medicina interna

H602 HagemanFactor

HagemanFactorSeeFactor XIIBlood.

HaloperidolSerum 603

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HaloperidolSerum2. May require assistance if the client is

uncooperative.3. MAYbedrawnduringhemodialysis.

Procedure1. Obtaina3-mLbloodsample.

PostprocedureCare1. Refrigeratethespecimen.

ClientandFamilyTeaching1. Forperiodicmonitoring, it isnotneces-

sarytorestrictfoodorfluids.2. If activated charcoal was given for ele-

vated levels, the client should drink 4-6glasses of water each day for 2 days topreventconstipation.Theactivatedchar-coalwillalsocausestoolstobeblackforafewdays.

3. Referclientswithintentionaloverdoseforcrisisintervention.

4. Referrals to appropriate rehabilitationcentersandtherapeuticcommunitypro-gramsshouldbeofferedtoallclientswhomaybeinterested.

FactorsThatAffectResults1. Therapeutic norms are not well estab-

lished; laboratory values vary amongclientsonequaldoses.

2. Significantloweringofserumhaloperidolleveloccurswiththecoadministrationofcarbamazepineand/orbarbiturates.

3. Increasedlevelscanoccurinclientsusingthedrugfluoxetineand insmokerswitha2D6*10homozygousgenotype.

OtherData1. For consistency, collect the specimen at

least12hoursafterthelastdose(troughlevel).

2. Extrapyramidal effects occur frequentlyduring the first few days and are doserelatedalthoughtheycanoccurevenwithsmalldoses.

3. Diphenhydraminemayinterferewithsomemethodsusedtomeasurehaloperidol.

4. Haloperidol can cause cardiac arrhyth-mias,includingQ-Tintervallengthening,amplificationofhypokalemiaandhypo-magnesemia,and inoverdosemaycausemyocarditis.

5. Fatty liver increases susceptibility toadverseeffects.

6. Endovascularcoolinghasbeensuccessfulintreatingneurolepticmalignantsyndrome.

Norm. Negative.Therapeuticlevel 3-20g/LPaniclevel >25g/L

Panic Level Symptoms and TreatmentSymptoms. Hypotension, sedation withrespiratory depression severe enough tocauseashocklikestate,severeextrapyrami-dal neuromuscular reactions (dystonia,hyperreflexia, and oculogyric crises), andrhabdomyolysiswithhypertoniaaspartofneurolepticmalignantsyndrome(NMS).

TreatmentNote: Treatment choice(s) depend(s) onclients history and condition and episodehistory.1. Ipecacmaybeusedtoinducevomiting,

with due regard for haloperidols anti-emeticpropertiesandaspirationhazards.Inductionofvomitingiscontraindicatedin clients with no gag reflex or withcentral nervous system depression orexcitation. Gastric lavage may also beused,followedbyactivatedcharcoalandsaline cathartics. Intravenous diphen-hydramine (Benadryl) can be used totreatextrapyramidalsymptoms.

2. HemodialysisandperitonealdialysiswillNOTremovehaloperidol.

Usage. Periodicmonitoringfortherapeuticlevelsinclientsreceivinghaloperidol.Screen-ingforhaloperidoltoxicityoroverdose.

Description. Haloperidol is a butyrophe-nonethatactsasanantipsychotic,sedative,and antiemetic. It depresses the centralnervoussystem,directlyactsonthechemo-receptor trigger zone (CTZ), and inhibitscatecholamines.Thisdrug isused in agita-tion,schizophrenia,andthemanicphaseofmanic-depressive psychosis and tomanagevocal utterances in Gilles de la Tourettessyndrome.Itisabsorbedinthegastrointes-tinal tract, concentrated in the liver, andexcreted in theurineand inbile.Hasbeenknowntoinducetorsadesdepointes.

ProfessionalConsiderationsConsentformNOTrequired.

Preparation1. Tube: Red topped, red/gray topped, or

goldtopped.

604 HamsTest(AcidifiedSerumTestAcidHemolysinTest)Blood

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HamsTest(AcidifiedSerumTestAcidHemolysinTest)BloodPostprocedureCare1. Defibrinatethesampleimmediately.

ClientandFamilyTeaching1. Results are normally availablewithin 24

hours.

FactorsThatAffectResults1. Hemolysis of the specimen invalidates

results.2. Transfusion of red blood cells within

thelast3weeksmaycausefalse-negativeresults.

3. False-positive results may occur in dys-erythropoietic anemia, spherocytosis,aplasticanemia,andleukemia.

OtherData1. PNHhasbeenacandidateformyelopro-

liferative disease occurring in 55%-65%of cases of myeloid metaplasia andprimarymyelofibrosis.

2. The paroxysmal nocturnal hemoglobin-uria(PNH)geltestcanreplaceHamstestforscreening.

3. 40%positiveHamstest forPNHassoci-ated with CD59 or CD55 erythrocytedeficiency.

Norm. Negative,

HHct 605

be depleted rapidly by any condition thatdestroysredbloodcells.



goldtopped.

Procedure1. Drawa4-mLbloodsample.

PostprocedureCare1. Reportabnormalvitalsignsonthelabo-

ratoryrequisition.2. Deliver the specimen to the laboratory

immediately,takingcarenottoshakeit.

ClientandFamilyTeaching1. Results may not be available for several

days.2. Call the physician if noting symptoms

of hemolysis, which include back pain,chills, distended neck veins, fever,

flushing, hypotension, tachycardia, andtachypnea.


results.2. Specimen contact with peroxidase or

other oxidants may falsely elevate theresult.

OtherData1. Do not consider this test alone for

diagnosis.2. Haptoglobin levels rise to normal by 4

monthsofage.3. In about 1% of the population (4%

of African-Americans), haptoglobinis permanently absent (congenitalahaptoglobinemia).

4. Negative correlation between umbilicalcord haptoglobin during delivery andbilirubinvalueon5thdaymakinghapto-globinapredictorofneonataljaundice.

HawkeyeImagingSeeDual Modality ImagingDiagnostic.

HbSeeGlycosylated HemoglobinBlood.

HBDHSeeHydroxybutyrate DehydrogenaseBlood.

hCFHrpSeeBTA test for Bladder CancerDiagnostic.

hCGSee Human Chorionic Gonadotropin, Beta SubunitSerum, or Pregnancy Test, Routine, Serum and QualitativeUrine.

HCO3

SeeBicarbonateBlood.

HctSeeHematocritBlood.

H606 Hcy

HcySeeHomocysteinePlasmaorUrine.

HcySUSeeHomocysteinePlasmaorUrine.

HDL,HDL-CSeeHigh-Density Lipoprotein CholesterolBlood.

HE4SeeHuman Epididymis Protein 4Blood.

Head-UpTiltTableTestSeeTilt Table TestDiagnostic.

HearingTestforLoudness,RecruitmentSeeAudiometry TestDiagnostic.

HeartScanDiagnosticDipyridamole Injection. Replaces the tread-mill portion of the test for clients withchronic lung disease, peripheral vasculardisease, impaired mobility, medicationtherapy that prevents demonstration ofmaximal exercise effort (calcium-channelblockers,beta-adrenergicblockers),orpostmyocardialinfarctionriskstratification.

Description. Heart scan encompasses anyof several noninvasive scans that involveradiopharmaceuticalinjection.

The electron beam CT (EBCT) scandetectsandquantifiesthedegreeofcalcifiedatherosclerotic plaques in any coronaryartery.Radiationexposureisminimal(FDAstates

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mostprominent48-72hoursafteraninfarc-tion, and disappear within 1 week. A spotthatdoesnotdisappearindicatescontinuedmyocardialdamage.

The thallium-201 scan is used to showmyocardial perfusion, location, and extentofacuteorchronicmyocardialinfarctionorcoronaryarterydisease;alsoshowseffective-ness of angioplasty, angina therapy, orgrafted coronary arteries. An analog ofpotassium, this radionuclide is absorbedintohealthy tissuewhileavoidingdamagedtissue, forming spotson the scan. Ischemicareas(whicheventuallyabsorbisotope)canbedifferentiatedfrominfractedareas(whichnever absorb isotope) by repeating thescan within 5 minutes.May be performedunderstress.Thalliumscansareoftencom-bined with dipyridamole administration(describedbelow)becausethiscausesgreaterthallium uptake and improved quality ofimagesandaccuracyofdiagnoses.Thecom-bination isused for clientswhoareunableto perform exercise treadmill or bicycletestinginconjunctionwiththeirscan.

The MUGA scan is used to assess thefunctionoftheleftventricleandshowmyo-cardialwallabnormalities.Oncetheisotopeisinjected,theheartappearsasamapwithall fourchambers, and thegreatvesselsarevisualizedsimultaneously.Aseriesofimagesaretakenduringsystole(lowisotopeinleftventricle) anddiastole (high isotope in leftventricle).Thesecanbeshownlikeamovieorsuperimposedtoshowtheleftventricularfunction, and the ejection fraction can becalculated.Maybeperformedunderstress.

The nitroglycerin scan is an additionalfeatureoftheMUGAscan.Anotherseriesofimagesistakentoevaluatetheeffectivenessof sublingual nitroglycerin administration.Maybeperformedunderstress.

The sestamibi exercise testing and scanis used to evaluate cardiac perfusionbefore and after a treadmill exercise test.The injected radiopharmaceutical 99mTc-pertechnetate (sestamibi) is taken up byischemic or infarcted cardiac cells that didnot improveinperfusionwithexerciseandisseenasahotspotinnuclearimaging.

Thesestamibi-dipyridamole stress test and scanisusedinclientswhocannotwalkonatreadmillorpedalabicyclebecauseofphysi-calmobilitylimitations.Dipyridamoleisanantiplatelet drug used in nuclearmedicine

foritscoronaryarteryvasodilatoryaction.Itcauses increased endogenous adenosinelevels,whichcausesaneffecton theperfu-sionoftheheartmusclesimilartothatofanexercisetest.Forthistest,thecardiacperfu-sioniscomparedinscanstakenbeforeandafterthetraceranddipyridamoleinjections.Because the areas that vasodilate can drawblood flow from less perfused areas, thetestcancauseischemiaandinfarction.Thusthis test carries specific risks related tothe radiopharmaceutical administered andrequiresacardiologisttobepresentinmanyinstitutions.

The single-photon emission computed tomography (SPECT) scanisanewernuclearmedicineprocedureinwhichtheradiophar-maceutical technetium-99m hexamethylpropylene amineoxime is injected intrave-nously. This substance decomposes andremains for several hours in the heart andothertissues,where itcanbedetectedwiththeSPECTcamera.Thecamerasendsimagesto a computer that can reproduce visualimages,orslices,oftheheartalongseveralplanes. An advantage of SPECT imagingoveroldernuclearmedicinescans is that itcanproduceclear,moreaccurateimages.

ProfessionalConsiderationsConsentformISrequired.

RisksPersantine (dipyridamole): chest pain(angina),ECGchanges,andischemia,includ-inginfarction,bronchospasm,nausea,vomit-ing, hypotension, headache, dyspnea, facialflushing. Radiopharmaceutical or radiola-beled albumin: allergic reaction (itching,hives,rash, tight feeling inthethroat,short-ness of breath, bronchospasm, anaphylaxis,death).

Treadmill testing: cardiac ischemia,includingmyocardial infarction,dysrhyth-mias,hypotension,hypertension,dizziness.ContraindicationsClientswhoareunabletoliemotionlessforthe scan; women who are breast-feeding;previousallergicreactiontoradiopharma-ceutical or radiolabeled albumin if use isplanned.

