Ebook Mosby''s manual of diagnostic and laboratory tests (5th edition): Part 1

i


Pagana: Mosby’s Manual of
Diagnostic and Laboratory Tests, ed 5,
Case Studies
Realistic Scenarios with related
questions to help you develop
skills in critical thinking

Pagana manual


Kathleen Deska Pagana, PhD, RN

Timothy J. Pagana, MD, FACS

Professor Emeritus
Department of Nursing
Lycoming College
President, Pagana Keynotes & Presentations

Williamsport, Pennsylvania

Medical Director, Emeritus
The Kathryn Candor Lundy Breast Health
Center and The SurgiCenter
Susquehanna Health System
Williamsport, Pennsylvania

3251 Riverport Lane
St. Louis, Missouri 63043

MOSBY’S MANUAL OF DIAGNOSTIC AND LABORATORY TESTS, FIFTH EDITION
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Copyright © 2010, 2006, 2002, 1998 by Mosby, Inc., an affiliate of Elsevier Inc.

ISBN: 978-0-323-08949-4

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they should
be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility
of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages
and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any

injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material herein.
International Standard Book Number 978-0-323-08949-4

Senior Content Strategist: Tamara Myers
Content Manager: Jean Sims Fornango
Publishing Services Manager: Deborah L. Vogel
Senior Project Manager: Jodi M. Willard
Design Direction: Margaret Reid

Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1


We lovingly dedicate this book to our delightful grandchildren:
Ella Marie Gaul
Jocelyn Elizabeth Gaul
Timothy William Gaul
Justin Aquinas Gaul
Juliana Kathleen Pericci
Luke Michael Pericci


Reviewers
Michael Andary, MD, MS
Professor
College of Osteopathic Medicine
Michigan State University
East Lansing, Michigan

Stephen Krau, PhD, RN, CNE
Associate Professor
School of Nursing
Vanderbilt University
Nashville, Tennessee

Valerie Bush, PhD, FACB
Clinical Laboratory Director
Bassett Medical Center
Cooperstown, New York

Geralyn López-de-Victoria, PhD, MS
Science Department Chair
Midlands Technical College
West Columbia, South Carolina

Karmen A. Grant, MS, RN, CNDR
Nursing Instructor
Rogers State University
Claremore, Oklahoma

Carla R. Lynch, MS, RN
Nursing Instructor
Rogers State University
Claremore, Oklahoma

Joseph Hawkins, MS Ed., CNMT
Associate Professor and Program Director
Nuclear Medicine Technology
Florida Hospital College of Health Sciences

Orlando, Florida

Naser Nejadi, BS, MSc
Tehran University of Medical Sciences
Tehran, Iran

Michael Horner, DO
Department of Michigan State University
Lansing, Michigan
Mary Anne Jessee, MSN, RN
Assistant Professor
School of Nursing
Vanderbilt University
Nashville, Tennessee

vi

Sandra Rome, RN, MN, AOCN
Clinical Nurse Specialist
Cedars-Sinai Medical Center
Los Angeles, California
Bonnie L. Welniak, MSN, RN
Assistant Professor of Nursing
Monroe County Community College
Monroe, Michigan


Preface
This book provides the user with an up-to-date, extensive manual that allows rapid access to clinically
relevant laboratory and diagnostic tests. A unique feature of this manual is its consistent format, which

provides a comprehensive approach to laboratory and diagnostic tests. Tests are categorized according
to either the method of testing (e.g., x-ray, ultrasound, nuclear scan) or the type of specimen (e.g., blood,
urine, stool) used for testing. Every chapter of this book is based on this categorization. Each chapter
begins with an alphabetical listing of all tests in the chapter to aid the user in locating discussions
quickly. An overview follows the list and contains general information concerning test methods and
related patient care.
Chapter 1 includes a discussion of guidelines for proper test preparation and performance. New
coding requirements for ordering tests have been added along with a description of common laboratory
methods. Standard Precautions and other clinically important information for the health care provider
are included to ensure accurate diagnostic and laboratory testing. This information is essential for
health care economics so that tests are performed in a timely fashion and do not need to be repeated
because of problems in patient preparation, test procedure, or specimen handling. Communication
and collaboration with other health care providers are emphasized. The privacy rules resulting from
the Health Insurance Portability and Accountability Act (HIPAA) are explained in relationship to
diagnostic and laboratory test results.
Throughout the book, information is explained in a comprehensive manner to enhance full
understanding of each particular test. Every feature of test discussion is geared to provide complete
information in a sequence that best simulates priorities in clinical practice. The following information
is provided, whenever possible, for a thorough understanding of each diagnostic test:
• Name of test. Tests are listed by their complete name. A complete list of abbreviations and alternative
test names follows each main entry.
• Normal findings. Normal values are listed, when applicable, for the infant, child, adult, and elderly
person. Also, where appropriate, values are separated into categories of male and female. We realize
that normal ranges for laboratory tests vary significantly depending on the method of testing and
the particular laboratory. For this reason, we strongly encourage the user to check the normal values
at the institution where the test is performed. This should be relatively easy because most laboratory
reports indicate normal values.
• Critical values. These values give an indication of results that are well outside the usual range for
normal. These results generally require immediate intervention.
• Indications. This section describes the main uses for each test. Emphasis is placed on the type of patient signs and symptoms that lead to the indications for each test.

