Quick Links
Main Menu
More Links

Latest Nursing Jobs &
Clinical Update Alerts!

Subscribe to get timely notifications.

Latest Nursing Jobs Vacancies
NCLEX & CGFNS Practice Questions

Tag: Biopsy

Bone Marrow Aspiration and Biopsy

Bone Marrow Aspiration and Biopsy

Bone marrow aspiration is one of the diagnostic tools used to assess the status of the hematopoietic system. It involves extracting small amounts of myeloid tissue from a bony cavity (e.g., the sternum or iliac crest). The posterior-superior spine portion of the iliac crest is considered the first choice site because there is a higher percentage of success in obtaining quantities of bone marrow sufficient for diagnostic testing.

Bone marrow aspiration provides accurate information on the relative number of stem cells and their development and morphological structure. A follow-up technique, bone marrow biopsy, provides a more specific morphology of the bone.

OVERVIEW

Complications
● Potentially painful
● Potential hemorrhage at the site
● Risk of introducing infection to the bone, which can lead to osteomyelitis
● Retroperitoneal hemorrhage caused by penetration into the bowel cavity by too deep a penetration of the iliac crest
● Unsuccessful biopsy (known as dry tap)
CLICK HERE for more resources on Fundamentals of Nursing
OPTIONS
● Bone marrow aspiration
● Bone marrow biopsy

RATIONALE
● To assess the hematopoietic system
● To evaluate hematopoietic abnormalities



INDICATIONS
● Unexplained anemia
● Unresolved neutropenia after withdrawal from antibiotic therapy
● Suspected metastatic disease
● Abnormal hematopoietic disorder (leukemia, idiopathic thrombocytopenia, pancytopenia)
● Lymphoproliferative disorders, including lymphoma
● Immunodeficiency disorders, including HIV
● Fever of unknown etiology
● Suspected unusual presentation of an infectious disorder (fungal, tuberculosis)
● Chromosomal analysis
● Bone marrow transplantation

CONTRAINDICATIONS
● Severe osteoporosis
● Hemophilia
● Known radiation to bone site

◗ Informed consent required

PROCEDURE

Bone Marrow Aspiration and Biopsy

Equipment
Prepackaged disposable kits are available.
● Gloves—sterile
● Povidone-iodine (Betadine)
● Fenestrated drape—sterile
● 3-mL syringe
● Two needles—21 gauge and 25 gauge, 1½ inch
● 1% or 2% lidocaine without epinephrine
● 10-mL syringe prepared with ethylenediamine tetra-acetic acid (EDTA) solution
rinse
● Complete blood count purple-top (EDTA) laboratory test tube
● No. 11 scalpel
● Bone marrow aspiration needle
● Jamshidi bone marrow biopsy needles (optional)
● Microscope glass slides
● Fixative specimen container
● 4 × 4 gauze—sterile
● Tape



CLICK HERE for more resources on Laboratory & Diagnostic Test

Procedure

BONE MARROW ASPIRATION—ILIAC CREST
● Position the client comfortably on abdomen. A pillow under the area of the procedure may relax the individual.
● Identify the posterior-superior landmarks.
● Cleanse the area of the aspiration and 3 inches surrounding with povidone-iodine.
● Open the bone marrow kit.
● Put on sterile gloves.
● Draw up lidocaine in the 3-mL syringe with the 25-gauge needle.
● Insert the needle intradermally at the site, and inject a small amount of lidocaine until a wheal has formed.
● Replace the 25-gauge needle with the 21-gauge needle, and penetrate deeper into the tissue until the periosteum of the site is felt. Inject approximately 1 mL into the area; then slowly withdraw while infiltrating the needle tract with the remaining solution.
● While waiting for local anesthetic to work (5 to 10 minutes), confirm that the obdurator of the biopsy needle is locked in place and the cap is secured.
● When the skin is anesthetized, use the No. 11 scalpel and make a small (0.25 cm or less) stab wound.
● Insert the biopsy needle at a 90-degree angle into the incision with the capped end in the palm of hand and the shaft between two fingers (usually index and middle fingers) until resistance of the periosteum is felt.
● Instruct the client that the next part of the procedure may cause a pressure sensation.
● Simultaneously begin to apply downward pressure and alternate clockwise and counterclockwise motions to penetrate the cortex of the bone.
● Continue this until penetration for approximately 1 cm until the “give” of the cortex is felt. Halt downward pressure, and advance approximately 1 to 2 mm farther to ensure placement in the marrow. The biopsy needle should be held in place by the skin and bone.
● Unlock the cap of the syringe, withdraw the obturator, and attach the EDTA-prepared 10-mL syringe.
● Counsel client that pain may be felt at this time and to remain as still as possible.
● Pull up on the plunger of syringe. This creates a vacuum, allowing bone marrow contents to be aspirated. If no material is withdrawn, advance the needle an additional 1 to 2 mm, and repeat aspiration.
● If still no response, withdraw the needle from that periosteum site, and try another site within the incision.
● Withdraw a minimum of 5 mL of marrow. A good specimen shows grossly visible bone spicules.
● Prepare the smears (may be performed by nonsterile assistant) in the following manner – Thinly spread the bone marrow aspiration material over one glass specimen slide and cover with second slide.
● Gently squeeze the two slides together, and allow any excess blood to drain off the slides.
● After excess blood is removed, roll the slides apart lengthwise.
• This allows thinning of any layering of the specimen.
● On successful aspiration, remove the needle, and apply pressure over the area using a quarter-folded 4 × 4 gauze and tape as a pressure dressing.
● Have the client remain supine for 1 hour with pressure dressing in place.
● After 1 hour, the client may get up and leave.