Dipyridamole. Previous allergy to dipyri-damole; unstable cardiac status; allergy toaminophylline(whichisusedasanantidote

608 HeartScanDiagnostic

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to adverse effects of dipyridamole); ami-nophylline or pentoxifylline taken withinthe last 48 hours; severe asthma orbronchospasm.

Relative Contraindications, Dipyridam-ole. Congestive heart failure, status posthearttransplantation,bilateralcarotidarterydisease, days 1-3 after acute myocardialinfarction.

TreadmillTesting. Activeunstableangina,recent significant changes in ECG, alcoholintoxication, uncontrolled dysrhythmias,chest pain, acute infection, cardiac inflam-mation (myocarditis, pericarditis), acutecongestive heart failure, coronary insuffi-ciency syndrome, digitalis toxicity, heartblocks(2,3),thrombophlebitis,recentpul-monary embolism, inability to walk on atreadmillorpedalabicycle.

Procedure1. Electron beam CT (EBCT) scan: No IV

access required. Position supine onscannertable.Threeelectrodesareplacedon the inferior-anterior chest. An ECGtracingisobtained.Thentheclientsarmsareplacedoverheadandtheclientholdsbreath while the scanner passes abovebodyfromtheshoulderstothehips.ThenoneimagetakenduringeachheartbeatasconfirmedbyECGtracing.Totaltimefortestis30minutes.

2. PYP: Technetium-99m stannous pyro-phosphate(20mCi)isinjected2-3hoursbeforethetest.Imagesaretakenfromdif-ferentangles,withatotalof30-60minutesbeingusedforimaging.

3. Thallium-201: Resting imaging takesplacewithinthefirstfewhoursofcardiacsymptoms. The radionuclide is injected,and scanning begins within 5 minutes.Forstressscanning,anintravenouslineisstarted, and a blood pressure cuff andECGleadsareattached.After15minuteson a treadmill or bicycle, the client isinjected with radioactive thallium; 15minuteslater,imagingoccursfor1hour,witharepeatscanperformedwithinthenext 24hours.The thallium-201dose is1.5-3mCi.

4. Thallium-dipyridamole: ECG and bloodpressure are monitored continuouslythroughout this scan. After the restingimage is taken and the radionuclide isinjected,dipyridamoleisinjectedintrave-nouslyover4minutes.Someclientsmaybeaskedtoperformmildexercise,whichimproves blood flow through the coro-naryarteries,increasesuptakeofthethal-lium, and reduces the side effects of thedipyridamole. Thallium is then injectedabout 4minutes later, when peak coro-narybloodflowisexpected,andthefinalscan is taken. Aminophylline may beinfusedprophylacticallyorinresponsetoadverse side effects of the dipyridamole.Theclientmaythenreturnforredistribu-tionimaginginabout4hours.

5.MUGA: 15-20mCiof 99mTc-pertechnetateis tagged to serum albumin or red bloodcells; 1 minute after injection, imagingbegins. The client should be in a supinepositionthoughtheclientmaybeaskedtoexercise.Theproceduretakes1hour.

PrecautionsDuringpregnancy,risksofcumulativeradi-ation exposure to the fetus from imagingstudiesmustbeweighedagainstthebenefitsof the procedure. Although formal limitsfor client exposure are relative to thisrisk:benefit comparison, the United StatesNuclear Regulatory Commission requiresthat the cumulative dose equivalent to anembryo/fetus from occupational exposurenot exceed 0.5 rem (5mSv). Radiationdosage to the fetus is proportional to thedistance of the anatomy studied from theabdomenanddecreasesaspregnancypro-gresses. For pregnant clients, consult theradiologist/radiologydepartmenttoobtainestimatedfetalradiationexposurefromanyoftheseprocedures.

Preparation1. Assess for history of hypersensitivity to

radioactivedyes.2. Haveemergencyequipmentreadilyavail-

able. This includes aminophylline tocounteractthesideeffectsofdipyridam-ole if the dipyridamole test is to beperformed.

3. For scans conducted with stress testing,obtainabaseline12-leadECG.

4. SeeClientandFamilyTeaching.5. Justbeforebeginningtheprocedure,take

atime out to verify the correct client,procedure,andsite.

HeartScanDiagnostic 609

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6.Nitroglycerin: A cardiologist assesses abaseline MUGA scan, injects nitroglyc-erin,takesanotherscan,andrepeatsthisprocedure until blood pressure reachesdesiredlevel.

7. Sestamibi exercise testing and scan:Aftera12-leadECGmachineisattachedtochestelectrodes, the nuclearmedicine techni-cian injects the tracer and completes arestingscan,whichlastsapproximately30minutes.TheECGandbloodpressurearethenmeasuredcontinuouslyastheclientcompletestheexerciseportionofthetestonatreadmill.Heartrate,bloodpressure,andECGarerecordedevery1-2minutesduringeach3-minutestage.Ifvitalsignsand ECG have remained stable, thenuclearmedicine technician then injectsadditional tracer 1 minute before theclient comes off the treadmill. The finalscan of another 30 minutes is thencompleted.

8. Sestamibi-dipyridamole stress test and scan: After a 12-lead ECG machine isattached to chest electrodes, the nuclearmedicinetechnicianinjectsthetracerandcompletes a resting scan, which lastsapproximately 30 minutes. The client isinstructed to perform isometric handgripsuntildipyridamoleinjectiontohelpprevent thedrugs side effects.TheECGand blood pressure are then monitoredcontinuouslyasadoseofdipyridamoleisinjectedover4minutes.2-7minuteslater,the nuclear medicine technician injectsthe sestamibi tracer. The side effects ofPersantine may include chest pain, dys-rhythmias, nausea, vomiting, broncho-spasm, headache, flushing, or dizzinessandhypotension.Thesideeffectsmaybetreated with intravenous aminophylline,which acts as an adenosine receptoragonist.30minutesafterthetracerinjec-tion,thefinalscaniscompleted.

9. Single-photon emission computed tomog-raphy (SPECT) scan: The client istransported to the nuclear medicinedepartment, positioned supine on thescanningtable,andlefttorestquietlyforapproximately 10minutes.A radiophar-maceutical is injected intravenously andallowed to circulate. The SPECT scanis then taken while the client liesmotionless.

PostprocedureCare1. Monitor the pulse, blood pressure, and

respirationsevery15minutes2.2. For scans that involved stress testing or

administrationofdipyridamole,theclientismonitoreduntilvitalsignsorECGpat-terns,orboth,returntobaselinevalues.

ClientandFamilyTeaching1. Do not take drugs or drink caffeine-

containing beverages for 6 hours beforetesting(24hoursfortheSPECTscan).

2. Some tests take several hours. Bringreading material or other diversionalactivity.

3. PYP, thallium-201, dipyridamole:Fastfor4hoursbeforethetest.

4.Dipyridamole: Do not take drugs con-taining aminophylline for 48 hoursbeforethetest.

5. Thallium-201, MUGA, nitroglycerin:Report fatigue, pain, or shortness ofbreath immediately, particularly if stress(exercise)isused.

6. Youmaybeaskedtomoveintodifferentpositionsduringthescan.

7. Drinkplentyoffluids for24hoursaftertheprocedure.

8. Forpositiveresultsreducemodifiableriskfactors:smokingcessation,dietarymodi-fication,maintainhealthyBPandcholes-terollevels.

FactorsThatAffectResults1. Digitalisandquinidinealtercontractility.

Notationshouldbemadeonthechart.2. Bundle branch block, left ventricular

hypertrophy,orhypokalemia.3. Thallium-201 scans may produce false-

negative results in clients with single-vesseldisease.

4. MUGAdoesnotgivepositiveresults for24 hours after myocardial infarction(MI),andsoitcannotbeusedtodiagnoseacuteMI.

5. Radionuclidesorradioactivetracerswithlong half-lives from recent scans willinterferewiththequalityoftheimages.

OtherData1. Thelargertheperfusiondefect,thepoorer

theprognosis.2. Abnormalitiesoftheheartscanmayindi-

catetheneedforfurtherstudiesorcardiaccatheterization.

610 HeartShuntScanDiagnostic

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3. Health care professionals working in anuclearmedicineareashouldwearafilmbadgeatwaistlevel(thelevelclosesttotheclient).

4. Technetiumhalf-lifeis6hours.Thalliumhalf-lifeis73hours.

5. Health care professionals working in anuclearmedicineareamustfollowfederalstandards set by theNuclear Regulatory

Commission. These standards includeprecautions for handling the radioactivematerial and monitoring of potentialradiationexposure.

6. The MUGA scan is used to monitorcardiac function in clients receiving car-diotoxicantineoplasticchemotherapy.

7. See also Stress/exercise testDiagnostic;Stresstest,PharmacologicDiagnostic.

HeartShuntScanDiagnosticNorm. Normalpulmonarytransittimeandchamber-fillingsequence.

Usage. Determines improper shunting ofblood in heart disorders, especially inchildren.

Description. The heart shunt scan is anangiography study used to examine thetransit of a bolus of technetium-99m intothejugularvein.Imagesaretakentofollowthe bolus on its journey through the heartchambers tovisualizeanyabnormalshunt-ingofbloodbetweenchambers.

ProfessionalConsiderationsConsentformISrequired.

PostprocedureCare1. Assessthevenipuncturesiteforbleeding,

hematoma.2. Observe the client carefully for up to 60

minutesafterthestudyforapossible(ana-phylactic)reactiontotheradionuclide.

3. Wear rubber gloves when discardingurinethat isvoidedupto24hoursafterthe procedure. Wash the gloved handswithsoapandwaterbeforeremovingthegloves.Washtheunglovedhandsafterthegloveshavebeenremoved.

ClientandFamilyTeaching1. Meticulously wash the hands with soap

andwateraftereachvoidfor24hours.

FactorsThatAffectResults1. None.

OtherData1. Thistestisspecificforleft-to-rightshunt

andright-to-leftshunt.2. Health care professionals working in a

nuclearmedicineareashouldwearafilmbadgeatwaistlevel(thelevelclosesttotheclient).

3. Health care professionals working in anuclearmedicineareamustfollowfederalstandards set by theNuclear RegulatoryCommission. These standards includeprecautions for handling the radioactivematerial and monitoring of potentialradiationexposure.

4. Technetiumhalf-lifeis6hours.

RisksInfection.ContraindicationsDuringpregnancyorbreast-feeding.

Preparation1. Have emergency equipment readily

available.

Procedure1. Withtheclientpositionedina20-degree

Fowlersposition,radionuclideisinjectedintotheexternaljugularvein.

2. Scanningisperformedforapproximately45minutes.

HeartSonogramSeeEchocardiographyDiagnostic.

HeartUltrasoundSeeEchocardiographyDiagnostic.