• Test explanation. This section provides a comprehensive description of each test. The explanation
includes fundamental information about basic pathophysiology related to the test methods, what
diseases the test results may indicate, and the location where the test is generally performed. Also, in
this section, patient sensation, test duration, and the type of health care professional involved in the
testing are described.
vii


viii

Preface

• C
 ontraindications. This information alerts the user to patients who should not have the test performed. As in other segments of the book, each contraindication is fully explained with an in-depth
rationale. Patients frequently highlighted in this section include those who are pregnant, who are
allergic to iodinated or contrast dye, or who have bleeding disorders.
• Potential complications. This section alerts the user to potential problems that will necessitate astute
posttesting assessments and interventions. Not only is each complication fully explained in detail,
but also patient symptoms and appropriate interventions are described. For example, a potential
complication of an intravenous pyelogram is renal failure, especially in the elderly patient. An appropriate intervention may be to hydrate the patient before the test and force fluids afterward.
• Interfering factors. This section includes a thorough discussion of factors that can invalidate or alter
the test results. An important feature of this section is the inclusion of drugs that can interfere with
test results. Drugs that increase or decrease test values are indicated by a drug icon ( ) for quick
a­ ccess.
• Procedure and patient care. This section emphasizes the role of nurses and other health care providers in diagnostic and laboratory testing by addressing psychosocial and physiologic interventions.
Patient teaching priorities are noted with a special icon ( ) to highlight information to be communicated to patients. For quick location of essential information concerning the testing procedure,
this section is divided into before, during, and after time sequences.
• Before. This section addresses the need to explain the procedure and to allay patient concerns or
anxieties. Dietary restrictions, bowel preparations, baseline pretest assessment, and the need for
informed consent are discussed.

• During. This section provides a complete and thorough description of the testing procedure,
alternative procedures, and methods of testing. In most instances, a step-by-step description of
testing procedures is provided. This information is important because all health care providers
involved in the particular test should have a good understanding of what the procedure entails so
they can assist more completely in the testing process.
• After. This section includes vital information that the nurse or other health care provider should
know concerning postprocedure care of the patient. This includes information on specific posttest
assessment, medication administration, recognition of posttest complications (with suggestions
for interventions), home care, and follow-up.
• Test results and clinical significance. As the name implies, this section describes the significance of
the test findings. A unique feature of this manual, compared with other books on diagnostic and
laboratory tests, is an extensive discussion of the pathophysiology of the disease process and how
it relates to the test result. This provides enhanced understanding of the diagnostic test and better
understanding of many disease processes.
• Related tests. This section, another unique feature of the text, includes a list of tests that are related to
the main test under discussion. This includes tests that provide similar information, tests that provide confirmatory information, and other tests used to evaluate the same organ, disease process, or
symptom complex. A short description and page numbers for all related tests are included for ease in
cross-referencing. This aids the reader to develop a broader understanding of diagnostic testing and
indicates where the reader may go to obtain more information on the topic of interest.
This logical format emphasizes clinically relevant information. The clarity of the format facilitates a full
understanding of content essential to both students and health care providers, and its uniformity allows
the user to quickly recognize where information of interest may be found.
Multiple colors have been used to help locate tests, highlight critical information, and generally
improve the readability of the text. Another key feature is the use of color photographs and illustrations
throughout the book. Many tables are also included to simplify or summarize complex material
regarding clinical care, test categories, or disease processes.


Preface

ix

Feature boxes are used throughout the book to highlight and summarize important clinical data.
They allow the reader to assimilate important information at a glance. There are three types of feature
boxes: Clinical Priorities, Age-Related Concerns, and Home Care Responsibilities. Clinical Priorities
boxes emphasize pertinent information specific to understanding and performing a particular test.
For example, coagulation studies must be assessed before invasive studies (e.g., liver biopsy) that may
cause bleeding. Chest x-ray examinations should be performed after procedures (e.g., pleural biopsy)
that may cause a pneumothorax. Age-Related Concerns boxes primarily address pediatric and geriatric
priorities. For example, the risk for dye-induced renal failure is emphasized in the dehydrated elderly
patient scheduled for an intravenous pyelogram. The bowel preparation for children of different ages is
described in the barium enema study. Home Care Responsibilities boxes focus on factors that need to be
addressed after a test is performed. With an increasing number of procedures being performed on an
outpatient basis, the patient has the responsibility for detecting problems and knowing what to do when
they occur. Often, the patient returns home with instructions or guidelines for recognizing problems
such as infection, bleeding, or urinary retention.
New to this edition is a comprehensive listing of diagnostic and laboratory tests used when evaluating
a patient with a common disease or condition. These are based on the International Classification of
Disease (ICD) codes (see p. xi). This alphabetical list should be invaluable to readers who want to know
the testing possibilities for common problems such as adrenal abnormalities, AIDS, Alzheimer’s disease,
bowel obstruction, breast cancer, and others. For emphasis, this material is placed before Chapter 1.
Also new is a description of commonly performed laboratory methods, which is placed in Chapter 1.
This section explains methods used to evaluate blood, urine, spinal fluid, and other specimens. Methods
such as latex agglutination, agglutination inhibition, hemagglutination, electrophoresis, immunoassay,
polymerase chain reaction, and FISH techniques are examples.
Appendix A, Alphabetical List of Tests, helps the user locate specific tests at a glance. Appendix B, List
of Tests by Body System, familiarizes the user with other related studies the patient or client may need
or the user may want to review. This information should be especially useful for students and health
care providers working in specialized areas. For example, all tests related to infertility are listed in the
Reproductive System section. Appendix C provides a list of Panel Tests such as cardiac enzymes, lipid

profile, liver profile, and thyroid studies. Appendix D contains a list of Abbreviations for Diagnostic and
Laboratory Tests. Finally, a comprehensive Index includes the names of all tests and their synonyms
and other relevant terms found within the tests. Typical Abbreviations and Units of Measurement are
located on the inside cover.
Many new studies such as anti-glycan antibodies, laboratory genetics, neuron-specific enolase,
galectin-3, and ProstaScint scan have been added. All other studies have been revised and updated.
Outdated tests have been eliminated. Illustrations and photographs have been extensively updated, and
many new ones have been added.
We sincerely thank Mosby/Elsevier for invaluable assistance and dedication to our books over
30 years. We also thank our editors—Jean Sims Fornango, Brandi Flagg, and Jodi Willard—for their
enthusiasm and support. We invite comments from users of this book so that we may improve our goal
of providing useful and relevant diagnostic and laboratory test information to users of future editions.
Kathleen D. Pagana
Timothy J. Pagana