BONE MARROW BIOPSY—USUALLY PERFORMED ON THE ILIAC CREST
● Position the client comfortably on abdomen. A pillow under the area of the procedure may relax the individual.
● Identify the posterior-superior landmarks.
● Cleanse the area of the aspiration and 3 inches surrounding with povidone-iodine.
● Open the bone marrow kit.
● Put on sterile gloves.
● Draw up lidocaine in the 3-mL syringe with the 25-gauge needle.
● Insert the needle intradermally at the site and inject a small amount of lidocaine until a wheal has formed.
● Replace the 25-gauge needle with the 21-gauge needle, and penetrate deeper into the tissue until the periosteum of the site is felt. Inject approximately 1 mL into the area; then slowly withdraw while infiltrating the needle tract with the remaining solution.
● While waiting for local anesthesia to work (5 to 10 minutes), confirm that the obdurator of the biopsy needle is locked in place and cap is secured.
● When the skin is anesthetized, use the No. 11 scalpel and make a small (0.25 cm or less) stab wound.
● Insert the biopsy needle at a 90-degree angle into the incision with the capped end in the palm of hand and the shaft between two fingers (usually index and middle fingers) until resistance of the periosteum is felt.
● Instruct patient that he or she may feel pain and pressure.
● Simultaneously begin to apply downward pressure and alternate clockwise and counterclockwise motions to penetrate the cortex of the bone.
● Continue this until penetration for approximately 1 cm until the “give” of the cortex is felt. Halt downward pressure, and advance approximately 1 to 2 mm farther to ensure placement in the marrow. The biopsy needle should be held in place by the skin and bone.
● When the biopsy syringe has been placed in the marrow, withdraw the needle 3 mm to have it placed in the cortex.
● Redirect the angle of the needle toward the anterior iliac spine, and advance it into the cortex until resistance decreases.
● Remove the obdurator and perform an alternate clockwise and counterclockwise motion for a distance of 2 cm.
● Proceed to rock the needle clockwise five times and then counterclockwise five times to ensure a good specimen.
● Change the angle approximately 15 degrees, and repeat previous step. This allows the specimen to be severed from the marrow.
● Cover the opening of bone marrow needle with your thumb and withdraw it.
● Insert the obturator and allow the specimen to be pushed out onto sterile 4 × 4 gauze.
● Prepare the smears (may be performed by nonsterile assistant) in the following manner
● Using a light touch, gently touch four glass slides to the specimen on the gauze.
● Place the specimen in a container with the fixative agent.
● On completion, remove needle, and apply pressure over the area using a quarter-folded sterile 4 × 4 gauze and tape as a pressure dressing.
● Have the client remain supine for 1 hour with pressure dressing in place.
● After 1 hour, client may get up and leave.