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HeavyMetalsBlood and 24-Hour UrineNorm.Blood SIUnitsAntimony 0.0520.019g/dL 4.351.6nmol/LArsenic 2-23g/L 0.03-0.31mol/L Chronicpoisoning 100-500g/L 1.33-6.65mol/L Acutepoisoning 600-9300g/L 7.98-124mol/LBismuth 0.1-3.5g/L 0.5-16.7nmol/LCadmium 0.4g/L Smokers 0.6-3.9g/L 5.3-34.7nmol/L Nonsmokers 0.3-1.2g/L 2.7-10.7nmol/L Toxic 100-3000g/L 0.9-26.7mol/LCobalt 0.11-0.45g/L 1.9-7.6nmol/LCopper Infants 20-70g/dL 3.1-11mol/L Child,6years 90-190g/dL 14.1-29.8mol/L Child,12years 80-160g/dL 12.6-25.1mol/L Adultmale 70-140g/dL 11.0-22.0mol/L Adultfemale 80-155g/dL 12.6-24.3mol/L Pregnant 118-302g/dL 18.5-47.4mol/LLead Child

612 HeavyMetalsBloodand24-HourUrine

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dyspnea, ARDS. Chronic = fatigue, head-ache, loss of memory, apathy, emotionalinstability,Swift-Feerdisease(usuallyseenininfants/children=autonomichypertension,tachycardia, dermatologic pruritus, rash,oral ulcers and musculoskeletal changesincludingweaknessandlossoftone),pares-thesia, ataxia, deafness, dysarthria, visualdeterioration,dysphagia,coma,anddeath.

Nickel:Contactdermatitis,irritabilityofgastrointestinal and respiratory systems,diffuse interstitial pneumonitis, and cere-bral edema with severe poisoning. Littledata to support carcinogenic potential.Treatment:sodiumdiethyldithiocarbamate(investigationalchelatingagent).

Selenium: Garlic smell in breath andurine,metallictaste,headaches,nausea,vom-iting,pneumonia,andpulmonaryedema.

Thallium: Early sign is painful periph-eralneuropathy in feet/legsoftenmisdiag-nosed as Guillain-Barr. Alopecia begins5-14daysafterexposure.Ataxia,pulmonaryedema,vomiting,constipation,restlessness,delirium, and coma. Antidote is Prussianblue(Radiogardase).

Vanadium: Rhinitis, wheezing, nasalhemorrhage, conjunctivitis, cough, sorethroat,andchestpain.

Zinc: Cough, chest discomfort, tachy-cardia,hypertension,gastrointestinalirrita-tion, nausea, vomiting, diarrhea, andmetallictasteinmouth.

TreatmentNote: Treatment choice(s) depend(s) onclients history and condition and episodehistory.

Antidotes for heavy-metal poisoningincludeBAL (British anti-Lewisite, dimer-caprol), deferoxamine, dimercaprol, andEDTA. Heavy metals respond to hemo-dialysis or hemoperfusion in varyingdegrees (poor to well). FDA approvedantidote for cesium is Prussian blue(Radiogardase).

Toxic or Poisoning Symptoms and TreatmentSymptomsAntimony:Vomiting.

Arsenic:Gastricpain,vomiting,profusediarrhea,confusion,convulsions,hypoten-sion, heart failure, pulmonary edema,shock,ventriculardysrhythmias,coma,anddeath in acute poisoning; and diarrhea,scaling and bronze pigmentation of skincalled raindrops in the dust, hair loss,anemia,liverdisease,Meeslines(transversewhite striae on fingernails), metallic tasteandperipheralneuropathy(2-8weekspostexposure)inchronicpoisoning.

Bismuth:Weakness,decreasedappetite,fever,halitosis,blackgumline, rheumatic-typepain,andrenaldamage.

Cadmium: Pneumonia, pulmonaryedema, and cardiovascular collapse frominhalation; violent gastrointestinal symp-tomsfromacuteingestion;andosteomala-cia and renal dysfunction from chronicingestion.

Cobalt:Thyroidglandhyperplasia,giantcellpneumonitis,hypersensitivitypneumo-nitis, pulmonary fibrosis, bronchiolitisobliterans,cardiomyopathy,nervedamage,andmyxedema.

Copper: Nausea, vomiting, headache,diarrhea,abdominalpain,Wilsonsdisease,Indian childhood cirrhosis, noncaseatinggranuloma,pulmonaryfibrosis.

Lead:Initialanorexia,severeabdominalpain,vomiting,peripheralneuropathy,irri-tability,andapathy.Alsoanemia,constipa-tion,hepatotoxicity,pancreatitis, saturninegout, hypertension, sperm abnormali-ties. In BLLs between 40-70g/dL symp-toms similar to depression, 80-150g/dLmemory problems, insomnia, personalitychanges,andover150g/dLencephalopa-thy,seizure,coma,papilledema.

Mercury:Acute= chills,GI upset, poorappetite,drymouth,constrictionofbilateralvisual fields, paresthesia, weakness, cough,

Blood SIUnits

Thallium

HeavyMetalsBloodand24-HourUrine 613

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Usage. Screening for heavy-metal toxicityfrom overexposure, ingestion, or occupa-tional exposure. Disorders for individualmetalsfoundundertestlistingsforindivid-ualmetals.Drugsthatmayfurtherincreasesome values include carbamazepine, estro-gens, oral contraceptives, penicillamine,phenobarbital,phenytoin,andsodiumsalts.

Description. Heavy metals include anti-mony, arsenic, bismuth, cadmium, cobalt,copper,lead,mercury,nickel,selenium,thal-lium,vanadium,andzinc.

Antimony exposure occurs in cigarettesmokers,miners, smelters, andore-refineryworkers.

Arsenic is found naturally in food(seafood,rice,mushrooms,poultry)andtheenvironment as well as in pesticides.Increased values found in immigrant farmworkers and electronic, metal, glass, andceramicworkers. Treatment is by chelatingagentsBAL3-4mg/kg IMq 4-12hours orDMSA 10mg/kg orally every 8 hours 5daysthenevery12hoursasneeded.

Bismuth exposure occurs in workers incosmetic, disinfectant, and pigment indus-tries. Itmayalsooccuras a resultof treat-mentforsyphilis.

Cadmiumaccumulatesinthelungs,liver,andkidneysbyexposuretofood,water,air,and cigarette smoke. Increased urine levelsfoundinpersonsworking/livingnearwasterecyclingcenters.Levelsincreasewithage.

Cobalt, a component of vitamin B12, isfound in most foods. It is also used totreat some resistant anemias and someradiosensitive malignancies. Occupationalexposure occurs with glass and ceramicpigmentation, electroplating, chemical andpetroleumindustries,grindingandsharpen-ing of hard metal tools, and animal-feedmanufacturing.

Copperisatraceelementfoundinnormaldiets. It isoneof thefewheavymetals thatarepotentiallyharmfulat lowlevelsaswellasattoxiclevels.ToxiclevelsmaybecausedbyBuergerdisease,theuseofcopperIUDs,ingestionofcontaminatedsubstances,elec-troplating, metal reclamation, roasting,crushing,smelting,andfungicideexposure.The biliary tract is the primary route ofelimination. Gastrointestinal symptomsoccuraroundwholebloodlevelsnear3mgof Cu per liter. Treatment is by chelating

agents (CaNa2-EDTA, BAL) or fungicideexposure.

Lead is absorbed into the body by theingestion of lead-containing paint or afterindustrialexposuresuchasinoccupationofbattery plant, metal welder, painter, con-struction worker, lead miner, firing rangeworker,glassblower,shipbuilder(boneleadlevelsarehigherinmeninblue-collaroccu-pations)or fragmentsof leadshot ingamebirds.IncreasedinBuergerdisease,ingestionofmoonshinealcohol, secondhandciga-rette smoke ingestion and in immigrantfarm workers. Exposure adversely affects achilds academic achievement and reducescognitive abilities and increases sterility inexposedadults.CDCstatesnolevelof leadin children can be specified as safe. Treat-mentincludeschelationtherapy(oralDMSAorparenteralCalciumEDTA).

Mercuryisfoundinfungicides(antifun-galsinpaints),industrialprocesses,cosmet-ics, explosives, dyes, pigments, preservativeinsomevaccinesandcontactlenssolutions,andfish(livinginpollutedwater).Itcanalsobe ingested in the form of mercury salts.Highmercurylevelshavebeennotedamongdental workers, persons with amalgamfillings, and persons with acute atopiceczema.Highvaluesareariskfactorforisch-emic heart disease. After acute exposureblood samples are reliable for 2-3 days.Treatmentofchoice isDMSA,dialysismayalsobeneeded.

Nickel is ubiquitous in soil, water, andmanyfoods.Nickeldoesnotaccumulateinhumans,andacutetoxicityisusuallyrelatedtoexposuretonickelcarbonyl.Currentdataare insufficient to indicate risk of carcino-genesisfromnickelexposure.

Selenium isametalusedfortheactivityofhumanglutathioneperoxidase.Exposureoccursasaresultofthemanufactureofglass,paints, dyes, electronic equipment, fungi-cides,rubber,andsemiconductors.DecreasedinBuergerdisease.

Thalliumispresentincosmetics,pesticides,andsomemedications.Itisabsorbedthroughintactskinandmucousmembranes.

Vanadium is a corrosion-resistant metalthat does not occur innature.Theprimarysourceofexposureisfromthediet.Occupa-tionalexposureoccursduringboiler-cleaningoperations as a result of the generation ofvanadium oxide dust. The kidneys are the

614 HeavyMetalsBloodand24-HourUrine

H

primary route of excretion. Toxicity overallislow.

Zinc is a tracemetal important for cel-lular growth andmetabolism. Toxicity canoccur from industrial exposure and con-sumptionofacidic foodorbeverages fromgalvanizedcontainers.DecreasedinBuergerdisease.


Preparation1. Blood:

a. Tube: Metal-free tube containingEDTAanticoagulant.

b. Do NOT draw specimens duringhemodialysis.

2. 24-hour urine:a. Obtaina3-L,plastic,acid-washedcol-

lectioncontainer.Useaplasticbedpanorurinalforvoidedspecimens.

b.Writethebeginningdateandthetimeofcollectiononthecontainerandthelaboratoryrequisition.

Procedure1. Blood:Drawa10-mLbloodsample.2. 24-hour urine:Savealltheurineina3-L

plastic, acid-washed container for 24hours.

PostprocedureCare1. DoNOTspinblood.2. 24-hour urine: Record the total volume

andtheendingtimeofcollectiononthespecimen container and label the con-tainerwiththeclientinformation.

3. Refrigeratethespecimen(s).

ClientandFamilyTeaching1. 24-hour urine: Save all the urine voided

forthenext24hoursandurinatebeforedefecating to avoid contaminating theurinespecimenwithstool.Ifanyurineisaccidentallydiscarded,discard theentirespecimen and restart the collection thenextday.

FactorsThatAffectResults1. Adiet high inheavymetalsmay elevate

results.2. Occupational exposure may elevate

results.3. Arecentseafooddietmaycauseincreased

arsenicvalues.

4. A diurnal variation exists such that thehighest copper levels are found in themorning.

5. Copper levels are 8%-12% higher inAfrican-Americans.

6. Drugs that may further increase somevaluesincludedimercaprol,loopdiuretics(intravenous), naproxen, penicillamine,sodiumchloride,andthiazidediuretics.

OtherData1. Makesurethespecimenforthe24-hour

urineisnotvoidedintoametalbedpanorurinal.

2. Urine is the preferred specimen forarsenic if symptoms are present or inacuteexposure.Bloodtestingisreliablewithin 10 days after acute arsenic poi-soning, but urine results are detectableforweeks.

3. Supplemental vanadyl sulfate, used bysome athletes to enhanceweight train-ing,canincreasevanadiumlevels.

4. Many asymptomatic occupationallyexposed workers have elevated vana-diumlevels.

5. Exceptforleadandcadmium,evidenceislackingontoxicitylevels.

6. In the absence of acute toxicity, serialtestingisusuallymoreinformativewhenappliedincontextwithphysicalexami-nation and knowledge of exposurehistory.