Contents
Testing for Common Diseases and Conditions, xi
1 Guidelines for Proper Test Preparation and Performance, 1
2 Blood Studies, 11
3 Electrodiagnostic Tests, 536
4 Endoscopic Studies, 578
5 Fluid Analysis Studies, 630
6 Manometric Studies, 687
7 Microscopic Studies and Associated Testing, 703
8 Nuclear Scanning, 779
9 Stool Tests, 847
10 Ultrasound Studies, 861
11 Urine Studies, 903
12 X-Ray Studies, 981

13 Miscellaneous Studies, 1079
Bibliography, 1132
Illustration Credits, 1135
Appendixes
A Alphabetical List of Tests, 1136
B List of Tests by Body System, 1145
C Panel Testing, 1152
D Abbreviations for Diagnostic and Laboratory Tests, 1154

x


Testing for Common
Diseases and Conditions
This listing is designed to help the health care provider focus on possible tests ordered with certain common
diseases or conditions. The numbers and letters reflect ICD-10 codes, which are described on pp. 1 and 2.
Adrenal Functional Abnormalities:
E 24-27, E 35, C 74
• 17-Hydroxycorticosteroids
• 17-Ketosteroids
• 21 Hydroxylase antibodies
• Adrenal steroid precursors
• Adrenocorticotropic hormone (ACTH)
• Adrenocorticotropic hormone stimulation test
• Adrenocorticotropic hormone stimulation
with metyrapone
• Aldosterone
• Cortisol, blood
• Cortisol, urine
• Dexamethasone suppression

• Glucose
AIDS/Immunologic Deficiency:
B 20-24
• Bone marrow aspiration
• Cell surface immunophenotyping
• Complement assay
• Complete blood count (CBC)
• Immunoglobulin quantification
• Cytokines
• Fungal testing
• Hepatitis virus studies
• HIV drug resistance testing
• HIV serology
• HIV RNA quantification
• Human lymphocyte phenotyping
• Immunoglobulin quantification
• Protein quantification
• Tuberculosis testing
• Viral Testing: cytomegalovirus,
toxoplasmosis, herpes simplex, Epstein-Barr

Allergy: T 78
• Allergy blood testing
• Allergy skin testing
• Cutaneous immunofluorescence antibodies
• HLA-B27
• Immunoglobulin quantification
Alzheimer’s Disease/Dementia:
G 30, F 00-03
• Amyloid beta protein

• Cerebrospinal fluid analysis
• CT scan of the brain
• Electroencephalography
• Electrolytes
• MRI of the brain
• Nuclear brain scan
• PET scan
• Tau protein
• Thyroid function studies
Anemia: D 50, D 51, D 55, D 60-61, D 65
• Anti-parietal cell antibody
• Blood smear
• Bone marrow biopsy
• Complete blood count (CBC)
• 2,3-Diphosphoglycerate
• Erythropoietin
• Ferritin
• Folic acid
• Heinz body
• Hematocrit (Hct)
• Hemoglobin (Hgb)
• Hemoglobin electrophoresis
• Intrinsic factor
• Iron testing
xi


xii
•
•

•
•
•
•
•
•
•

Testing for Common Diseases and Conditions
 ed blood cell (RBC) count
R
Red blood cell indices
Reticulocyte count
Sickle cell screen
Thyroid stimulating hormone (TSH)
Total blood volume
Transferrin receptor assay
Vitamin B12
Zinc protoporphyrin

Arthritis: M 15-19
• Anticyclic citrullinated peptide antibody
• Antinuclear antibody
• Arthrocentesis with synovial fluid analysis
• Arthroscopy
• Bone scan
• Bone x-rays
• Ceruloplasmin
• C-reactive protein
• Complement assay

• Cytokines
• Erythrocyte sedimentation rate
• HLA-B27
• Immunoglobulin electrophoresis
• MRI
• Protein electrophoresis
• Rheumatoid factor
• Uric acid
Back Pain: M 40-54
• MRI of the spine
• Myelography
• Spinal x-rays
Bowel Obstruction: K 56
• Barium enema
• Colonoscopy
• Electrolytes
• KUB x-ray
• Obstruction series
• Sigmoidoscopy
• Small bowel follow-through
• Stool for occult blood
Breast Cancer: C 50
• Bone scan
• Breast cancer genomics
• Breast cancer tumor analysis
• Breast cyst and nipple discharge fluid analysis

•
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•

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 reast ductal lavage
B
Breast scintigraphy
Breast ultrasonography
CA 15-3
CEA
Cell culture drug testing
Chest x-ray
CT of the liver
Ductoscopy
Estrogen receptor assay
Genetic testing
Mammography
MRI of the breast
PET scan

Progesterone receptor assay
Sentinel lymph node biopsy
Stereotactic biopsy

Carcinoid: E 34
• 5-Hydroxyindoleacetic acid
• Neuron specific enolase
• Octreotide scan
• Serotonin
Cardiac Arrhythmia: I 47-49
• Cardiac catheterization
• Cardiac stress testing
• Echocardiography
• Electrocardiography (EKG)
• Electrophysiologic studies
• Holter monitoring
• MRI of the heart
• Transesophageal echocardiography
Cervical Cancer: C 53
• Abdominal ultrasound
• Cervical biopsy
• Colposcopy
• CT scan of the abdomen and pelvis
• Human papilloma virus
• MRI of the abdomen and pelvis
• Papanicolaou smear
• PET scan
• Vaginal ultrasound
Cirrhosis: K 70, K 71, K 74
• Alanine aminotransferase

• Albumin
• Aldosterone


Testing for Common Diseases and Conditions
•
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 lkaline phosphatase
A
Alpha1-antitrypsin
Alpha-fetoprotein
Ammonia
Antimitochondrial antibody
Anti-liver/kidney microsomal antibody
Anti-nuclear antibody
Anti-smooth muscle antibody
Antithrombin III
Aspartate aminotransferase
Bilirubin
Ceruloplasmin
Cold agglutinins
Complete blood count (CBC)
Copper
Electrolytes
Endoscopic retrograde
cholangiopancreatography (ERCP)
Ethyl alcohol
Febrile agglutinins
Gamma glutamyl transpeptidase

