FOR FUTURE MEDICAL PROFESSIONALS Venipuncture Course & Training Kit A BASIC COURSE IN PHLEBOTOMY AND IV TECHNIQUES
A product developed and marketed by THE APPRENTICE CORPORATION
Author: Dr. Anton Scheepers Copyright© The Apprentice Corporation 2013 All rights reserved. THE APPRENTICE CORPORATION: COPYRIGHT INFORMATION All material contained in this The Apprentice Doctor® Venipuncture Course is protected by international copyright laws. Copyright of the contents of The Apprentice Doctor® CD-ROMs, DVD-ROMs and website content (including but not limited to text, pictures, sketches, logos, animations, photographic material, video material, sound samples, and graphic art) is the sole property of The Apprentice Corporation. All the rights of The Apprentice Corporation are reserved. No part of The Apprentice Doctor® CD-ROMs, DVD-ROMs, websites, books, or e-books may be reproduced or transmitted in any form or by any means without the express written consent of The Apprentice Corporation. Contact information for written consent may be requested from:
The Apprentice Corporation 275 Woodward Avenue Kenmore, NY 14217 U.S.A. Or per email: [email protected]
We appreciate your integrity in this regard.
First edition - October 2013 Venipuncture Course and Kit |
PREFACE
A basic understanding of general human (or veterinary) hospitals and training institutions. The basic principles anatomy and physiology, especially the cardiovascular and essential steps, however, should remain very similar. system, is required in order to understand and safely apply Workable protocols and standards in a mission hospital in the techniques that the student will learn. rural Tanzania in Africa will be quite different from what Every “simple” venipuncture procedure is in essence a is acceptable in a top level training hospital in New York. minor surgical procedure governed by the basic principles Medical professionals should always use the highest of surgery: standards and never compromise patient or personal • Have a comprehensive understanding of basic safety. medical sciences, especially anatomy and physiology Despite thorough research, the author and contributing of the relevant areas and systems. professionals aren’t necessarily perfect. Should you • Follow the basic principles of sterility and asepsis, notice any mistakes in either the theory or the practical including the use of barrier techniques. demonstrations on DVD-ROM, kindly report this to the • Take a medical history and interpret this information author in writing or email. Your suggestions will be to modify your treatment plan. appreciated for future versions. • Use good lighting. The www.TheApprenticeDoctor.com website and • Respect life and bodily tissues. community complement our products by offering future • Perform the procedure in a humane and professional medical professionals a chance to join like-minded manner. students and by providing a platform for learning from • Anticipate the possibility of complications and deal practicing healthcare professionals. You will find a suitable them promptly and effectively. community in your area, and you’ll receive lots of free advice and support. The Apprentice Doctor® Venipuncture Skills Course Dr. Anton Scheepers, The Apprentice Corporation staff, and Kit are not intended to be used as a substitute for and The Apprentice Doctor® community leaders would clinical training. Instead, The Apprentice Doctor® offers like to wish you a successful future and look forward to a firm foundation so students can successfully master being of assistance towards fulfilling your dreams! the initial learning curve in a non-clinical setting before confidently entering the clinical situation. The Apprentice Doctor® Venipuncture Course and Kit is recommended training material for all healthcare The Apprentice Doctor® Venipuncture Course and Kit professionals whether prospective, in training, or qualified: consist of: • Medical students 1. The Apprentice Doctor® Venipuncture Course on • Pre-medical students DVD-ROM • Paramedics and EMT students 2. The Apprentice Doctor® Venipuncture Kit with a • Nursing students Venipuncture Trainer, as well as a variety of medical • Phlebotomy students items to complete all the practical projects. • Dental students • Veterinary students IMPORTANT NOTES: • Surgery interns/registrars The information offered in The Apprentice Doctor® • Advanced first aid practitioners Venipuncture Course material is based on recent • Military medics guidelines set by the World Health Organization (WHO), • High school students interested in a career in medicine and the Centers for Disease Control and Prevention (CDC). (guidance required) The References section gives more information with links • Practicing healthcare professionals who would like to to help you keep track of the latest information. improve their venipuncture skills Keep in mind that specifics may differ from the information or protocol of your local hospital or training institution. The Apprentice Doctor® Venipuncture Course is In a clinical field, there are often a number of acceptable intended as supportive training material for formally protocols, knowledge of more than one offers students registered and accredited medical, dental and veterinary a fuller picture. Protocols and standards may vary in courses. In itself, this course does not qualify one as a different regions and countries, as well as in different phlebotomist or any other type of medical professional.