7. Blood lead levels have been correlatedwithhigherlevelsofserumtotalcholes-terolandhigh-densitylipoprotein.

8. Increased intake of ascorbic acid hasbeen shown to decrease blood leadlevels.

9. Genetic linkages: LeadChromosome3;Cadmium2,18,20,X;Mercury5;Selenium4,8;Zinc2.

10. AmericanCollegeofMedicalToxicologystatesthatpost-challengeurinarymetaltesting has not been scientifically vali-dated,hasnodemonstratedbenefit,andmaybeharmfulwhenappliedinassess-ment and treatment of patients withmetalpoisoning.

11. See also ArsenicBlood, hair, nails orurine; CadmiumSerum and 24-hoururine;CopperSerum;CopperUrine;LeadBlood and urine; MercuryBlood and urine; ThalliumSerum or24-hoururine;ZincBlood.

HHelicobacterpyloriAntigenTestStool 615

HeinzBodyStainDiagnosticProcedure1. Drawa3.5-mLbloodsample.2. Invert the tube gently several times to

adequately mix the sample and theanticoagulant.

PostprocedureCare1. Refrigeratethespecimen.2. Current administration of antimalarials,

furazolidone,nitrofurantoin,phenacetin,procarbazine,orsulfonamidesshouldbenotedonthelaboratoryrequisition.

ClientandFamilyTeaching1. Results are normally available within

24-48hours.

FactorsThatAffectResults1. Hemolysis or clotting of the specimen

invalidatestheresults.2. Antimalarials, dapsone, furazolidone

(in infants), nitrofurantoin, phenacetin,phenylhydrazine, procarbazine, resorcin,andsulfonamidescancausefalse-positiveresults.

OtherData1. Heinzbodiespercellvaryfrom1to20.2. G6PD deficiency often affects Dutch,

German,orFrenchindividuals.

Norm. Negative.

Positive. G6PD deficiency, Heinz bodyanemia, hemolytic anemia, homozygousbeta-thalassemia, and after splenectomy.Drugs include acetanilid, aminosalicylicacid, analgesics, aniline, antipyretics, chlo-rates, hydroxylamine, naphthalene, nitro-benzene,phenolderivatives,phenothiazines,phenylhydrazine,phenylsemicarbazide,pyr-idine, resorcin, salicylazosulfidine, sodiumsulfoxone, sulfapyridine, sulfones, tolbuta-mide,andlargedosesofvitaminK.

Negative. NoHeinzbodyidentified.

Description. Heinzbodiesaresmall,irreg-ular particles of denatured hemoglobinwithinmatureredbloodcells.Theseappearwhen stained with methyl violet or cresylbluebutnotunderWright-stainedprepara-tions. The presence of Heinz bodies in astained specimen indicates an abnormalhemoglobinstructure.


Preparation1. Tube:Lavendertopped.2. Contact the laboratory to arrange for

testing.

HelicalCTSeeComputed Tomography of the BodyDiagnostic.

HelicobacterpyloriAntigenTestStoolNorm. Negative for the presence of H. pyloriantigens.

Usage. Providesearlierevaluationthantheureabreathtestof thesuccessof treatmentforH. pyloriinfection.

Description. See Urea breath testDiagnostic.TheH. pylori stool antigen testisoneofthenewesttestsdevelopedtoevalu-ateforthepersistenceofbacteriaanddetectstheH. pyloriantigenthatisshedinthestoolof clientswith activeH. pylori infection.Apositivetestasearlyas7daysafterthecom-pletionoftreatmentindicatesthatthetreat-ment was not successful. This tests early

usefulness isassensitiveandspecificas theurea breath test, which should not be per-formedforatleast4-6weeksaftertreatment,for evaluation of treatment success. Preva-lence in asymptomatic Japanese is 37.5%.Cytotoxin-associated gene (cagA) detectedin50%-60%fecalspecimens.


Preparation1. Obtainacleancontainer.

Procedure1. Obtainasmallsampleofstoolinaclean,

drycontainer.

H616 HelicobacterpyloriQuickOfficeSerology,SerumandTiterBlood

2. ThestoolissmearedonaMicroplatecoatedwith H. pylori antibodies and incubated,andtheresultingcolorchangeiscomparedtoachart.Thegreater thedegreeofcolorchange,thegreatertheamountofH. pyloriantigeninthestoolsample.

PostprocedureCare1. None.

ClientandFamilyTeaching1. Do not take omeprazole, lansoprazole,

or pantoprazole within 14 days beforethe test.

2. Do not take bismuth mixtures (e.g.,Pepto-Bismol) within 1 month beforethetest.

3. Test results are normally available inabout3hours.

4. Intakeofyogurt,containingLactobacillus acidophilus and Bifidobacterium lactis,twice a day for 6 weeks suppresses H. pyloriinfection.

5. ActiveH. pyloriareshedbyvomitusalso.

FactorsThatAffectResults1. Recent intake of bismuth-containing

compounds(Pepto-Bismol)orlansopra-zolemaycausefalse-negativeresults.

2. Sensitivity is93.1%.Specificity is94.6%.Thisiscomparabletoothertestmethodssuchasthoselistedbelow.

OtherData1. See also Campylobacter-like-organism

testSpecimen;Helicobacter pylori quickoffice serology, Serum and titerBlood;andUreabreathtestDiagnostic.

2. HpSAImmunoCardSTATisanaccuratetestforH. pyloriinfection,buthasalowsensitivityinchildren.

3. Sensitivityandspecificityofstool-PCRis62.5%and92.3%.

4. Detection of alkyl hydroperoxidasereductase protein (AhpC) antigen byimmunoblotting in stool is useful non-invasivemethodforaccuratediagnosisofH. pyloriinadolescentsandchildren.

HelicobacterpyloriQuickOfficeSerology,SerumandTiterBloodNorm. Negative.

Usage. Duodenal ulcers, gastric cancer,gastriculcers,gastritis(chronic),lymphoma(stomach),andpepticulcers.

Description. H. pylori are heterogeneousS-orC-shaped,gram-negativebacilliwithasmoothoutercoatandtwotofourunipolarflagella. The virulence of these organismsvaries geographically. They were firstdetectedinthestomachsofclientswithgas-tritisaround1990andhavenowbeenshowntobethemajorcauseofactivechronicgas-tritis.Inaddition,theevidencethatH. pyloriplayamajorroleinthepathophysiologyofduodenal and peptic ulcers and possiblygastric ulcers is compelling.An associationbetween H. pylori and gastric cancer andlymphoma of the stomach may also exist.There isnoknownnatural reservoir forH. pyloriintheenvironment,butitisbelievedthattheseorganismsarespreadbythefecal-oralororal-oralrouteandincludevomitusasamodeoftransmission.TheQuickOfficeSerology test may be performed in thephysicians office in 20 minutes on serum,providingayes-or-noanswertothepresence

of IgA and IgG antibodies to H. pylori.Laboratory-based serology tests are morespecific than office-based tests in that theyquantitate antibody levels, providing titersso that antibody levels can be monitoredafter therapy. An elevated antibody levelindicatesactiveorrecentinfection.Becauseantibodiesremaininthebloodlongaftertheinfectioniseradicated,thistestcannoteval-uateresponsetotreatment.Instead,theureabreathtestshouldbeusedtoconfirmeradi-cation after treatment (see Urea breathtestDiagnostic).



goldtopped.


PostprocedureCare1. If shipping the sample to an off-site

laboratory, keep the specimen coolwithfrozen coolant from April through

HELLP(Hemolysis,ElevatedLiverEnzymes,LowPlatelets)SyndromePanelSerum 617

H

October and with refrigerated coolantfromNovemberthroughMarch.

ClientandFamilyTeaching1. Becauseserologictestsmayremainposi-

tive for many months after successfultreatmentforH. pylori,othertestsarealsorecommended for evaluating progress(endoscopyorbreathtest).

2. Intakeofyogurt,containingLactobacillus acidophilus and Bifidobacterium lactis,twice a day for 6 weeks suppresses H. pyloriinfection.

FactorsThatAffectResults1. Serologictestingaloneisassociatedwith

high false-positive rates because of pastinfectionwithoutactivedisease.

OtherData1. Thesetestsrequire1mLofserum.2.H. pylori affects about 20% of clients

youngerthan40yearsand50%ofthoseolder than60years.H. pylori isuncom-moninyoungchildren

3. Associated genes include sabA (91.3%),cagA(65%),vacA(97.5%),iceA(97.5%),babA2(48.8%).

4. More than 90% of duodenal ulcers arecausedbyH. pylori.

5. Noninvasive 13C-labeled urea breath testisusefulforinitialassessment.

6. The A2142G and A2143G mutations inthe 235 rRNA gene are associated withclarithromycinresistance.

7. See also Campylobacter-like-organismtestSpecimen.

HELLP(Hemolysis,ElevatedLiverEnzymes,LowPlatelets)SyndromePanelSerumNorm. Bloodpressurewithinnormallimitsorbelow160/110mmHg.Completebloodcount (CBC) and liver enzymes withinnormallimits.

Usage. Laboratory studiesofbloodvaluesandliverenzymeswillconfirmdiagnosisofsyndrome.Testsrepeateddailyorevery8-12hoursinseverecases.Servesasafoundationforclientcare.

Description. Pregnancy-related syndromeassociated with severe cases of pregnancy-induced hypertension (PIH)/preeclampsia,affects 60% primigravidas, occurs overallin4%-12%ofclientswithincreasedriskintwinpregnancies,andmostoftenpresentsin28-32weeksofpregnancy.Overallincidence0.17%-0.85%ofallbirthsor1:400pregnantwomen. Pathophysiologic cause of syn-dromeisunknown.Persistenthypertensionresultsinadecreaseinintrinsicvasodilators(prostacyclinandnitricoxide)andincreasedproductionof vasopressors such as throm-boxane. A chain of events leads to wide-spread vasospasms, acute renal failure,pulmonaryedema,ascites,pleural effusion,ARDS,DIC,and/ormultiple-organdamage.Postpartum hemorrhage occurs frequentlywhenplateletcount50U/LAST(SGOT)>72U/LBilirubin>1.2mg/dLBUN>10mg/dLCr>2mg/dLHct15mmHgoverbaselinevalue

618 HemagglutinationTreponemalTestforSyphilis(HATTS)Serum

H

Dependent edema thatprogresses tonon-dependentedemaofupperarms,upperlegs,abdomen,face,andneck

Epigastric pain, right upper abdominalquadranttenderness

Hemolyticanemia:fatigue,pallor,dyspneaJaundiceProteinuria:+4Pulmonaryedema

2. Clients with HELLP syndrome usuallydeliver by cesarean section and need toreceivetherapeuticbloodcomponents.

3. Mother isvery illandherconditionwillbeof concern for at least 48hours afterdelivery.

4. Preeclampsiasubjectivecomplaintsincludemalaise, epigastric pain, nausea, vomiting,headache,andvisualdisturbances.

5. Conditionofthebabywilldependonges-tationalageattimeofdelivery,effectsofuteroplacental insufficiency (associatedwith PIH), and maternal hemorrhagebeforedelivery.

FactorsThatAffectResults1. Deliveryof fetuswillcorrectpreeclamp-

sia.HELLP syndrome is complicated bydisseminated intravascular coagulation(DIC)andpotentialliverrupture.

2. Hemolysis affects serum laboratoryresultsforliverfunction.

OtherData1. Usually develops between 20 and 37

weeks of gestation. Maternal mortalitycanbeashighas60%.