Hepatitis virus studies
Immunoglobulin quantification
Iron
Lactic dehydrogenase
Leucine aminopeptidase
Liver biopsy
Liver/spleen scan
5′-Nucleotidase
Paracentesis
Prothrombin time
Urine for bilirubin and urobilinogen
Zinc

Coagulation Abnormalities: D 68, P 61
•
•
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•
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•
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•
•

 ctivated clotting time
A
Antithrombin III
Bilirubin

Coagulating factor concentration
Complete blood count (CBC)
d-Dimer
DIC screening
Fibrinogen
Partial thromboplastin time (PTT)
Plasminogen
Plasminogen activator inhibitor-1 (PAI-1)
antigen
• Platelet aggregation
• Platelet antibody

•
•
•
•
•
•

 latelet count
P
Platelet function assay
Protein C, protein S
Prothrombin time (PT)
Thromboelastography
Thrombosis indicators

Colitis: A 00-09, K 50-52
•
•

•
•
•

 nti-glycan antibody
A
Clostridium difficile testing
Lactoferrin
Stool culture
Stool for ova and parasites

Colorectal Cancer: C 17-21
• Barium enema
• Carcinoembryonic antigen (CEA)
• Colon cancer tumor analysis
• Colonoscopy
• CT scan of the abdomen
• Genetic testing
• Septin 9 DNA methylation assay
• Sigmoidoscopy
• Stool for occult blood
• Ultrasound of the rectum
Coma: R 40
• Alcohol
• Ammonia
• Anion gap
• Arterial blood gases (ABG)
• Carboxyhemoglobin
• Electrolytes
• Ethyl alcohol

• Glucose
• Ketones
• Lactic acid
• Osmolality, blood
• Osmolality, urine
• Salicylate
• Substance abuse testing
Congestive Heart Failure: I 50
• Anti-myocardial antibody
• Cardiac catheterization
• Cardiac enzymes
• Cardiac nuclear scanning
• Chest x-ray
• Complete blood count (CBC)

xiii


xiv
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•

Testing for Common Diseases and Conditions

 reatine kinase
C
Drug monitoring
Echocardiography
Electrocardiography (EKG)
Electrolytes
Erythropoietin
Lipoproteins
MRI of the heart
Natriuretic peptides
Pericardiocentesis
PET scan
Thyroid function studies
Total blood volume
Transesophageal echocardiography
Triglycerides
Viral studies

Coronary Occlusive Disease: I 20-25
• Aldolase
• Anti-myocardial antibody
• Apolipoproteins

• Aspartate aminotransferase
• Cardiac nuclear scanning
• Creatinine kinase
• d-Dimer
• Echocardiography
• Electrocardiography
• Homocysteine
• Ischemia-modified albumin
• Lactic dehydrogenase
• Lipoprotein-associated phospholipase
• Lipoproteins
• Magnesium
• Microalbumin
• MRI of the heart
• Myoglobin
• PET scan
• Triglycerides
• Troponins
Diabetes: E10-14
• Anion gap
• C-peptide
• Diabetes mellitus autoantibody panel
• Electrolytes
• Glucagon
• Glucose tolerance
• Glucose, blood
• Glucose, postprandial

•
•

•
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 lucose, urine
G
Glycosylated hemoglobin
Insulin assay
Lactic acid
Lipid profile
Ketones
Lactic acid
Microalbumin
Osmolality, blood
Osmolality, urine
Urinalysis

Diarrhea: A02-09
• Anti-glycan antibodies
• Colonoscopy
• Carcinoid studies
• Clostridium difficile testing
• d-xylose absorption
• Febrile antibodies

• Electrolytes
• Fecal fat
• Gastrin
• Lactose tolerance
• Pancreatic enzymes
• Prealbumin
• Stool for occult blood
• Stool for ova and parasites
Dysfunctional Uterine Bleeding:
N 85, N 92-93
• Activated thromboplastin time (aPTT)
• Complete blood count
• CT scan of the abdomen and pelvis
• Endometrial biopsy
• Estrogen fractions
• Follicular stimulating hormone (FSH)
• HCG/pregnancy test
• Hysteroscopy
• Laparoscopy
• Luteinizing hormone (LH)
• Papanicolaou test/ThinPrep
• Platelet count
• Prothrombin time (PT)
• STD testing
• Ultrasound of the pelvis
Gallbladder/Biliary Disease:
C 22-24, K 80/K 87
• Abdomen ultrasound
• Alanine aminotransferase (ALT)

Testing for Common Diseases and Conditions
•
•
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•
•
•
•
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•
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 lkaline phosphatase (ALP)
A
Amylase
Bilirubin, blood and urine
Cholangiography
Electrolytes
Endoscopic retrograde
cholangiopancreatography (ERCP)
Gallbladder nuclear scanning
Laparoscopy
Leucine aminopeptidase (LAP)
Lipase
Magnetic resonance
cholangiopancreatography

Gastrointestinal Bleeding: K 92

• Blood typing
• BUN
• Coagulation panel (see Appendix C)
• Complete blood count (CBC)
• Esophagogastroduodenoscopy
• Gastrointestinal bleeding scan
• Sigmoidoscopy/colonoscopy
• Stool for occult blood
Hematuria: R 31
• Antiglomerular basement membrane antibody
• Complete blood count (CBC)
• Creatinine/BUN
• Electrolytes
• Kidney biopsy
• Myoglobin
• Pyelography
• Streptococcus
• Urinalysis
• Urine culture and sensitivity
Hemolysis: T 80, P 55
• Alanine aminotransferase (ALT)
• Blood smear
• Complete blood count (CBC)
• Coombs test, direct
• Creatinine/BUN
• Electrolytes
• Erythrocyte fragility
• Haptoglobin
• Myoglobin
• Reticulocyte count