Client Instructions
● Infection rarely is associated with this procedure. Observe for signs and symptoms of infection, however, such as
● Increased redness and warmth at the site
● Red streaks
● Swelling with drainage
● Pus from site
● Contact your health-care provider if any of the following symptoms occur within 48 hours
● Fever
● Abdominal pain
● Unrelieved site pain
● Leave the pressure dressing on for 12 hours. After that time, the dressing may be removed and a standard dressing applied.
● Keep the site clean and dry for 24 hours.
● Avoid strenuous exercise for 48 hours.
● Pain is usually minimal and may be relieved with acetaminophen (Tylenol) or acetaminophen with codeine (Tylenol No. 3).
● Return to the office in 48 hours for recheck.

BIBLIOGRAPHY
McCance K, Huether S. Pathophysiology: The Biological Basis for Disease in Adults and
Children. St. Louis, MO: Mosby; 1996.
Paulman P. Marrow sampling. Am Fam Physician. 1989;40(6):85–87.
Pfenninger JL, Fowler GC. Procedures for Primary Care Physicians. St. Louis, MO: Mosby; 2011.
CLICK HERE for more resources on Laboratory & Diagnostic Test

Anoscopy: Overview, Indications, Procedure

Anoscopy: Overview, Indications, Procedure

Anoscopy is the direct visualization of the anus using a speculum. It is used to screen, diagnose, and evaluate perianal and anal problems.

OVERVIEW
Used in
● Emergency departments
● Primary care settings

RATIONALE
● To screen, diagnose, and evaluate perianal and anal problems

INDICATIONS
● Rectal or anal bleeding or unusual discharge
● Perianal or anal pain
● Hemorrhoids
● Rectal prolapse
● Digital examination that reveals a mass
● Perianal abscess and condyloma



CONTRAINDICATIONS
● Acute cardiovascular problems—may stimulate the vasovagal reaction
● Acute abdominal problems
● Unwilling patient
● Stenosis of the anal canal
◗ Informed consent required
CLICK HERE for more resources on Fundamentals of Nursing
CLICK HERE for more resources on Laboratory & Diagnostic Test



PROCEDURE
Anoscopy

Equipment
● Anoscope
● Light source
● Gloves—nonsterile
● Drape—nonsterile
● Water-soluble lubricant (K-Y jelly)
● Large cotton-tipped applicators—nonsterile
● Monsel’s solution—to control bleeding (ferric subsulfate)
● 4 × 4 gauze—nonsterile
● Biopsy forceps
● Container with 10% formalin

Procedure
● Position the client in the left lateral decubitus position.
● Drape the client.
● Put on gloves.
● Tell the client you are going to touch him or her by the rectum.
● Spread the gluteal fold and examine visually.
● Have the client bear down and observe for hemorrhoids or prolapse.
● Lubricate your second digit with K-Y jelly and perform a digital examination.
● Lubricate the anoscope with K-Y jelly.
● Have the client take slow, deep breaths to relax the sphincter.
● Insert the anoscope slowly and gently into the anus toward the umbilicus.
● Remove the obturator.
● Visualize the rectal mucosa, noting the vasculature, pectinate line, transitional zone, and drainage.
● Remove fecal matter and drainage with a large cotton swab if necessary.
● Obtain a biopsy specimen if needed using the biopsy forceps. Place the tissue specimen in a container with 10% formalin.
● If bleeding is present, apply Monsel’s solution and pressure.
● Remove anoscope gently, and observe the mucosa for any injury.



Client Instructions
● Slight bleeding is normal after this procedure because of the possibility of an abrasion, tearing of the mucosa or anus, or hemorrhoids.
● If slight bleeding persists for more than 2 days, notify your health-care provider.
● To decrease pain and swelling, sit in a tub of warm water for 10 to 15 minutes three times per day.

BIBLIOGRAPHY
Pfenninger JL, Fowler GC. Procedures for Primary Care Physicians. St. Louis, MO: Mosby;
2011.

CLICK HERE for more resources on Fundamentals of Nursing
CLICK HERE for more resources on Laboratory & Diagnostic Test

Nursing Responsibilities during Breast Biopsy

Nursing Responsibilities during Breast Biopsy

Normal Findings
• Breast tissue consisting of cellular and noncellular connective tissue, fat lobules, and various lacti ferous ducts
• Pink appearance with more fatty than fibrous tissue
• Absence of abnormal cell development or tissue elements

Abnormal Findings
• Benign tumors such as in fibrocystic disease, adenofibroma, intraductal papilloma, mammary fat necrosis, and plasma cell mastitis (mammary duct ectasia)
• Malignant tumors such as in adenocarcinoma, cystosarcoma, intraductal carcinoma, infiltrating carcinoma or circumscribed carcinoma, colloid carcinoma, lobular carcinoma, sarcoma, and Paget’s disease

Nursing Implications
• Anticipate the need for additional testing.
• Provide emotional support to the patient during this period.