4 Venipuncture Course and Kit |
FOREWORD
In any practical endeavor—from writing a book, to proficiency, knowledge, and confidence to be successful in painting a picture, to performing a surgical operation—a the clinical situation. Simulation training is not an optional solid foundation in the basic skills of the discipline is an extra, but an essential step in training clinicians who are essential prerequisite. able to practice medicine safely while avoiding or at least The days when clinical skills were simply taught from senior minimize clinical errors. to junior, from one year to the next are long gone. Clinical An affordable venipuncture course and kit has been skills require an in-depth knowledge of the procedure long overdue. The authors, developers, and the various as well as the opportunity to practice in a simulation contributors should be commended on a task well done! environment, with definite guidelines to follow, and parameters to evaluate the student’s progress. Students Dr John Lemmer – Emeritus professor Oral Medicine and need to train in a non-clinical setting until they have the Periodontics, University of the Witwatersrand
WARNINGS
Before starting the course, please read these warnings • Re-use items only in a non-clinical practice carefully: situation. In a clinical setting, the re-use of items is • The Apprentice Doctor® Venipuncture Course and not recommended (such as tourniquets) or strictly Kit is an Educational product. All items in this kit are prohibited (used items such as needles, IV fluids, etc.). intended exclusively for non-clinical purposes. Do not Refer to your local hospital’s policies and protocols. use any of these items on actual human or animal • For any cut or needle prick injuries—squeeze the patients, even in an emergency. wound for 15-30 seconds to bleed out impurities, • This kit and its components are intended exclusively wash profusely with soap and water, apply pressure for training/educational purposes. They are not to stop the bleeding, and then apply an adhesive intended for use in any clinical setting, or in the cure, bandage strip. Seek professional medical assistance. mitigation, treatment, or prevention of disease in man • Discard all sharp instruments in the “Used Sharps or other animals. Biohazard Container” provided. On completion of • The Apprentice Doctor® Venipuncture Course and The Apprentice Doctor® Venipuncture Course Kit contains sharp instruments. Please be cautious! (including all the practical projects), close the sharps • Keep out of reach of children of 14 years and younger, waste container and take the container to a hospital, especially toddlers and babies. a healthcare facility or any medical professional • Adult supervision is required for students 15-17 years for proper sharps biohazard waste disposal. NEVER of age. It is essential that students 18 years and older dispose any sharps (used or unused) into a regular take extreme care while doing the practical projects. waste bag or bin! Alternatively contact us per email • Some items may contain latex rubber, not suitable for and we will mail a self-addressed box. Return with persons with latex allergies. your sharps container for safe disposal. • Always use clean items. Wash used items with liquid • Keep sharp instruments away from the eyes. Protective soap and water after each session then leave in an glasses or visors are recommended. antiseptic solution (e.g., Savlon) for 60 minutes. Rinse Important! Familiarize yourself with the warnings on thoroughly with clean water and dry before replacing the package and the disclaimer on the leaflets inside the in the kit. package and on the DVD-ROM before proceeding.
5 Venipuncture Course and Kit |
KEYS TO SYMBOLS USED IN THE PRACTICAL PROJECTS
VIDEO
Sharps will be used!
• Sharp or potentially sharp medical items or objects (e.g., glass medicine vials) will be used. • Perform the procedures in these projects with great caution and care. • Discard sharp and potentially sharp items ONLY in the sharps waste container. • Study the section ASPECTS OF SAFETY before doing these projects.
Blood hazard
• A definite possibility of blood contamination exists when performing these procedures in a real clinical setting. • Ensure that all relevant aspects of sterility and asepsis are in place, and use appropriate barrier techniques (gloves, masks, visors, protective glasses, etc.).
SIMULATION PROCEDURE
• Venipuncture Trainer is required – see PROJECT 10 to set up the Venipuncture Trainer. • Practice as much as you wish, within the limits of the safety guidelines and the restrictions regarding age. • It is essential that all students take great care with handling sharps while doing these practical projects.
6 Venipuncture Course and Kit |
CLINICAL PROCEDURE: RESTRICTED
Procedure may only be performed on real patients in a proper medical setting by either qualified medical professionals or students under proper supervision in a formal training facility with all relevant legalities and medical indemnities in place.
CLINICAL PROCEDURE: VOLUNTEERS ALLOWED
These procedures can be practiced on a suitable fellow student or other adult volunteer.