Hypertension: I 13-15
• Aldosterone
• Arteriography, kidney
• Catecholamines
• Cortisol
• Creatinine/BUN
• Creatinine clearance
• Electrolytes
• Metanephrines
• Magnetic resonance angiography, kidney
• Renin
• Thyroxine, triiodothyronine, TSH
• Tilt table testing
• Total blood volume
• Urinalysis
• Vanillylmandelic acid (VMA)
Infertility: N 97, N 46
• Anti-spermatozoal antibody
• Estrogen fractionation
• Follicle-stimulating hormone (FSH)
• Human chorionic gonadotropin
(pregnancy tests)
• Hysterosalpingogram
• Luteinizing hormone
• Papanicolaou smear/thin prep
• Progesterone
• Semen analysis
• Sims-Huhner test
• Testosterone

• Thyroid function studies
• Ultrasound of the pelvis
Leukemia/Lymphoma: C 81-96
• Bence Jones protein
• 11-Beta prostaglandin
• Blood smear
• Bone marrow biopsy
• Cell surface immunophenotyping
• Complete blood count (CBC)
• Cryoglobulins
• Cytokines
• Human T-cell lymphotrophic virus
• Microglobulin
• Proteins
• White blood cell count

xv


xvi

Testing for Common Diseases and Conditions

Liver Diseases/Cirrhosis: K 70-77
• Alanine aminotransferase (ALT)
• Aldolase
• Alkaline phosphatase (ALP)
• Alpha-fetoprotein
• Ammonia
• Anti-liver/kidney microsomal antibody

• Antimitochondrial antibody
• Aspartate aminotransferase (AST)
• Bilirubin
• CT scan of the liver
• Gamma glutamyl transpeptidase (GGTP)
• Hepatitis virus studies
• Lactic dehydrogenase (LDH)
• Leucine aminopeptidase (LAP)
• Liver biopsy
• Liver/spleen scan
• MRI of the liver
• 5′-Nucleotidase
• Paracentesis
• Prealbumin
• Ultrasound of the liver
Lung Cancer: C 34, C 38, C 39
• Alpha1-antitrypsin
• Bone scan
• Bronchoscopy
• Chest x-ray
• CT scan of the chest
• Lung biopsy
• Mediastinoscopy
• Neuron-specific enolase
• PET scan
• Pleural biopsy
• Pulmonary function tests
• Sputum cytology
• Thoracentesis and fluid analysis
• Thoracoscopy

Lupus Erythematosus: L 93, M 32
• Antichromatin antibody
• Anticardiolipin antibody
• Anti-DNA antibody
• Anti-extractable nuclear antigen
• Antinuclear antibody
• Complement assay
• Cryoglobulins
• Cutaneous immunofluorescence antibodies

• E
 rythrocyte sedimentation rate (ESR)
• Immunoglobulin quantification
• Ribosome P antibodies
Maternal/Fetal Evaluation: O 00-99
• Abdominal ultrasound
• Alpha-fetoprotein
• Amino acid profiles
• Amniocentesis
• Apt test
• Blood typing
• Chorionic villus sampling (CVS)
• Chromosome karyotype
• Cytomegalovirus testing
• Fetal biophysical profile
• Fetal contraction stress test (CST)
• Fetal fibronectin
• Fetal hemoglobin testing
• Fetal nonstress test (NST)
• Fetal nuchal translucency

• Fetal oximetry
• Fetal scalp blood pH
• Fetoscopy
• Genetic testing
• Glucose tolerance test (GTT)
• Hepatitis virus studies
• Herpes simplex testing
• Hexosaminidase
• Human chorionic gonadotropin
(pregnancy tests)
• Human placental lactogen
• Immunoglobulin quantification
• Laboratory genetics
• Maternal screen testing
• Newborn metabolic screening
• Papanicolaou test/ThinPrep
• Pelvic ultrasonography
• Pregnancy-associated plasma protein
• Pregnanediol
• Progesterone assay
• Rubella/rubeola titer
• Sexually transmitted disease culture
• Thyroid testing
• Thyroxine
• TORCH
• Toxoplasmosis antibody
• Urinalysis


Testing for Common Diseases and Conditions

Menopause: N 95
• Bone mineral density scan
• Estrogen fractionation
• Follicular stimulating hormone (FSH)
• Luteinizing hormone (LH)
• Mammogram
• Papanicolaou test/ThinPrep
Osteoporosis: M 80
• Alkaline phosphatase (ALP)
• Bone densitometry
• Bone turnover markers
• Spinal x-rays
• Vertebral fracture analysis
• Vitamin D
Ovarian Cancer: C 57
• CA-125
• Chest x-ray
• Complete blood count (CBC)
• CT scan of the abdomen and pelvis
• Laparoscopy
• Metabolic assay (see Appendix C)
• Paracentesis
• Pelvic ultrasound
• Pyelography
• Sigmoidoscopy
Pancreatitis: K 85-86
• Amylase, blood
• Amylase, urine
• Bilirubin
• CA 19-9

• Cholesterol
• CT scan of the abdomen
• Endoscopic retrograde
cholangiopancreatography (ERCP)
• Gallbladder ultrasound
• Lipase
• Lipoproteins
• Magnetic resonance
cholangiopancreatography (MRCP)
• MRI of the pancreas and biliary tract
• Pancreatobiliary FISH testing
• Triglycerides
• Ultrasound of the pancreas

xvii

Parathyroid Functional Abnormalities:
E 20-E 21, C 75
• Alkaline phosphatase (ALP)
• Bone densitometry
• Bone turnover markers
• BUN
• Creatinine
• Creatinine clearance
• Calcium, blood
• Calcium, urine
• Magnesium
• Parathyroid hormone (PTH)
• Parathyroid scan
• Phosphate

Peptic Ulcer: K 25-30
• Barium swallow
• Complete blood count (CBC)
• Esophageal function studies
• Esophagogastroduodenoscopy (EGD)
• Gastrin
• Gastroesophageal reflux scan
• Helicobacter pylori testing
• Upper gastrointestinal tract x-ray
• Urea breath test
Pheochromocytoma: C 74
• Abdominal ultrasound
• Catecholamines
• CT scan of the adrenal glands
• Homovanillic acid (HVA)
• Metanephrine, plasma free
• MRI
• Pheochromocytoma suppression and
provocative testing
• Vanillylmandelic acid (VMA)
Pituitary Functional Abnormalities:
E 22-23, C 75
• Adrenocorticotropic hormone (ACTH)
• Adrenocorticotropic hormone stimulation
with metyrapone
• Antidiuretic hormone (ADH)
• Cortisol, blood
• CT scan of the brain
• Dexamethasone suppression test
• Electrolytes

