1. Invasive diagnostic procedures-procedures that directly record the size, shape, or function of an organ and that are often complex or expensive or require utilization of highly trained personnel; these procedures may result in morbidity and occasionally death of the patient and therefore require the written consent of the patient or guardian.
    1. General nursing responsibilities:
      1. Before procedure: institute measures to provide for patient’s safety and emotional comfort.
        1. Have patient sign permit for procedure.
        2. Ascertain and report any patient history of allergy or allergic reactions.
        3. Explain procedure briefly, and accurately advise patient of any possible sensations, such as flushing or a warm feeling, as when a contrast medium is injected.
        4. Keep patient NPO 6 to 12 hours before procedure if anesthesia is to be used.
        5. Allow patient to verbalize concerns, and note attitude toward procedure.
        6. Administer preprocedure sedative, as ordered.
        7. If procedure done at bedside:
          1. Remain with patient, offering frequent reassurance.
          2. Assist with optional positioning of patient.
          3. Observe for indications of complications-shock, pain, or dyspnea.
      2. After procedure: institute measures to avoid complications and promote physical and emotional comfort.
        1. Observe and record vital signs.
        2. Check injection cut-down or biopsy sites for bleeding, infection, tenderness, or thrombosis.
          1. Report untoward reactions to physician.
          2. Apply warm compresses to ease discomfort, as ordered.
          3. If topical anesthetic is used during procedure (gastroscopy, bronchoscopy), do not give food or fluid until gag reflex returns.
          4. Encourage relaxation by allowing patient to discuss experience and verbalize feelings.
    2. Procedures to evaluate the cardiovascular system:
      1. Angiocardiography-intravenous injection of a radiopaque solution or contrast medium for the purpose of studying its circulation through the patient’s heart, lungs, and great vessels; used to check the competency of heart valves, diagnose congenital septal defects, detect occlusions of coronary arteries, confirm suspected diagnoses, and study heart function and structure before cardiac surgery.
      2. Cardiac catheterization-insertion of a radiopaque catheter into a vein to study the heart and great vessels.
        1. Right-heart catheterization-catheter is inserted through a cut-down in the antecubital vein into the superior vena cava, through the right atrium and ventricle, and into the pulmonary artery.
        2. Left-heart catheterization-catheter may be passed retrograde to the left ventricle through the brachial or femoral artery; it can be passed into the left atrium after right-heart catheterization by means of a special needle that punctures the septa; or it may be passed directly into the left ventricle by means of a posterior or anterior chest puncture.
        3. Cardiac catheterizations are used to:
          1. Confirm diagnosis of heart disease and determine the extent of disease.
          2. Determine existence and extent of congenital abnormalities.
          3. Measure pressures in the heart chambers and great vessels.
          4. Obtain estimate of cardiac output.
          5. Obtain blood samples to measure oxygen content and determine presence of cardiac shunts.
        4. Specific nursing interventions:
          1. Preprocedure patient teaching:
            1. Fatigue due to lying still for 3 hours or more is a common complaint.
            2. Some fluttery sensations may be felt-occur as catheter is passed backward into the left ventricle.
            3. Flushed, warm feeling may occur when contrast medium is injected.
          2. Postprocedure observations:
            1. Monitor ECG pattern for arrhythmias.
            2. Check extremities for color and temperature, peripheral pulses (femoral and dorsalis pedis) for quality.
      3. Angiography (arteriography)-injection of a contrast medium into the arteries to study the vascular tree; used to determine obstructions or narrowing of peripheral arteries.
      4. Pericardiocentesis (pericardial aspiration)-puncture of the pericardial sac is performed to remove fluid accumulating with pericardial effusion. The goal is to prevent cardiac tamponade (compression of the heart). Nursing responsibilities: monitor ECG and CVP during the procedure, have resuscitative equipment ready. Head of bed elevated to 45-60 degrees. Maintain peripheral IV with saline or glucose. Following the procedure, monitor BP, CVP, and heart sounds for recurrence of tamponade (pulsus paradoxus).
    3. Procedures to evaluate the respiratory system:
      1. Pulmonary circulation studies-used to determine regional distribution of pulmonary blood flow.
        1. Lung scan-injection of radioactive isotope into the body, followed by lung scintiscan, which produces a graphic record of gamma rays emitted by the isotope in lung tissues; used to determine lung perfusion when space-occupying lesions or pulmonary emboli and infarction are suspected.