2. CTandMRIplayacomplementaryroletosonographyindiagnosis.

3. Severe folate deficiency may mimicHELLPsyndrome.

4. Treatment may include recombinantactivated factor VII given IV at dose90microg/kg twice and/or dexametha-soneormethylprednisolone(125-250mgIV3-4timesperday).IngravecasesuseofIVurapidilorhydralazinefollowedbyoralnifedipineormetoprololisused.

5. Increased plasma protein 13 (PP13) inserumofmothersinthirdtrimesterindi-catespre-eclampsiaorHELLP.



goldtoppedforliverfunctiontests.2. DoNOTdrawduringhemodialysis.3. Lavendertoppedtubeforplatelets.4. Obtain intravenous access for possible

bloodproductinfusion(s).5. Obtainbaselinevitalsigns.

Procedure1. Drawa4-mLbloodsample.2. Management with fresh-frozen plasma

andpackedRBCs.Avoidplatelettransfu-sion because platelet consumption willoccur.

3. Monitorvitalsignsfrequently.

PostprocedureCare1. Specimen may be refrigerated but not

frozen.2. For clients with HELLP syndrome, the

critical period is 24 hours postpartum.During this time, the clients conditionoften worsens before improvement isseen.

ClientandFamilyTeaching1. Resultsavailablewithinanhour.

HemagglutinationTreponemalTestforSyphilis(HATTS)SerumNorm. Titer

Hematocrit(Hct)Blood 619

H


PostprocedureCare1. Sendthespecimentothelaboratoryand

refrigerateituntilitistested.2. All cases of syphilis should be reported

to the Centers for Disease Controland Prevention in Atlanta, Georgia, at:404-639-2206.

3. Sexualcontactsshouldbenotifiedintheeventofpositiveresults.

ClientandFamilyTeaching1. Fastovernightbeforethetest.2. Refer clients with elevated titers for

medicalmanagement,whichisnecessaryto slow or prevent the sequelae ofsyphilis.

3. Iftestingpositive:a. Notifyallsexualcontactsfromthelast

90 days (if in the early stage) to betestedforsyphilis.

b. Syphiliscanbecuredwithantibiotics.Thesemay worsen the symptoms forthefirst24hours.

c. Donothavesexfor2monthsanduntilafterrepeattestinghasconfirmedthatthesyphilisiscured.Usecondomsafterthat for 2 years. Return for repeattestingevery3-4monthsforthenext2yearstomakesurethediseaseiscured.

d.Do not become pregnant for 2 yearsbecausesyphiliscanbetransmittedtothefetus.

e. If left untreated, syphilis can damagemanybodyorgans,includingthebrain,over several years.Neurosyphilis (latestage)isverydifficulttotreatwithcur-rentlyavailableregimens.

FactorsThatAffectResults1. False-positiveresultsmaybeattributable

to hepatitis, infectious mononucleosis,leprosy,rheumatoidarthritis,orsystemiclupuserythematosus.

2. False-negativeresultsmayoccurinclientswith AIDS. Treponemal antigen testsdemonstrategreateraccuracyindetectinglate-stageinfectioninclientswithHIV.

OtherData1. Thistestmayremainpositiveindefinitely

forclientspreviouslyinfectedwithsyphi-lis. Thus it is not useful formonitoringclinical response to treatment forsyphilis.

2. Benzathine penicillin G is the drug ofchoicetotreatsyphilis.Severediseaseorimmunosuppressed clients may requireintravenous therapy. Consider doxycy-cline, ceftriaxone, or tetracycline withPCNallergy.Oraltherapywith2.0gramsofazithromycinisanalternativetherapy.

3. Serial quantitative cardiolipin antigentesting isused formonitoring treatmentresponse.

4. False-positive resultshavebeen reportedin IVdrugusers infectedwithHIV andhepatitisBvirus.

Hematocrit(Hct)BloodNorm.

SIUnitsFemalesAdult 37%-47% 0.37-0.47Pregnant 30%-46% 0.30-0.46AdultMales 40%-54% 0.40-0.54Cordblood 42%-60% 0.42-0.60ChildrenNeonates 40%-68% 0.40-0.683months 29%-54% 0.29-0.541-2years 35%-44% 0.35-0.446-10years 31%-45% 0.31-0.45PanicLevels 60% 0.60

620 Hematocrit(Hct)Blood

H

Panic Level Symptoms and TreatmentIncreasedNote:Treatmentchoice(s)depend(s)onclientshistoryandconditionandepisodehistory.

Cause Symptoms PossibleTreatmentsHemoconcentration Decreasedpulsepressureand

volume,decreasedskinturgor,decreasedvenousfilling,drymucousmembranes,lowcentralvenouspressure,orthostatichypotension,tachycardia,thirst,andweakness

AdministerIVfluids.Monitorhematocrit.

Stoporreducedoseofdiureticsiftheyarecontributorstocondition.

Truepolycythemiaovertransfusion

Extremitypainandredness,facialflushing,irritability,anasarcadecreasingQRSvoltagewithseverefluidoverload

AdministerIVfluids.Monitorhematocrit.

Observeforsignsofthrombosis.Performbloodlettingbyvenipuncture(phlebotomy).

Hemodilution Rales,anxiety,edema,hypertension,jugularvenousdistention,restlessness,andshortnessofbreath

Administerdiuretics.Restrictsodium.

Restrictfluids.Monitorhematocritandintakeandoutput.

Administeroxygen.Bloodloss Hypotension,bleeding,hypoxia Identifyandtreatcauseof

bleeding.Giveisotonicfluids.Performbloodtransfusion.Administeromeprazole(ifbloodlossiscausedbybleedingesophagealvarices).

Protectairways;administeroxygenasneeded.

Increased. Addisonsdisease,blooddoping(autologoustransfusiontoimproveathleticperformance), burns (severe), dehydration(severe),diabetesmellitus,diarrhea,eclamp-sia, erythrocytosis, hemoconcentration,hemorrhage,pancreatitis(acute),polycythe-mia,shock,andtetralogyofFallot.Anycon-ditionthatincreasesredbloodcells(RBCs).

Decreased. Anemia, bone marrow hyper-plasia, burns (severe), cardiac decompensa-tion, cirrhosis, congestive heart failure, cysticfibrosis, fatty liver, fluid overload, hemolyticreactionstochemicalsordrugsorprosthetics,hemorrhage, hydremia of pregnancy, hyper-thyroidism,hypothyroidism, idiopathic steat-orrhea,intestinalobstruction(late),leukemia,overhydration, pancreatitis (hemorrhagic),pneumonia, and pregnancy. Also, conditionsthatdecreaseRBCs.Drugsincludeacetamino-phen, acetohexamide, aminosalicylic acid,amphotericin, antimony potassium tartrate,

antineoplastic agents, antibiotics, atabrinehydrochloride, chloramphenicol, chloroquinehydrochlorideorphosphate,doxapramhydro-chloride, ethosuximide, ethotoin, furazoli-done,haloperidol,hydralazinehydrochloride,indomethacin,isocarboxazid,isoniazid,mefe-namicacid,mephenytoin,mercurialdiuretics,metaxalone, methaqualone, methsuximide,methyldopa, methyldopate hydrochloride,nitrates, nitrofurantoin, novobiocin sodium,oleandomycin,oxyphenbutazone,parametha-dione, pargyline hydrochloride, penicillins,phenacemide,phenelzinesulfate,phenobarbi-tal,phensuximide,phenylbutazone,phenytoinsodium,phytonadione,primidone,radioactiveagents, rifampin, spectinomycin hydrochlo-ride, sulfonamides, tetracyclines, thiazidediuretics, thiocyanates, thiosemicarbazones,tolazamide, tolbutamide, tranylcyprominesulfate,trimethadione,tripelennaminehydro-chloride,troleandomycin,valproicacid,vege-tariandiet,vitaminA,andzidovudine(AZT).

HHemoglobin(Hb,Hgb) 621

Description. Hematocrit is thepercentageof red blood cells in a volume of wholeblood.


Preparation1. Tube: Lavender topped or heparinized

capillarytubewitharedbandontheanti-coagulantend.

2. DoNOTdrawduringhemodialysis.

Procedure1. Draw a 3.5-mL blood sample from an

extremitythatdoesnothaveintravenousfluids infusing into it to avoid hemodi-luted samples. Do not leave the tourni-quet in place for longer than 1 minuteduringcollection.

2. For a capillary puncture (fingers, toes,heels), establish a free flow of blood tominimize dilution with tissue fluid. Fillthe capillary tube from the red-bandedendtoabouttwo-thirdscapacityandsealthisendwithclay.

3. For a central venous access device, tem-porarily stop all fluids infusing throughports, prepare injection port withpovidone-iodine solution or alcohol,using only 10-mL syringes flush with10mL of 0.9% NaCl, and immediatelywithdraw10mLofdiscardblood.With-draw required blood volume with newsyringesandtransferspecimentoappro-priate tubes. Flush port with 10mL of0.9%NaCl.(Refertoyourfacilityspolicyandproceduremanual orobtain relatedcurrent standards from IntravenousNursing Society, Oncology NursingSociety, or North American VascularAccess Network.) Flush solutions and

discardvolumesmayvarybyclientpopu-lationandpublishedguidelines.

PostprocedureCare1. Invertthetubegently10timestomix.2. Refrigeratethesampleafter10hours.Do

notfreezeit.

ClientandFamilyTeaching1. Resultsarenormallyavailablewithinless

than24hours.


results.2. Results are elevatedwithdehydrationor

leukocytosisover100x109/L.3. False elevations occur with glucose

400mg/dL.4. Obtainthespecimenbeforebath,shower,

ormassagebecausethesecancauseatem-poraryriseinthevalue.

5. Highaltitudemayincreasethevalue.6. Levelmaymeasureasnormal,eveninthe

conditionofbloodloss,becauseofcom-pensatory mechanisms and/or overlyingconditionssuchasdehydration.

OtherData1. The hematocrit value is approximately

threetimesthevalueofthehemoglobin.2. Hematocrit does not detect iron defi-

ciencyininfants,butferritinlevelwillforthose9-18monthsofage.

3. Consider hemoglobin levels with pulseoximetryif hemoglobin is low andoxygen saturation is 100%, oxygenationcould be clinically and significantlyinadequate.

4. Clientsolderthan64yearswithahema-tocrit less than 39% should be treatedroutinely using preoperative storage ofautologousblood.

HemoccultSeeOccult BloodStool.

Hemoglobin(Hb,Hgb)Norm.

SIUnitsFemales 12-16g/dL 7.45-9.90mmol/LPregnant 10-15g/dL 6.3-9.9mmol/LMales 13.6-18.0g/dL 8.44-11.17mmol/L

Continued

H622 Hemoglobin(Hb,Hgb)

SIUnitsChildrenNeonates 14-27g/dL 8.69-16.76mmol/L3months 10-17g/dL 6.21-10.55mmol/L1-2years 9-15g/dL 5.58-9.31mmol/L6-10years 11-16g/dL 6.82-9.92mmol/LPanicLevels 12.41mmol/L

called heme. Heme contains iron atomsandtheredpigmentporphyrin.Eacheryth-rocyte contains approximately 300 millionmoleculesofhemoglobin.


Preparation1. Tube: Lavender topped or heparinized

capillarytubewitharedbandontheanti-coagulantend.