• Growth hormone


xviii
•
•
•
•
•
•
•
•
•

Testing for Common Diseases and Conditions

 rowth hormone stimulation test
G
Insulin-like growth factor
MRI of the brain
Prolactin level
Thyroid releasing hormone
Thyroid stimulating hormone (TSH)
Thyroid stimulating hormone stimulation test
Thyroxine (T4)
Triiodothyronine (T3)

Pneumonia: J 09-18
• Alpha1-antitrypsin
• Arterial blood gases (ABG)

• Blood culture and sensitivity
• Chest x-ray
• Cold agglutinins
• Complete blood count (CBC)
• CT scan of the lung
• Fungal testing
• Legionnaires disease antibody
• Mycoplasma pneumoniae antibodies
• Pulmonary function studies
• SARS virus testing
• Sputum culture and sensitivity
• Virus testing
Prostate Cancer: C 61
• Acid phosphatase
• Bone scan
• CT scan of the pelvis
• Cystoscopy
• MRI of the prostate
• PET scan
• ProstaScint scan
• Prostate and rectal ultrasound
• Prostate specific antigen (PSA)
• Ultrasound of the abdomen
• Ultrasound of the prostate and rectum
• Urine flow studies
Pulmonary Disease Acute/Chronic:
J 00-99
• Alpha1-antitrypsin
• Arterial blood gases (ABG)
• Bronchoscopy

• Chest x-ray
• CO2 content

•
•
•
•
•
•

 T scan of the chest
C
Drug monitoring
Oximetry
Pulmonary function tests
Sputum for culture and sensitivity
Sputum cytology

Renal Disease: N 00-19
• BUN/creatinine
• Creatinine clearance
• CT scan of the abdomen
• Electrolytes
• Microalbumin
• Microglobulin
• Neutrophil gelatinase–associated lipocalin
• Osmolality, blood/urine
• PET scan
• Pyelography
• Renal biopsy

• Renal scan
• Ultrasound of the kidney
• Urinalysis
• Urine culture and sensitivity
Renal Failure: N 17-19
• Aluminum/chromium
• Anion gap
• Arterial blood gases (ABG)
• BUN/creatinine
• CO2 content
• Complete blood count (CBC)
• Creatinine clearance
• Electrolytes, blood/urine
• Homocysteine
• Immunoglobulin quantification
• Magnesium
• Microglobulin
• Myoglobin
• Osmolality, blood/urine
• Phosphate
• Protein quantification
• Pyelography
• Renal biopsy
• Renal scan
• Uric acid
• Urinalysis


Testing for Common Diseases and Conditions
Sexually Transmitted Diseases:

A 50-64
• Chlamydia
• Herpes simplex
• Human papillomavirus (HPV)
• Papanicolaou smear
• Sexually transmitted disease culture
• Syphilis detection
• Ultrasound of the pelvis
Shortness of Breath J 44, J 45
• Arterial blood gases
• Chest x-ray
• CO2 content
• Complete blood count (CBC)
• CT scan of the chest
• d-Dimer
• Electrocardiography (EKG)
• Lung scan
• Oximetry

• P
 rothrombin time (PT)
• Transesophageal echocardiography (TEE)
Thrombocytopenia: D 69
• Bone marrow biopsy
• Capillary fragility test
• Complete blood count (CBC)
• Platelet antibody
• Platelet count
• Platelet mean volume
• Tourniquet test

Streptococcus Infection: A38, A 40
• Antiglomerular basement membrane
• Complement assay
• Streptococcus serology
• Throat and nose culture

Thromboembolism: D 68, I 74
• Anticardiolipin antibody
• Antithrombin activity and antigen assay
• Arterial blood gases (ABG)
• CT pulmonary angiography
• d-Dimer
• Factor V-Leiden
• Lung scan
• Oximetry
• Partial thromboplastin time (PTT)
• Plasminogen
• Plasminogen activator inhibitor-1 (PAI-1)
• Platelet count
• Prothrombin time
• Pulmonary angiography
• Thrombosis indicators
• Thromboelastography
• Venography, lower extremity
• Venous duplex scan

Stroke Syndrome: I 60-69
• Activated partial thromboplastin time
(aPTT)

• Brain scan
• Carotid artery duplex scan
• CT scan of the brain
• d-Dimer
• Echocardiography
• Electrolytes
• Homocysteine
• Lipoprotein-associated phospholipase
• Lumbar puncture and cerebral spinal fluid
analysis
• MRI of the brain
• Platelet count

Thyroid Functional Abnormalities:
E 00-07, C 73
• Antithyroglobulin antibody
• Antithyroid peroxidase antibody
• CT scan of the thyroid
• Thyroglobulin
• Thyroid scan
• Thyroid stimulating hormone (TSH)
• Thyroid stimulating hormone stimulation
• Thyroid stimulating immunoglobulins
• Thyroid ultrasonography
• Thyrotropin releasing hormone
• Thyroxine (T4), total and free
• Thyroxine binding globulin
• Triiodothyronine (T3)

Sleep Apnea: P 28, G 47

• Chest x-ray
• Oximetry
• Sleep studies

xix


xx

Testing for Common Diseases and Conditions

Transfusion Reaction: T 80
• Blood culture
• Blood typing
• Complete blood count (CBC)
• Coombs test, direct
• Coombs test, indirect
• Haptoglobin
• HLA-B27
• Neutrophil antibody screen
• Urinalysis
Tuberculosis: A 15-19
• Acid-fast bacilli (AFB)
• Chest x-ray
• CT scan of the chest
• Tuberculin skin testing
• Tuberculosis culture
• Tuberculosis testing
Urinary Stones: N 20-23
• BUN