        2. Pulmonary angiography-x-ray visualization of the pulmonary vasculature after the injection of a radiopaque contrast medium; used to evaluate pulmonary disorders, pulmonary embolism, lung tumors, aneurysms, and changes in the pulmonary vasculature due to such conditions as emphysema or congenital defects.
      2. Bronchoscopy-introduction of a special lighted instrument (bronchoscope) into the trachea and bronchi; used to inspect tracheobronchial tree for pathological changes, remove tissue for cytological and bacteriological studies, remove foreign bodies or mucous plugs causing airway obstruction, assess functional residual capacity of diseased lung, and apply chemotherapeutic agents.
        1. Prebronchoscopy nursing actions:
          1. Oral hygiene.
          2. Postural drainage is indicated.
        2. Postbronchoscopy nursing actions:
          1. Instruct patient not to swallow oral secretions but to let saliva run from side of mouth.
          2. Save expectorated sputum for laboratory analysis, and observe for frank bleeding.
          3. NPO until gag reflex returns.
          4. Observe for subcutaneous emphysema and dyspnea.
          5. Apply ice collar to reduce throat discomfort.
      3. Thoracentesis-needle puncture through the chest wall and into the pleura; used to remove fluid and occasionally air from the pleural space. Nursing responsibilities before thoracentesis:
        1. Position: high Fowler’s position or sitting up on edge of bed, with feet supported on chair to facilitate accumulation of fluid in the base of the chest.
        2. If patient is unable to sit up-turn onto unaffected side.
        3. Evaluate continually for signs of shock, pain, cyanosis, increased respiratory rate, and pallor.
    4. Procedures to evaluate the renal system:
      1. Renal angiogram-small catheter is inserted into the femoral artery and passed into the aorta or renal artery, radiopaque fluid is instilled, and serial films are taken.
        1. Used to diagnose renal hypertension and pheochromocytoma and differentiate renal cysts from renal tumors.
        2. Postangiogram nursing actions: check pedal pulse for signs of decreased circulation.
      2. Cystoscopy-visualization of bladder, urethra, and prostatic urethra by insertion of a tubular, lighted, telescopic lens (cystoscope) through the urinary meatus.
        1. Used to directly inspect the bladder; collect urine from the renal pelvis; obtain biopsy specimens from bladder and urethra; remove calculi; and treat lesions in the bladder, urethra, and prostate.
        2. Nursing actions following procedure:
          1. Observe for urinary retention.
          2. Warm sitz baths to relieve discomfort.
      3. Renal biopsy-needle aspiration of tissue from the kidney for the purpose of microscopic examination.
    5. Procedures to evaluate the renal system:
      1. Celiac angiography, hepatoportography, and umbilical venography-injection of a contrast medium into the portal vein or related vessel; used to determine patency of vessels supplying target organ or detect lesions in the organs that distort the vasculature.
      2. Esophagoscopy and gastroscopy-visualization of the esophagus, the stomach, and sometimes the duodenum by means of a lighted tube inserted through the mouth.
      3. Proctoscopy-visualization of rectum and colon by means of a lighted tube inserted through the anus.
      4. Peritoneoscopy-direct visualization of the liver and peritoneum by means of a peritoneoscope inserted through an abdominal stab wound.
      5. Liver biopsy-needle aspiration of tissue for the purpose of microscopic examination; used to determine tissue changes, facilitate diagnosis, and provide information regarding a disease course. Nursing action: place patient on right side and position pillow for pressure, to prevent bleeding.
      6. Paracentesis-needle aspiration of fluid from the peritoneal cavity; used to relieve excess fluid accumulation or for diagnostic studies.
        1. Specific nursing actions before paracentesis:
          1. Have patient void-to prevent possible injury to bladder during procedure.
          2. Position-sitting up on side of bed, with feet supported by chair.
          3. Check vital signs and peripheral circulation frequently throughout procedure.
          4. Observe for signs of hypovolemic shock-may occur due to fluid shift from vascular compartment following removal of protein-rich ascitic fluid.