2. Do NOT draw specimen duringhemodialysis.

Procedure1. Draw a 3.5-mL blood sample from an

extremitythatdoesnothaveintravenousfluids infusing into it. Do not leave thetourniquet in place for longer than 1minuteduringcollection.

2. For capillary puncture (fingers, toes,heels), establish a free flow of blood tominimize dilution with tissue fluid. Fillthe capillary tube from the red-bandedendtoabouttwo-thirdscapacityandsealthisendwithclay.

3. Centralvenouscatheter(seeHematocritBlood).

PostprocedureCare1. Invertthetubegently10timestomixit.2. Thespecimenisstableatroomtempera-

ture for 10 hours; then refrigerate it forupto18hourstotal.

ClientandFamilyTeaching1. Resultsarenormallyavailablewithinless

than24hours.

FactorsThatAffectResults1. Hemolysisofthespecimeninvalidatesthe

results.2. Results are falsely elevated by lipemic

samplesandleukocytosis>30109/L.3. Obtainthespecimenbeforebath,shower,

ormassagebecausethesecancauseatem-poraryincreaseinthevalue.

Panic Level Symptoms and TreatmentIncreased. SeeHematocritBlood.Panic Level Symptoms and TreatmentDecreased. SeeHematocritBlood.

Increased. Burns(severe),congestiveheartfailure, chronic obstructive pulmonarydisease(COPD),dehydration,diabeticreti-nopathy, diarrhea, erythrocytosis, hemor-rhage, hemoconcentration, high altitudes,intestinal obstruction (late), polycythemiavera,snorers,andthromboticthrombocyto-penicpurpura.Alsoconditionsthatincreaseredbloodcells (RBCs).Drugs includegen-tamicin,methyldopa,andpentoxifylline.

Decreased. Andersens disease, anemia(iron deficiency), carcinomatosis, cirrhosis,cystic fibrosis, deoxygenated blood (2%decrease),diabetesmellitus typeI(predictsmortality),fatemboli,fattyliver,fluidreten-tion,hemolysis,hemolyticreactiontochem-icals or drugs or prosthetics, hemorrhage,Hodgkins disease, hydremia of pregnancy,hyperthyroidism,hypervitaminosisA,hypo-thyroidism, idiopathic steatorrhea, intrave-nous overload, leukemia, lymphoma, otitismedia, platelet apheresis, pregnancy, renalcorticalnecrosis,sarcoidosis,severehemor-rhage,systemiclupuserythematosus,tetral-ogyofFallot,andtransfusionofincompatibleblood.Also, conditions that decreaseRBCsor hemoglobin (organophosphate insecti-cides). Drugs include antibiotics, antineo-plastic agents,Apresoline (hydralazineHClwith hydrochlorothiazide), aspirin, hydan-toin derivatives, indomethacin, linezolid,losartan, monoamine oxidase inhibitors,primaquine, rifampin, sulfonamides, tridi-one,andzidovudine(AZT);vegetariandiet.

Description. Hemoglobin is the oxygen-carrying pigment of the RBCs. It is com-posed of amino acids that form a singleprotein called globin and a compound

HHemoglobinA2Blood 623

4. Highaltitudemayincreasethevalue.5. Themean hemoglobin level in African-

Americans is 0.4-1.0g/dL lower thanthat in Caucasians after the first decadeoflife.

6. Duringexercise,arterialhemoglobinsat-urationfalls.

OtherData1. The hemoglobin value is approximately

onethirdthevalueofthehematocrit.2. Recent animal studies of hemoglobin

have indicated that itmayplaya role in

bloodpressureregulationbycarryingandreleasingsupernitric oxide, a formofgasthatcausesrelaxationofmusclecellsinperipheralbloodvessels.

3. DialysispatientshaveincreasedmortalityifhematocritisloworhighandEPOusewithHct>13g/dlmayincreasemortalityinthosewithESRDorCKD.

4. After ischemic stroke,Hct>50 indepen-dentpredictorofmortalityinwomen.

5. One unit of blood (300mL) transfusedwill change the Hct between 0.7% and3.1%.

HemoglobinA1aSeeGlycosylated HemoglobinBlood.

HemoglobinA1bSeeGlycosylated HemoglobinBlood.

HemoglobinA1cSeeGlycosylated HemoglobinBlood.

HemoglobinA2BloodNorm.

SIUnits(MassFraction)Cordblood 0%-1.8% 0-0.018Birthto6months 0-3.5% 0-0.035>6months 1.5%-3.5% 0.015-0.035Beta-thalassemia Trait 3.7%-6.5% 0.037-0.065 Sicklecelltrait 1.7%-4.5% 0.017-0.045

Increased. Anemia (megaloblastic) andbeta-thalassemia(homozygous).Blacksmithoccupation.

Decreased. Anemia (iron deficiency,microcytic,sideroblastic),alpha-thalassemia,beta-thalassemia, erythroleukemia, genemutation 0/00, hemoglobin A2-Monrealemutation,andhemoglobinHdisease.

Description. HemoglobinA2isanormallypresent hemoglobin component consti-tuting 2%-3% of the normally presenthemoglobin.Found in2%-3%ofMaurita-nian populations and 1.5% worldwide

population are carriers of -thalassemia.Thistestisusedtohelpdifferentiatehemo-globin abnormalities. Classic phenotype ofheterozygous-thalassemiaisincreasedHbA2,RBC,anddecreasedMCVandMCH.


Preparation1. Tube:Lavendertopped.

Procedure1. Draw a 2-mL blood sample, without

hemolysis.

624 HemoglobinElectrophoresisBlood

H

PostprocedureCare1. Invertthetubegently10timestomix.

ClientandFamilyTeaching1. Results are normally available within

24-48hours.

FactorsThatAffectResults1. Hemolysis or clotting of the specimen

invalidatestheresults.2. Clients with both beta-thalassemia and

irondeficiencymaydemonstratenormal

HbA2levelsandmayneedtoberetestedaftertakingironsupplements.

3. In clients who have received recentblood transfusions, the results may beunreliable.

OtherData1. HbA2 cannot bemeasured in the pres-

enceofHbC,HbE,orHbO.2. 52 genotypes have been observed in

thalassemia.

HemoglobinElectrophoresisBloodNorm.

SIUnits(HbFraction)HemoglobinA >95% >0.95 Infants 10%-30% 0.10-0.30HemoglobinA2 1.5%-3.5% 0.01-0.04HemoglobinF

Hemoglobin(Free),PlasmaandQualitativeUrine 625

H

Procedure1. Drawa2.5-mLbloodsample.

PostprocedureCare1. Deliver the specimen to the laboratory

immediatelybecauseabnormalhemoglo-binsareunstable.

2. Recent(withinthepast4months)bloodtransfusion(s) should be noted on thelaboratoryrequisition.

ClientandFamilyTeaching1. Theclientshouldwearamedical identi-

ficationtagifchronicanemiaispresent.2. If the sickle cell trait or the disease is

present,offergeneticcounseling.

FactorsThatAffectResults1. Redbloodcelltransfusionwithinthepre-

vious4monthsmaymaskorreducethepresenceofabnormalhemoglobins.

2. Hemoglobins A2, C, and S may bedecreasedinirondeficiency.

3. False-negativetestsoccurinhemoglobinS with clients with polycythemia or inthoselessthan3monthsofage.

OtherData1. Morethan350variantsofHbhavebeen

recognized.2. Changes in the proportion of normal

typesofhemoglobinmayimplyahemo-lyticdisease.

Hemoglobin(Free),PlasmaandQualitativeUrineNorm.Urine. Negative.Blood SIUnitsNormal 1.55mol/LIntravascularhemolysis >30mg/dL >4.65mol/LHemoglobinuriaoccursat >150mg/dL >23.25mol/LCherry-redplasmaoccursat >200mg/dL >31mol/L

IncreasedinPlasma.Autoimmunehemo-lytic anemia, burns, cold hemagglutinins,disseminated intravascularcoagulation, fal-ciparum malaria, intravascular hemolysis,leptospirosis,lupuserythematosus,paroxys-mal nocturnal hemoglobinuria, septicemia,sickle cell anemia, thrombosis, transfusionreaction, and traumatic hemolysis. Drugsinclude analgesics, antimalarials, cinchonaalkaloids, nitrofurantoins, sulfonamides,and sulfones.Clients receivingfluid substi-tuteofhydroxyethylstarch(HES).

PositiveinUrine. Autoimmunehemolyticanemia,blackwaterfever,bladderirrigation,burns,Clostridium perfringensinfection,dis-seminatedintravascularcoagulation,hemo-lytic anemia, kidney infarctions, malaria,paroxysmalnocturnalhemoglobinuria,poi-sonings, pregnancy, transfusion reaction,and transurethral prostatectomy. Drugsinclude arsenic, bacitracin, ciprofloxacin,coumadin, cyclophosphamide, fenoprofen,gold salts, indomethacin, mebendazole,nitrofurantoin, phenacetin, phenothiazines,

phenylbutazone,polymyxinB,quinine,andsuprofen.

Description. Freehemoglobinishemoglo-bin that escapes from erythrocytes duringintravascularhemolysis.Asmallamountofhemoglobin is normally present, but it isincreasedinthebloodstreamandurineaftermassivehemolysis.



goldtopped,andgreentoppedforplasmasample.

2. Obtain a sterile plastic specimen con-tainerfortheurinesample.

3. If the female client is menstruating,rescheduletheurinetest.

Procedure1. Plasma:DoNOTdrawfromanextremity

with intravenous solution infusing. Drawthebloodsampleusingan18-gaugeneedlewithanattachedinfusiontubingasfollows:

H626 HemoglobinProfile

a. Gentlyplacethetourniquetaroundtheupperarm.Followthiswithvenipunc-ture of the antecubital vein with aslittletraumaaspossible.

b. Release the tourniquet and clamp thetubingassoonasflashbackoccurs.

c. Collect 3mL of blood in the redtoppedtube.Removethetopfromthegreentoppedtube,andcollect5mLofblood.Replacethetopoftheheparin-izedgreentoppedtube.

d. Clamp the tubing, withdraw theneedle,andapplypressuretotheveni-puncturesite.

2.Urine: Obtain a 20-mL random urinespecimeninasterileplasticcontainer.

PostprocedureCare1. Plasma:Sendthespecimentothelabora-

tory immediately. The plasma must beseparatedfromthecellswithin1-2hours.

2.Urine:a. Donotshakethespecimen.b. Dipacommercialdipstickintheurine

andmatchthestickwithacolorblockorchart,orsendthesticktothelabora-toryimmediately.

c. Refrigerate the specimen if the test isnotperformedwithin1hour.

ClientandFamilyTeaching1. Urinatebeforedefecatingandavoidcon-

taminatingtheurinewithtoilettissue.

FactorsThatAffectResults1. Hemolysisofbloodspecimensinvalidates

theresults.Thespecimen-collectionpro-cedure is critical because anydamage tored blood cells can produce falsely ele-vatedresults.

2. False-positive urine resultsmay occur ifthespecimeniscontaminatedwithmen-strualblood.

3. Ascorbicacid(ormedicationscontainingascorbic acid as a preservative, such asantibiotics) may cause false-negativeurinetestsbyinhibitingreagentactivity.

4. Bromides,copper, iodides,andoxidizingagentscausefalse-positiveurinetests.

OtherData1. Ifplasmahemoglobinlevelsareincreased,

encourage periods of rest to preserveusablehemoglobin.

2. Freehemoglobincanoftenbedetectedinthe urine when red blood cells cannotbecause they lyse in strongly alkaline ordiluteurine.

