lenses. If the client wears corrective glasses, the visual acuity tests are performed twice – once with the glasses and once without. If the client does not wear glasses, or their glasses are unavailable, the test is performed once. Cover one eye with the pinhole occluder and instruct the client to identify the shapes they can distinguish, starting from the largest at the top and working down, left-to-right. Note the level at which the client is unable to correctly identify half of the shapes in the row. The shapes used in this chart are “circle, apple, square, house”. The client’s vision score is determined by the last row they were able to successfully identify over half of the presented shapes in. The score associated with each row is printed alongside it (e.g. 20/30 for row #6). If the client’s score is 20/40 or poorer, the test is repeated with the pinhole occluder covering the testing eye. Results follow the format “20 / ___”. Summarize the test results in the corresponding section on the patient flow sheet. Example: Right VA= 20/40 without specs, 20/20 with pinhole and Left VA= 20/40.
- 33. Visual Acuity Measurement – Counting and Motion Tests If the client’s vision is too poor to perform any of the three chart tests, simple tests of light and motion perception can be performed. Visual field may also be tested by having the client focus on a single point, and determining how far away from the point of focus details (such as number of fingers raised) can accurately be recognized. The test shown has the client identify which finger is moving. Counting Fingers CF Ability to count fingers at given distance. Hand Motion HM Ability to distinguish a hand if it is moving or not in fromt of the patient’s face.
- 34. Visual Acuity Measurement - Results The vision acuity results are recorded in a comparative format. The top number represents the distance the test was performed at (20 for this clinic’s tests, 6 in parts of the world that use metric measurements) The lower number represents the distance a person with average vision could distinguish the letter/shape at. A score of 20/15 means that the client could distinguish letters at 20 feet that most people would need to stand closer - at 15 feet - in order to distinguish. Conversely, a score of 20/25 means that the client could only distinguish letters at 20 feet that most people could recognize from a greater distance - 25 feet. In the United States, legal blindness is defined as a vision of 20/200 or poorer. Driving licenses require that the holder have a vision of 20/40 or higher. If the vision improves with a pinhole occluder, it indicates the visual impairment is due to irregularities in the cornea, a problem in the lens, or refractive error, which is correctable with spectacles or a new prescription.
- 35. Electrocardiogram An electrocardiogram (ECG or EKG) may be performed if a heart condition is being claimed, or if a heart condition is otherwise suspected (e.g. complaints of chest pain). Before the electrodes are connected, the client name and information must be entered into the terminal.
- 36. 12-lead ECG – Electrode Placement Technique Electrode Placement V1 4th Intercostal space to the right of the sternum V2 4th Intercostal space to the left of the sternum V3 Midway between V2 and V4 V4 5th Intercostal space at the midclavicular line V5 Anterior axillary line at the same level as V4 V6 Midaxillary line at the same level as V4 and V5 RL Right Leg, anywhere above the ankle and below the torso RA Right Arm, anywhere between the shoulder and the elbow LL Left Leg, anywhere above the ankle and below the torso LA Left Arm, anywhere between the shoulder and the elbow Note that “right” and “left” are relative to the client, not the viewer.
- 37. Photography Guidelines Colored photographs may be requested to identify skin conditions, detail disfigurement or disfiguring scar(s) of the head, face or neck, or other situation where the physician determines it necessary. Under special circumstances photographs may be pre-ordered by the case coordinator and will be specified on the service bill. Unless otherwise noted, the following regions may be photographed: Face Neck Head
- 38. Photography Guidelines - Technique This technique requires a dedicated digital camera. HIPAA guidelines prohibit the use of personal cameras or cellphones to be used for this purpose. Using a black marker, write the veteran’s full name, provider name, contact number and DOA on a sheet of letter-size yellow paper. Identify the client before taking the photograph. Ask the client to hold the sheet of paper or chart with the appropriate identifying information next to the area needing to be photographed You may hold the identification information yourself so long as you are keeping your hands out of the photograph. Proceed by taking the photographs of the disfigured or injured area(s). Review the photographs for clarity before the claimant is discharged from the clinic.