        2. Specific nursing actions following paracentesis:
          1. Apply pressure to injection site and cover with sterile dressing.
          2. Measure and record amount and color of ascitic fluid; send specimens to lab for diagnostic studies.
      7. Small-bowel biopsy-a specimen is obtained by passing a tube through the oral cavity and is microscopically examined for changes in cellular morphology. Nursing responsibilities:food or fluids 8 hours before procedure. Obtain written consent. Remove dentures if present. Monitor vital signs before, during, and after procedure for indications of hemorrhage. Procedure takes approximately 1 hour.
    6. Procedures to evaluate the reproductive system in women:
      1. Culdoscopy-surgical procedure in which a culdoscope is inserted into the posterior vaginal cul-de-sac; used to visualize: uterus, fallopian tubes, broad ligaments, and peritoneal contents.
      2. Hysterosalpingography-x-ray examination of uterus and fallopian tubes following insertion of a radiopaque substance into the uterine cavity; used to determine patency of fallopian tubes and detect pathology in uterine cavity.
      3. Breast biopsy-needle aspiration or incisional removal of breast tissue for microscopic examination; used to differentiate among benign tumors, cysts, and malignant tumors in the breast.
      4. Cervical biopsy and cauterization-removal of cervical tissue for microscopic examination and cautery; used to control bleeding or obtain additional tissue samples.
      5. Uterotubal insufflation (Rubin’s test)-injection of carbon dioxide into the cervical canal; used to determine fallopian tube patency.
    7. Procedures to evaluate the neuroendocrine system:
      1. Radioactive iodine uptake test (iodine 131 uptake)-ingestion of a tracer dose of ¹³¹I, followed in 24 hours by a scan of the thyroid for amount of radioactivity emitted.
        1. High uptake indicates hyperthyroidism.
        2. Low uptake indicates hypothyroidism.
      2. Eight-hour intravenous ACTH test-administration of 25 units of ACTH in 500 mL of saline over an 8 hours period.
        1. Used to determine function of adrenal cortex.
        2. 4 hr urine specimens are collected, before and after administration, for measurement of 17-ketosteroids and 17hydroxycorticosteroids.
        3. In Addison’s disease, urinary output of steroids does not increase following administration of ACTH; normally steroid excretion increases threefold to fivefold following ACTH stimulation.
        4. In Cushing’s syndrome, hyperactivity of the adrenal cortex increases the urine output of steroids in the second urine specimen tenfold.
      3. Cerebral angiography-fluoroscopic visualization of the brain vasculature after injection of a contrast medium into the carotid or vertebral arteries; used to localize lesions (tumors, abscesses, intracranial hemorrhages, and occlusions) that are large enough to distort cerebrovascular blood flow.
      4. Myelogram-through a lumbar-puncture needle, a contrast medium is injected into the subarachnoid space of the spinal column to visualize the spinal cord; used to detect herniated or ruptured intervertebral disks, tumors, or cysts that compress or distort spinal cord. Nursing responsibilities: elevate head of bed with water-soluble contrast; flat with oil contrast; check for bladder distention with metrizamide (water soluble); vital signs every 4 hours for 24 hours.
      5. Brain scan-intravenous injection of a radioactive substance, followed by a scan for emission of radioactivity.
        1. Increased radioactivity at site of abnormality.
        2. Used to detect brain tumors, abscesses, hematomas, and arteriovenous malformations.
      6. Lumbar puncture-puncture of the lumbar subarachnoid space of the spinal cord with a needle to withdraw samples of cerebrospinal fluid (CSF); used to evaluate CSF for infections and determine presence of hemorrhage. Not done if increased intracranial pressure (ICP) suspected.
    8. Procedures to evaluate the skeletal system.Arthroscopy-examination of a joint through a fiberoptic endoscope called an arthroscope. Usually done in the OR (same-day surgery) under aseptic conditions using a local anesthetic, although a general anesthetic may be used. A tourniquet is used to reduce blood flow to the area while the scope is introduced through a cannula. Saline is used as the viewing medium. Biopsy or removal of loose bodies from the joint may be done. A compression dressing (Ace bandage) is applied. Restrictions vary according to surgeon preference and nature of procedure. Weight bearing may be immediate or restricted for 24 hours. Teach patient to observe for signs of infection.