3. Theurine test is often part of a routineanalysis.

HemoglobinProfileSeeCO-oximeter Profile, Arterial or VenousBlood.

HemoglobinSSeeHemoglobin ElectrophoresisBlood;Sickle Cell TestBlood.

Hemoglobin,Unstable,Heat-LabileTestBloodNorm.

HepaticFunctionPanel(HFP)Blood 627

H

PostprocedureCare1. Invertthetube10timesgentlytomixthe

specimen.


hours.

FactorsThatAffectResults1. Reject specimens received more than 3

hoursaftercollection.

OtherData1. The test should be run with a normal

control.

Hemoglobin,Unstable,IsopropanolPrecipitationTestBloodNorm. Negative. No precipitation at 40minutes.

Positive. Heinz body anemia and slightopacity at 10 minutes in the presence ofhemoglobinH.Theabnormal chainofHbMont Saint-Aignan is a variant associatedwith hemolytic anemia. Autosomal domi-nant Hemoglobin Pitie-Salpetriere identi-fiedinJapanesepersons.

Description. Unstable hemoglobin is atype of hemoglobin, normally absent, thatprecipitatesfasterthannormalhemoglobin.After precipitation, unstable hemoglobinformsHeinz bodies, inclusions attached toerythrocyte membranes that increase thefragility of the red blood cell and lead tohemolysis. Unstable hemoglobin is detect-ablewhensubjectedtoisopropanol.


Preparation1. Inform the laboratory of the time the

specimenwillbearriving.2. Tube:Lavendertopped.


PostprocedureCare1. Invertthesamplegently10timestomix.2. Send the specimen to the laboratory

immediatelybecausethetestmustberunwithfreshblood.


hours.

FactorsThatAffectResults1. ThepresenceofhemoglobinFmaycause

afalse-positiveresult.

OtherData1. Moresensitivethanheatdenaturization.

HemophilicFactorBSeeFactor IXBlood.

HepaticFunctionPanel(HFP)BloodNorm. See individual test listings:AlanineAminotransferaseSerum, AlbuminSerum, urine, and 24-hour urine,Alkaline phosphataseSerum, AspartateaminotransferaseSerum, and BilirubinSerum.

Usage. Seeindividualtestlistings.

Description. TheHFPisatermdefinedbyTheCentersforMedicareandMedicaidSer-vices(CMS)intheUnitedStatestoindicateagroupof tests forwhichabundledreim-bursementisavailable.Thepanelisdisease-oriented, meaning that payment through

Medicare is available only when the test isusedtodiagnoseandmonitoradiseaseandpayment is not available when the test isused for screeningpurposes in clientswhohavenosignsandsymptoms.AllthetestsinthepanelmustbecarriedoutwhenaBMPisprescribed.



goldtoppedandonebluetopped.

628 HepatitisAAntibody,IgMandIgG(HAV-Ab)Blood

H

2. Do NOT draw specimens duringhemodialysis.

Procedure1. Draw a 3- to 5-ml blood sample in

each tube.


ClientandFamilyTeaching1. Seeindividualtestlistings.

FactorsThatAffectResults1. Seeindividualtestlistings.

OtherData1. Seeindividualtestlistings.

HepatitisAAntibody,IgMandIgG(HAV-Ab)BloodNorm. Negative.

Positive. HepatitisA(formerlycalledinfec-tioushepatitis)andjaundice.

Description. IgMisamarkerforthehepa-titis A virus that appears 2-4 weeks afterexposure and is detectable for only 4-8weeks.Itdoesdifferentiatebetweenanacuteinfectionandapastorpreexistinginfection.Hepatitis A is never chronic, but acuterelapses occur with an overall fatality of0.2%.IgGreplacesIgM,andtheseantibodiespersist for life, providing immunity fromreinfection of hepatitis A. Hepatitis A isusually transmitted through the fecal-oralroute although it can be transmitted viabloodtransfusion.HepatitisAisemerginginthe Middle East region, especially in ages5-14years.


Preparation1. SeeClientandFamilyTeaching.2. Tube: Red topped, red/gray topped, or

goldtopped.3. Screentheclientfortheuseofherbalprepa-

rationsornaturalremediessuchasChinesejin bu huan (gold-inconvertible, Jin BuHuan Anodyne Tablets, patent medicinewith misidentified constituents: essenceoftienchi[tianqi]flowers,Noto-ginseng;alsokombucha; alsoLycopodium serratum,orclubmoss;butwithplantalkaloidlevo-tetrahydropalmatine, a potent neuroactivesubstance) and Bougainvillea Wild (Nyc-taginaceae:Bougainvillaea).


PostprocedureCare1. Remove the serum and freeze it if the

bloodwillnotbetestedwithin7days.


days.2. A person cannot be infectedmore than

oncewithhepatitisA.Vaccinationrecom-mendedforhospitalworkers.

3. Hepatitis A can be prevented by goodhandwashing.Washyourhandswellwithsoapandwaterandwithrapidscrubbingactionafterurinatingordefecating.

4. Do not drink alcohol, beer, or wine ortake medicine that contains acetamino-phen or paracetamol for 3 weeks, or asspecifiedbyyourphysician.

5. Malfunction of other organs occurs in30%ofclients, includingintegumentary,musculoskeletal(joints),respiratory,car-diovascular,anddigestivesystems.

FactorsThatAffectResults1. If using the radioimmunoassay tech-

nique, injection of radionuclides withinthelastweekmayfalselyelevateresults.

2. HerbsornaturalremediesthatmaycausehepatitisincludeChinesein bu huan(seeabove).

3. Herbs or natural remedies thatdecreasehepatitisareBougainvilleaWild(Nyctaginaceae).

4. Peripheralstemcelltransplantcauseslossofantibodiesin14%ofclients.

OtherData1. Thistestrequires2mLofserum.2. Theserumisstableatroomtemperature

for7daysandindefinitelyiffrozen.3. IntheUnitedStates,althoughmorethan

50%ofthepopulationispositiveforanti-HAVIgG,itisclinicallyinsignificant.

4. Thepresence of anti-HAV IgGdoesnotrule out acute hepatitis B or non-A,non-Bhepatitis.

HepatitisBCoreAntibody(Anti-HBc)Blood 629

H

5. Screening for HAV and HBV is recom-mended with elevated serum transami-naselevels.

6. The vaccine Epaxal can be used as abooster,Havrix is avaccine forhepatitisA with an 87% seroprotection rate and

Avaximhasa90%5-yearprotectionrate.Substantial immune response occurs foratleast12yearstore-exposure.

7. Two-dose schedule (0 and 6months) forcombinedhepatitisAandBelicits similarimmunogenicityasthethree-doseregimen.

HepatitisBCoreAntibody(Anti-HBc)BloodNorm. Negative.

Positive. HepatitisB.

Description. Hepatitis B core antibody isthe antibody marker that arises 1-2 weeksafter contraction of the hepatitis B virus,increases during the chronic phase of theillness,andremainspresentforlife.Itisthemostreliabletesttodeterminethepresenceof hepatitis B infection in the absence ofhepatitisBsurfaceantibodyandhepatitisBsurfaceantigen.




rationsornaturalremediessuchasChinesejin bu huan (gold-inconvertible, Jin BuHuan Anodyne Tablets, patent medicinewithmisidentifiedconstituents: essenceoftienchi [tianqi] flowers, Noto-ginseng;alsokombucha; alsoLycopodium serratum,orclubmoss;butwithplantalkaloidlevo-tetrahydropalmatine, a potent neuroactivesubstance), and BougainvilleaWild (Nyc-taginaceae:Bougainvillaea).





days.2. Hepatitis B can be spread by blood

and other body fluids, including thesharingofneedlesandsexualcontact.An

infectedmothercanpasstheinfectiontoherbaby.

3. Liver transplantation is associated withahighrateofviraltransmissionwithcar-riers present in 16% liver donors (Italy)but recipients did not have a significantimpact on graft survival. Donor racedoes not predict graft failure in livertransplantation.

4. TohelppreventthespreadofhepatitisB,washyourhandswellwithsoapandwateranduserapidscrubbingactionafteruri-natingordefecating.

5. Do not drink alcohol, beer, or wine ortake medicine that contains acetamino-phen or paracetamol for 3 weeks, or asspecifiedbyyourphysician.

FactorsThatAffectResults1. If the radioimmunoassay technique is

used, the injection of radionuclideswithin the last week may falsely elevateresults.

2. HerbsornaturalremediesthatmaycausehepatitisincludeChinesejin bu huan(seeabove).

3. Herbs or natural remedies that decreasehepatitis are Bougainvillea Wild(Nyctaginaceae).

4. False positive in persons recently vacci-natedforinfluenza.

OtherData1. Theserumisstableatroomtemperature

for7daysandindefinitelyiffrozen.2. Wastewater treatment plant workers are

atincreasedrisk.3. Two-dose schedule (0 and 6 months)

for combined hepatitis A and B elicitssimilarimmunogenicityasthethree-doseschedule.

4. ClientswithchronicGVHDareatsignifi-cantriskforHBVreactivation.

630 HepatitisBeAntibody(Anti-HBe,HBeAb)Serum

H

HepatitisBeAntibody(Anti-HBe,HBeAb)SerumPostprocedureCare1. Remove the serum and freeze it if the



days.


used,injectionofradionuclideswithinthepreviousweekmayfalselyelevateresults.

2. Anherbornaturalremedythatmaycausehepatitis includes Chinese jin bu huan(seeabove).

3. Anherbornaturalremedythatdecreaseshepatitis isBougainvilleaWild (Nyctagi-naceae:Bougainvillaea).

4. Methylprednisolone and antilympho-globulin for treating severe aplasticanemiacandevelophighlevelsofhepati-tisBeantibodyinpatients.


for7daysandindefinitelyiffrozen.2. The test ismoremeaningfulwhenmea-

sured in conjunction with hepatitis B eantigen.

3. The test should be prescribed only inclientswithdocumentedrecentinfectionofhepatitisB.

4. Tenofovir in combination with emtric-itabine isalternativetreatmentforhepa-titisBpatientsonadefovir.

Norm. Negative.


Description. Hepatitis B e antibody is aserummarker for hepatitis B that appears8-16 weeks after infection and indicatesresolution of acute infection. The presenceofthisantibodyinclientswithchronicposi-tivehepatitisBsurfaceantigenindicatesanasymptomatic,healthycarrier.


Preparation1. SeeClientandFamilyTeaching.2. Tube: Red topped, red/gray topped, or

goldtopped.3. Screentheclientfortheuseofherbalprep-

arationsornaturalremediessuchasjin bu huan (gold-inconvertible, Jin Bu HuanAnodyne Tablets, patent medicine withmisidentified constituents: essence oftienchi [tianqi] flowers, Noto-ginseng;alsokombucha;alsoLycopodium serratum,orclubmoss;butwithplantalkaloidlevo-tetrahydropalmatine,apotentneuroactivesubstance) andBougainvilleaWild (Nyc-taginaceae:Bougainvillaea).


HepatitisBeAntigen(HBeAg)BloodNorm. Negative.


Description. Usually appearing within4-12weeksofinfection,hepatitisBeantigenis one of the first indicators of hepatitis Binfection, usually preceding symptoms andrepresentingthegreatestthreatoftransmis-sion.Itisusuallypresentforonly3-6weeks.Persistenceoftheantigenforgreaterthan3monthsissuggestiveofchronicliverdiseaseorhepatocellularcarcinomaofgenotypesAthroughH;clientswithgenotypeHBV/GorCmorefrequentlyhaveHBeAg.



goldtopped.2. Screen the client for the use of herbal

preparations or natural remedies suchas Chinese jin bu huan and Bougainvil-leaWild.





days.