• Calcium
• Creatinine
• CT scan the abdomen

•
•
•
•
•
•
•
•
•

 lectrolytes
E
KUB
MRI
Pyelography
Renal ultrasound
Uric acid, urine/serum
Urinalysis
Urinary stone analysis
Urine culture and sensitivity

Vascular Disease: I 65-70, I 77
• Apolipoprotein
• Arteriography
• Fluorescein angiography
• Glucose

• Homocysteine
• Intravascular ultrasound
• Lactic acid
• Lipoprotein associated phospholipase
• Lipoproteins
• Plethysmography, arterial
• Triglycerides
• Vascular ultrasound studies


CHAPTER

Guidelines for Proper
Test Preparation and
Performance

1

OVERVIEW
Coding for Diagnostic and Laboratory Tests, 1
Laboratory Methods, 2
Standard Precautions, 5
Proper Sequencing and Scheduling of Tests, 5
Procedure and Patient Care, 6

Overview
A complete evaluation of patients with signs or symptoms of disease usually requires a thorough history
and physical examination, as well as efficient diagnostic testing. The correct use of diagnostic testing
can confirm or eliminate the presence of disease and improve the cost efficiency of screening tests in a
community of people without signs or symptoms of disease. Finally, appropriate and thoughtfully timed

use of diagnostic testing allows monitoring of disease and treatment.
Furthermore, health care economics demands that laboratory and diagnostic testing be performed accurately and in a timely fashion. Tests should not have to be repeated because of improper
patient preparation, test procedures, or specimen collection technique. The following guidelines will
describe the responsibilities of health care providers to ensure safety and accuracy in diagnostic
testing.
Patient education is the single most important factor in ensuring accuracy and success of test results.
All phases (before, during, and after) of the testing process must be thoroughly explained to the patient.
A complete understanding of these factors is essential to the development of nursing processes and
standards of care for diagnostic testing.
The interpretation of diagnostic testing is no longer left to the physician alone. In today's complex
environment of high-tech testing and economic restrictions, individuals representing many health
care professions must be able to interpret diagnostic tests to develop a timely and effective treatment
plan.

CODING FOR DIAGNOSTIC AND LABORATORY TESTS
The International Classification of Diseases, Clinical Modification (ICD-CM) is used to code and
classify disease (morbidity data). The ICD-Procedure Coding System (PCS) is used to code inpatient
procedures. “ICD-10” is the abbreviated way to refer to 10th revision of these codes. In October
1


2

Overview

2014, use of ICD-10 will be mandated as a HIPAA requirement. These codes provide an alphanumeric designation for diagnoses and inpatient procedures. These codes are developed, monitored, and
copyrighted by the World Health Organization. In the United States, the NCHS (National Center for
Health Statistics) which is part of CMS (Centers for Medicare and Medicaid Services) oversees the
ICD codes. Using these codes, government health authorities can track diseases and causes of death,
and compare mortality. All of the patient's diseases and conditions are converted to an ICD code.

This information is required for use by third-party health care payers and providers and all points
of service. Each diagnostic test must reflect the ICD code that most accurately identifies the patient's
medical condition. Accurate coding is necessary so that data can be accurately collected, testing
accurately interpreted, and medical care properly reimbursed. Complying with this coding requirement is no small task because there are there are about 140,000 codes in the ICD-10 catalogs. See
p. xi for a listing of common codes. For additional information about this coding requirement, see
/>ICD10FAQs.pdf.

LABORATORY METHODS
To understand laboratory diagnostic testing, it is helpful to have a basic understanding of commonly
performed laboratory methods that can be used on blood, urine, spinal fluid, and other bodily specimens. Most laboratory diagnostic tests use serologic and immunologic reactions between an antibody
and an antigen. Precipitation is a visible expression of the aggregation of soluble antigens. Agglutination
is a visible expression of the aggregation of particulate antigens or antibodies. As the specimen is progressively diluted, persistent precipitation or agglutination indicates greater concentrations of the antigen or antibody. Dilution techniques are therefore used to quantify the pathologic antigen or antibody in
the specimen. Commonly used laboratory methods and their variations are described in the following.

Latex Agglutination
Latex agglutination is a common laboratory method in which latex beads (that become visibly obvious
when agglutination occurs) are coated with antibody molecules. When mixed with the patient's specimen
containing a particular antigen, agglutination will be visibly obvious. C-reactive proteins are identified by
this method. In an alternative latex agglutination method (for example, as needed for pregnancy testing
or rubella testing), latex beads are coated with a specific antigen. In the presence of antibodies in the
patient's specimen to that specific antigen on the latex particles, visible agglutination occurs.

Agglutination Inhibition
Agglutination inhibition is another laboratory method based on the agglutination process. In this
process, if one is trying to identify a particular molecule, for example hCG, the patient's specimen
is incubated with anti-hCG. Latex particles coated with hCG are then added to the mixture. If the
patient’s specimen contains hCG, those molecules will attach to the anti-hCG during incubation leaving
no anti-hCG molecules to attach to the hCG coated latex beads. Therefore, agglutination would not
occur because the patient’s endogenous hCG “inhibited” the agglutination.

Hemagglutination
Hemagglutination laboratory methods are used to identify antibodies to antigens on the cell surface of
red blood cells (RBCs). Like latex, RBC agglutination is visible. Blood typing for transfusions uses this
laboratory method. In an alternate method of hemagglutination, different antigens can be bound to
the RBC surface. When added to the patient's specimen, specific antibodies can be identified by RBC
agglutination.


Electrophoresis
Electrophoresis is an analytic laboratory method where an electrical charge is applied to a medium on
which the patient's specimen has been placed. Migration of charged molecules (particularly proteins) in
the specimen can be separated in an electrical field. Proteins can then be identified based on their rate
of migration. Serum protein electrophoresis utilizes this method.
Immunoelectrophoresis.  Immunoelectrophoresis is a laboratory method that allows the previously
electrophoresed proteins to act as antigens to which known specific antibodies are added. This provides
specific protein identification. With dilution techniques as described, these particular proteins can
be quantified. This method is used to identify gammopathies, hemoglobinopathies, and Bence Jones
proteins.
Immunofixation Electrophoresis.  Immunofixation electrophoresis (IFE) is particularly helpful
in the identification of certain diseases. In this method, a specific known antibody is added to a
previously electrophoresed specimen. The antigen/antibody complexes become fixed (that is attached)
to the electrophoretic gel medium. When the non-fixed proteins are washed away, the protein immune
complexes that remain fixed to the gel are stained with a protein-sensitive stain and can be identified
and quantified. IFE is particularly helpful in identifying proteins that exist in very small quantities in
the serum, urine, or CSF.