Purpose
• To differentiate between benign and malignant breast tumors



Description
Breast biopsy is performed to confirm or rule out breast cancer after clinical examination, mammography, or
thermography has identified a mass. Common techniques include fine-needle or needle biopsy (performed when
a patient has a fluid-filled mass that’s been identified by ultrasonography) and open biopsy (performed to allow access to the complete tissue system, which can be sectioned to allow more accurate
evaluation). In some cases, stereotactic breast biopsy may be used. This involves immobilizing the breast and allowing a computer to calculate the exact location of the mass based on x-rays from two angles.
A breast biopsy can usually be done on an outpatient basis under local anesthesia; however, an excisional open
biopsy may require general anesthesia. If sufficient tissue is obtained and the mass is found to be a malignant tumor, specimens are sent for estrogen and progesterone receptor assays to assist in determining future therapy and the prognosis.
The usual procedures for needle and open biopsies are as follows:

Needle Biopsy
• The patient is instructed to undress to the waist, and is placed in a sitting or recumbent position with her arms
at her sides.
• The biopsy site is prepared, a local anesthetic is administered, and the syringe (luer-lock syringe for aspiration, Vim-Silverman needle for tissue specimen) is introduced into the lesion.
• Fluid aspirated from the breast is expelled into a properly labeled, heparinized tube; the tissue specimen is placed in a labeled specimen bottle containing normal saline solution or formalin. With fine needle aspiration, a slide is made for cytology and viewed immediately under a microscope. (Because breast fluid aspiration isn’t considered diagnostically accurate, some practitioners aspirate fluid only from cysts. If such fluid is clear yellow and the mass disappears, the aspiration procedure is diagnostic and therapeutic, and the aspirate is discarded. If aspiration yields no fluid or if the lesion recurs two or three times, an open biopsy is then considered appropriate.)
• Pressure is exerted on the biopsy site and, after bleeding stops, an adhesive bandage is applied.

CLICK HERE for more resources on Laboratory & Diagnostic Test
CLICK HERE for resources on Fundamentals of Nursing

Open Biopsy
• After the patient receives a general or local anesthetic, an incision is made in the breast to expose the
mass.
• The practitioner may then incise a portion of tissue or excise the entire mass. If the mass is smaller
than ¾” (2 cm) in diameter and appears benign, it’s usually excised; if it’s larger or appears malignant, a
specimen is usually incised before the mass is excised. Incisional biopsy generally provides an adequate specimen for histologic analysis.
• The specimen is placed in a properly labeled specimen bottle containing 10% formalin solution. Tissue that appears malignant is sent for frozen section and receptor assays. Receptor assay specimens must not be placed
in the formalin solution.
• The wound is sutured and an adhesive bandage applied.
Because breast cancer remains the most prevalent cancer in women, genetic researchers are continually working to identify women at risk.




Interfering Factors
• Failure to obtain an adequate tissue specimen
• Failure to place the specimen in the proper solution

Precautions
• Breast biopsy is contraindicated in the patient with a condition that precludes surgery.

Nursing Considerations(Responsibilities)
Before the Test
• Confirm the patient’s identity using two patient identifiers according to facility policy.
• Describe the procedure to the patient, and explain that breast biopsy permits microscopic examination of a breast tissue specimen. Offer her emotional support, and assure her that breast masses don’t always indicate cancer.
• Inform the patient scheduled for a needle biopsy that she’ll need to sit still during the procedure.
• If the patient is to receive a local anesthetic, advise her that she doesn’t need to restrict food, fluids, and medication. If she’s to receive a general anesthetic, advise her to fast from midnight before the procedure until after the biopsy.
• Tell the patient who will perform the biopsy, and where and when it will be done. Explain that pretest studies, such as blood tests, urine tests, and chest X-rays, may be required.
• Make sure the patient or a responsible family member has signed an informed consent form.
• Check the patient’s history for hypersensitivity to anesthetics.