HepatitisBSurfaceAntigen(HBsAg:HAA)Blood 631

H


used, injection of radionuclides withinthe previous week may falsely elevateresults.




for7daysandindefinitelyiffrozen.

2. Clientswithchronicpositivetestsshouldalso be tested for the hepatitis B e coreantibody,whichindicatesthattheclientisanasymptomatic,healthycarrier.

3. AhepatitisBvaccineisavailableandrec-ommendedforhealthcareworkers.

4. Tenofovir in combination with emtric-itabine isalternativetreatmentforhepa-titisBpatientsonadefovir.

5. Hepatitis B surface antigen1logreductionatmonth6predictssustainedresponse.

6. Sustained response to interferon treat-mentislowinchronichepatitisBpatientswithgenotypeD.

HepatitisBSurfaceAntibody(HBsAb)BloodNegative. Limits of detection 2-10U/L.Post vaccine testing >10U/L or >10mIU/mLconfersprotection.


Description. This marker appears 2-16weeks after hepatitis B surface antigen hasdisappeared. It usually represents clinicalrecoveryand immunity to thevirus. Itwillalso be present during passive transfer inbloodbytransfusionorbyadministrationofhepatitisBimmuneglobulin(HBIG).Pres-ence of the hepatitis B surface antibodyalong with the hepatitis B surface antigenindicatesapoorprognosis.




preparationsornaturalremediessuchasChinese jin bu huan and BougainvilleaWild(Nyctaginaceae:Bougainvillaea).





days.



2. Anherbornaturalremedythatmaycausehepatitisincludesjin bu huan(seeabove).



for7daysandindefinitelyiffrozen.2. Thereisahighprevalenceofpositivetests

amongintravenousdrugabusers.3. Reverse seroconversion of hepatitis B

virus is common after autologous andallogeneicbonemarrowtransplants.

4. Hexavacvaccinewaswithdrawn in2005amidstconcernsaboutlong-termhepati-tisBprotection.

HepatitisBSurfaceAntigen(HBsAg:HAA)BloodNegative. Limits of detection 0.02-1.0 ng/mL.


Description. The hepatitis B surfaceantigen usually appears between 4 and 12weeksof infection. It is indicativeof activehepatitisB,eitheracuteorchronic(HBsAg

632 HepatitisCAntibodySerum

H

persistsmorethan6months).Itistheearli-est indicator of hepatitis B, specificity of99%, often preceding clinical symptoms.ChronichepatitisBcanoccurwithouthepa-titisBsurfaceantigendetectedduetovari-antsasingenotypeA.HBsAgiscommoninclientsundergoingimmunotherapy,chemo-therapy, or bone marrow transplant. Pres-ence of the hepatitis B surface antibodyalong with the hepatitis B surface antigenindicatesapoorprognosismaking this testuseful to predict clinical and treatmentoutcomes.

Thistest,requiredbytheFoodandDrugAdministrationwhenclientswishtodonateblood, has helped reduce the incidence ofhepatitis.








ClientandFamilyTeaching1. If the client is giving blood, explain the

donationprocedure.2. Results may not be available for several

days.


used,injectionofradionuclideswithinthepreviousweekmayfalselyelevateresults.



4. Genotype A and other rare mutationsproducefalsenegativeresults.

5. False positive results in heparinizedsamples, pregnancy, autoimmune dis-eases, chronic liver disease, interferenceswith hemoglobin or bilirubin, personsrecentlygivenhepatitisBvaccine,


for7daysandindefinitelyiffrozen.2. This testdoesnotscreenforhepatitisA,

hepatitisC,ornon-A,non-Bviruses.3. HBsAgmayalsobepresentinmorethan

5% of clients with Down syndrome,hemophilia, Hodgkins disease, andleukemia.

4. When HBsAg is found in donor blood,it must be discarded because it carriesa 40%-70% chance of transmittinghepatitis.

5. Reportconfirmedviralhepatitistopublichealthauthorities.

6. Potatoes have been used successfully toorallyadministerthevaccine.

7. Subgenotypes worldwide include: B1Japan,B2China,B3Indonesia,B4Vietnam,C1KoreaandChina,C2ChinaandBan-gladesh,C3Oceania,C4AboriginesAus-tralia,andD1-D4Europe,Asia,andAfrica.

HepatitisCAntibodySerumNorm. Negative.

Positive. Hepatitis C and non-A, non-Bhepatitis and some post kidney transplantdiabetesmellitus(PTDM)clients.

Description. Anassayto identifyantibod-iesof the IgGclass to thehepatitisCvirus(HCV), a newly identified gene to a ribo-nucleicacid(RNA)virusthatdoesnothavethequalitiesofeitherhepatitisAorhepatitisB;20%ofposttransfusionhepatitisfallsinto

thiscategory.Transmissionisviaexposuretocontaminated blood via intravenous druguse and abuse, organ transplant (before1992),transfusions(ofbloodbefore1992,ofclotting factors before 1987), dialysis, andneedlesticks.InfantsborntoHCV-positivemothersarealsoatrisk.HepatitisCinfects200millionpeopleworldwideandisrespon-sible for up to 10,000 deaths each year.ClientswithhepatitisCmaycarrytheviruschronically and not develop active diseaseuntilmanyyearsafterinitialinfection.

HepatitisCGenotype(HCVGenotype)Serum 633

H








ClientandFamilyTeaching1. If the client is giving blood, explain the

donationprocedure.2. Results may not be available for several

days.





4. Thistestis97%sensitivefordetectingthepresenceofhepatitisCvirus,butcannotdifferentiatebetweenchronic,acute,andpast/resolvedinfection.

OtherData1. Thistestrequires0.5mLofserum.2. Theserumisstableatroomtemperature

for7daysandindefinitelyiffrozen.3. Notifypublichealthauthoritiesifthetest

resultsarepositive.4. Up to now, there has been no commer-

cially available serologic test to detecthepatitisCantigen(HCAg).

5. TheincidenceintheUnitedStatesis1.8%andforchronicdialysisclientsitis9%.

6. Inner-city STD-infected obstetric clientsare at high risk for hepatitis C, as wellas clients whose alcohol intake is >40 gper day.

HepatitisCGenotype(HCVGenotype)SerumNorm. Negative.

Usage. GenotypingofthehepatitisCvirus(HCV)affectedRNAisutilized,inconjunc-tion with the clients clinical presentationandotherlaboratoryfindings,todeterminea treatmentplan and the clients prognosisandtoassistinidentifyingacauseforclientswithadiagnosisofhepatitisC.

Increased. Identification of hepatitis Cgenotypesubtype1a,1b,

Decreased. 1c,2a,2b,2c,3a,3b,4a-h,5a,and6a.

Positive. Individual tests may yield addi-tionalgenotypes.

Description. HCV is a genus from thefamilyFlaviviridae.ItsRNAissinglestrandedand has heterogeneous subtypes. Nucleicacid sequencingof the viral genomedeter-mines the type and subtype of the viralgenome. Treatment decisions are based onthe specific genotype identified in theaffected HCV RNA. Clients with chronicHCVareatagreaterriskfordevelopmentof

cirrhosis and hepatocellular carcinoma.Genotype I runs amore severe course andhasafasterprogression.


Preparation1. Tube:Lavenderorgoldtopped.2. Specimens may not be drawn during

hemodialysis.3. Screentheclientfortheuseofherbalprepa-

rationsornaturalremediessuchasChinesejin bu huan (gold-inconvertible, Jin Bu Huan Anodyne Tablets, patent medicinewithmisidentifiedconstituents: essenceoftienchi [tianqi] flowers, Noto-ginseng;alsokombucha; alsoLycopodium serratum,orclubmoss;butwithplantalkaloidlevo-tetrahydropalmatine, a potent neuroactivesubstance) and Bougainvillea Wild (Nyc-taginaceae:Bougainvillaea).

Procedure1. Collect 2mL of blood (minimum

0.5mL).

634 HepatitisDeltaAntibody(TotalAnti-HDV)Serum

H

2. Transportspecimeniniceimmediatelytolaboratory.


ClientandFamilyTeaching1. A complete history should be obtained

before testing to identifypossible causesofHCV.

2. Treatmentoptionsshouldbeexplainedtoclient on receipt of the results. Specialattentiontothepossiblesideeffectsoftheantiviralagentsshouldbeprovided.

FactorsThatAffectResults1. Qualitative (detect circulating HCV

RNA)andquantitative(measurethecir-culating HCV RNA) testing should becompleted before genotyping. (Samplescontaininglessthan1000RNAcopies/mLmaynotbesuitableforgenotypetesting.)

2. HCVgenotypingisnoteffectiveinclientswith mixed hepatitis types (hepatitisA and B); the test will be read asindeterminate.

3. Heparinized collection tubes or clientsreceiving heparin will render the test

invalid and will be read asindeterminate.



OtherData1. Genotypes 1 and 4 are associated with

more complicated disease and are lessresponsive to interferon treatment ascomparedtogenotypes2and3,especiallyinAfrican-Americanswithchronichepa-titisC.

2. The antiviral agent ribavirinmay be anadjunctive therapy option in chronicHCV and may be considered in morecomplicated cases in addition to treat-mentwithinterferon.

3. Non-A, non-B HCV is most frequentlythe origin of parenterally inducedhepatitis.

4. Genotype4iscommoninEasternMedi-terranean and Egypt; genotype 1 iscommoninJapan;genotype3iscommoninIndia.

HepatitisDeltaAntibody(TotalAnti-HDV)SerumNorm. Negative.

Positive. HepatitisD.

Description. Anassaytoidentifytotal(thatis, predominantly IgG) antibodies to thehepatitisDvirus.HepatitisD is an incom-pletevirusrequiringthepresenceofHBsAgof the hepatitis B virus for replication andexpression. It infects only clients concur-rentlyinfectedwithhepatitisBvirusorthosewho have a preexisting hepatitis B virusinfection.HepatitisDvirusismostcommonamongintravenousdrugabusers,hemophil-iacs,andclientswhohavereceivedmultiplebloodtransfusions.ItisamoresevereformofhepatitisthanhepatitisBalone,account-ingforahigherincidenceofchronichepati-tisandcirrhosis.

Clinically, hepatitis D virus cannot bedistinguishedfromothertypesofhepatitis.SerologictestsmustbepositiveforhepatitisBvirusandtotalanti-HDVtomakeadiag-nosisofhepatitisD.HepatitisDvirusisnota reportable disease inmost of theUnited

Statesatthepresenttime.Prevalenceamonghealth care workers is 8.6%. Incidence ofhepatitisDhasdecreasedmarkedlywithuseof HBV vaccine although increased preva-lence seen in those with chronic HBVinfection.




rationsornaturalremediessuchasChinesejin bu huan (gold-inconvertible, Jin Bu Huan Anodyne Tablets, patent medicinewithmisidentifiedconstituents: essenceoftienchi [tianqi] flowers, Noto-ginseng;alsokombucha; alsoLycopodium serratum,orclubmoss;butwithplantalkaloidlevo-tetrahydropalmatine, a potent neuroactivesubstance) and Bougainvillea Wild (Nyc-taginaceae:Bougainvillaea).

HepatobiliaryScan(HIDAScan)Diagnostic 635

H





days.


used, injectio

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