Immunoassay
Immunoassay is an important laboratory method of diagnosing disease. In the past, radioimmunoassay
(RIA) was performed using a radioactive label that could identify an antibody/antigen complex at very
low concentrations. Unfortunately, there are significant drawbacks of using radioactive isotopes as labels.

Radioactive labels have a short half-life and are hard to keep on the shelf. These labels require considerable care to avoid environmental exposure. And finally, the costs associated with disposal of radioactive
waste are high.
Enzyme-Linked Immunosorbent Assay.  Enzyme linked immunosorbent assay (ELISA) techniques are able to detect immunocomplexes more easily when compared to RIA. This ELISA technique
(also known as enzyme immunoassay [EIA]) is able to detect antigens or antibodies by producing an
enzyme-triggered color change. In this method, an enzyme-labeled antibody or antigen is used in the
immunologic assay to detect either suspected abnormal antibodies or antigens in the patient's specimen. In this method, a plastic bead (or a plastic test plate) is coated with an antigen (e.g., virus). The
antigen is incubated with the patient’s serum. If the patient’s serum contains antibodies to the pathologic viral antigen, an immunocomplex forms on the bead (or plate). When a chromogenic chemical
is then added, a color change is noted and can be spectrophotometrically compared with a control
(or reference) serum identification. Then, quantification of abnormal antibodies in the patient’s serum
instigated by the viral infection can be performed. Similarly EIA can also be used for detection of
pathologic antigens in the patient’s serum. Testing for HIV, hepatitis, or cytomegalovirus commonly
uses these methods.
Autoimmune Enzyme Immunoassay.  Autoimmune enzyme immunoassay screening tests are
commonly used for the detection of antinuclear antibodies. EIA techniques (similar to what have been
described in the preceding) are used as the purified nuclear antigens are bound to a series of microwells
to which the patient's serum is serially diluted and added. After adding up peroxidase conjugated
antihuman IgG, a complex antibody/antigen “sandwich” is identified by color changes.

Guidelines

3

1

Overview


4

Overview

Chemiluminescent Immunoassays.  Chemiluminescent immunoassays are extensively used in
automated immunoassays. In this technique, chemiluminescent labels can be attached to an antibody
or antigen. After appropriate immunoassays are obtained (as described), light emission produced by
the immunologic reaction can be measured and quantified. This technique is commonly used to detect
proteins, viruses, and nucleic acid sequences associated with disease.
Fluorescent Immunoassays.  Fluorescent immunoassays consist of labeling antibody with
fluorescein. This fluorescein-labeled antibody is able to bind either directly with a particular antigen
or indirectly with antiimmunoglobulins. Under a fluorescent microscope, the fluorescein becomes
obvious as yellow-green light. Testing for Neisseria gonorrhea or antinuclear antibodies may use these
laboratory methods.
With the increasing use of automated analyzers, the use of chemiluminescence and nephelometry
has become extremely important to allow analyzers to quantify results in great numbers of specimens
tested in a short period of time. Nephelometry (in auto analyzers) depends on the light-scattering
properties of antigen/antibody complexes as light is passed through the test medium. The quantity of the cloudiness or turbidity in a solution then can be measured photometrically. Automated
C-reactive protein, alpha antitrypsin, haptoglobins, and immunoglobulins are often measured using
nephelometry.

Polymerase Chain Reaction
Since the complete human genome sequence became available in 2003, laboratory molecular genetics
has become an integral part of diagnostic testing. Molecular genetics depends on an in vitro method
of amplifying low levels of specific DNA sequences in a patient specimen to raise quantities of a potentially
present specific DNA sequence to levels that can be quantitated by further analysis. This process is
called Polymerase Chain Reaction (PCR). This is particularly helpful in the identification of diseases
caused by gene mutations (e.g., BRCA mutations), in the identification and quantitation of infectious
agents such as HPV or HIV, and in the identification of acquired genetic changes that may be present
in hematologic malignancies or colon cancer.
In PCR procedures, a known particular target short DNA sequence (ranging from 100 to 1000
­nucleotide pairs) is used. This known DNA sequence “primer” is then placed in a series of reactions with
the patient's specimen. These reactions are designed to markedly increase the number of ­comparable

abnormal DNA sequences that potentially exist in the patient's specimen. The increased number of
abnormal DNA sequences then can be identified and quantified. In many instances, the nucleic acid
of interest is ribonucleic acid (RNA) rather than DNA. In these circumstances, the PCR procedure is
modified by reverse transcription (reverse transcriptase PCR [RT PCR]). With RT PCR, abnormal RNA
can be amplified (increased in number), detected, and quantified.
Real-time PCR uses the same reaction sequence as described. In real-time PCR, fluorescence
resonance energy transfer is used to quantitate the DNA sequences of interest and identify points of
mutation. Real-time PCR provides a product that can be more accurately quantified.
Quantification of PCR derived DNA/RNA products can be performed in many ways. This can be
performed by simple gel electrophoresis, DNA sequencing, or using DNA probes. DNA probes are
presynthesized DNA primers that are used to identify and quantify the amplified DNA produced by
the PCR process. Hybridization techniques such as liquid phase hybridization interact with a defined
DNA probe and the potential targeted DNA in solution. DNA probes have become a very important
part of commercial laboratory molecular genetics. Microarray DNA chip technology (Microarray
analysis) places thousands of major DNA probes on one glass chip. After interaction with the patient’s specimen, the microarray chip can then be scanned with high speed fluorescent detectors that