CLICK HERE for more resources on Laboratory & Diagnostic Test
CLICK HERE for resources on Fundamentals of Nursing

During the Test
• Remind the patient undergoing a needle biopsy to sit still.
• Assist with the collection of specimens into the appropriate containers,if indicated.
• Send the specimens to the laboratory immediately, if appropriate.



After the Test
• If the patient has received a general or local anesthetic, monitor the patient’s vital signs regularly. If she
has received a general anesthetic, check her vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for the next 4 hours, and then every 4 hours.
• Administer analgesics for pain, as ordered, and provide ice bags for comfort.
• Instruct the patient to wear a support bra at all times until healing is complete.
• Observe for and report bleeding, tenderness, and redness at the biopsy site.
• Provide emotional support to the patient awaiting diagnosis.

Punch Biopsy

Biopsy is the removal of a small piece of tissue from the skin for microscopic examination. Partial or full thickness of skin over the lesion is removed for evaluation.

OVERVIEW

    Punch biopsy is used for full and partial dermal lesions such as

  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Actinic keratoses
  • Seborrheic keratoses
  • Lentigo (freckles)
  • Lipomas
  • Melanomas
  • Nevi
  • Warts—verruca vulgaris

RATIONALE

  • To confirm etiology of lesion for treatment
  • To establish or confirm a diagnosis for treatment and/or intervention

INDICATIONS

  • Partial- or full-dermal-thickness lesion not on the face, eye, lip, or penis

CONTRAINDICATIONS

  • Lesion on eyelid, lip, or penis, REFER to a physician.
  • Infection at the site of the biopsy
  • Bleeding disorder
  • Lesions that are deep or on the face, REFER to a physician.
  • Informed consent required

PROCEDURE

Punch Biopsy
Equipment

  • Antiseptic skin cleanser
  • Drape—sterile
  • Gloves—sterile
  • Disposable biopsy punch
  • Pickups—sterile
  • Scissors—sharp for the fine tissue—sterile
  • 3-mL syringe
  • 27- to 30-gauge, ½-inch needle
  • 1% lidocaine
  • Container with 10% formalin
  • 4 × 4 gauze
  • Nonstick dressing (Adaptic or Telfa)
  • Kling
  • Tape
  • Steri-Strips (if biopsy will be greater than 4 mm) or one suture

Procedure

  • Position the client so that the area to be biopsied is easily accessible.
  • Cleanse the skin with antiseptic skin cleanser.
  • Put on gloves.
  • Drape the area to be biopsied.
  • Anesthetize with 1% lidocaine.
  • With the thumb and index finger, spread the skin to apply tension opposite natural skin tension lines. This allows a more elliptical-shaped wound for easy closure.
  • Apply biopsy punch to skin, rotate per manufacturer’s directions, and remove the punch
  • With pickups, pull up loosened skin.
  • Cut with scissors, and place tissue in tissue container of 10% formalin.
  • If less than 2 to 3 mm, apply nonstick dressing and pressure dressing.
  • If greater than 4 mm, apply Steri-Strips and cover with 4 × 4 gauze.
  • Apply Kling and secure with tape.

Client Instructions

    • Keep dressing clean, dry, and in place for 48 hours to decrease the chance of bleeding and oozing.
    • Avoid touching or contaminating the area biopsied.
    • To prevent the chance of infection, take cephalexin (Keflex) 500 mg three times per day or amoxicillin (Amoxil) 500 mg twice a day for 5 days.
    • Some redness, swelling, and heat are normal. Return to the office if symptoms of infection occur, such as

● Yellow or green drainage
● Red streaks
● Pain
● Elevated temperature

  • Take acetaminophen (Tylenol) or ibuprofen (Motrin) every 4 to 6 hours as needed for pain.

BIBLIOGRAPHY
De Vries HJ, Zeegelaar JE, Middelkoop E, et al. Reduced wound contraction and scar formation in punch biopsy wounds. Native collagen dermal substitutes. A clinical study. Br J Dermatol. 1995;132(5):690–697.

Zuber TJ. Ingrown toenail removal. Am Fam Physician. 2002;65(12):2547–2550.

Copyright 2015, Nurses Zone, Lagos, Nigeria. All Rights Reserved.
WhatsApp No.: +2348055338879
Website Design Company in Lagos, Nigeria - CKDigital