DISCLAIMER
The producer or supplier of this application does not: • Offer any warranty regarding the accuracy or The supplier disclaims all liability for any direct or indirect correctness of any information contained in this damages—specific or consequential—related in any way application. to the information and instrumentation or to any items • Assume any responsibility for any damage or contained in this application. consequential damage related in any way to the information, instrumentation, or items contained in All practical exercises are performed exclusively at the this product/application or as a result of their use. user’s risk. The producer or supplier of this application disclaims any responsibility for any medical emergencies, The user takes full and exclusive responsibility for the safe medical problems, or any other problems whatsoever that application of any information contained in this application. may arise while using any instrument or item or applying The user also takes full and exclusive responsibility for any information supplied with this application. all safety aspects related in any way to the use of any instrument, or item supplied with this application. This Regarding correctness of information and potential exclusive responsibility applies equally to the user or to problems arising from any misinformation: any person being supervised by the user. Keep in mind that there are differing points of view in medicine and medical knowledge changes quickly. If No warranties are offered on the functional status or fitness you think that any information is incorrect, contact us at for the specific application of any information, instrument [email protected]. or item supplied in this application.
It is solely and exclusively the responsibility of the The supplier accepts no responsibility for the malfunction users of this application to ensure that the information of any instrument or item. (The buyer will be entitled to offered in this course is correct, current and in line with the replacement of such defective items within the time their hospital or institution’s guidelines and protocols. limits of the Basic Terms and Conditions).
7 Venipuncture Course and Kit |
The Apprentice Corporation, its employees, of using the kit or applying the information from the any associates, as well as the distributors of the course material. Using this Kit—the instruments, product completely absolve themselves of any items, and information supplied on the CD- liability or potential liability for any misadventure or ROM—is conditional upon your acceptance of this complications that may result from using this kit or disclaimer and commitment to honor copyrights. the information contained in the course material. We take no responsibility whatsoever for any adverse For further information on copyright see Copyright outcome, problems, or complications of any nature Information. that might occur as a direct or indirect consequence
REIMBURSEMENT POLICY
The Apprentice Corporation is confident that you will material in your possession then repackage the kit with be satisfied with this product in each and every way, as ALL the items and devices in their original condition, supported by our extremely low return statistics. before returning. Shipping is your responsibility and expense. Reimbursement will follow automatically If for any reason, you are dissatisfied with your choice, once the kit has been received in our warehouse and The Apprentice Corporation will be happy to reimburse has been inspected for completeness and damage. you (less postage and shipping charges) should you wish to return the complete medical kit, as well as the KINDLY INFORM US REGARDING YOUR INTENTION DVD-ROM in an undamaged state within 8 weeks of TO RETURN THE KIT VIA EMAIL. THE ORDER purchase. NUMBER AND THE DATE OF THE TRANSACTION SHOULD ACCOMPANY YOUR REQUEST FOR Please be ethical. It is simply unfair to order and open REIMBURSEMENT. the kit, as well as some of the items then copy the course material on your computer or other electronic device Email: [email protected] and then expect a refund on returning the product. For more information see the Basic Terms and Conditions Before returning, delete ALL copies of the course available on our website: www.TheApprenticeDoctor.com
8 Venipuncture Course and Kit |
RECOMMENDATIONS ON HOW TO USE THE APPRENTICE DOCTOR® VENIPUNCTURE KIT
VIDEO
To gain maximum benefit from The Apprentice knowledge of related complications and how to Doctor® Venipuncture Course and Kit, the following avoid, minimize and manage them. guidelines should be followed: • Study all of the medical terms in the Venipuncture • Read the WARNINGS and DISCLAIMER sections Glossary. Play the various Venipuncture games – attentively. They are available on The Apprentice and have fun while learning! Doctor® Venipuncture DVD. • Check out the hyperlinks, particularly the latest • Work systematically through course material. Be information on the WHO and CDC websites. sure that you understand each section and can Visit The Apprentice Doctor® Web site (www. perform the practical projects skillfully before TheApprenticeDoctor.com) for information proceeding to the next section. Do not skip a on other educational medical kits – like The section because you think it is unimportant or too Apprentice Doctor Suturing Course and Kit simple. Although basic principles often appear to and the Examine Patients Course and Kit as well be simple, you must understand and practice these as information about events like The Apprentice simple building blocks in order to succeed later Doctor Camps and Clubs. with more complicated applications. Perform the • Please direct all technical enquiries regarding practical skills projects only when you understand orders and products via the Contact us facility on the theory involved in that specific section. the website. Use the Ask Dr. Anton link on the • Start with the Introduction section. You will learn website for enquiries related to The Apprentice about the items contained in The Apprentice Doctor regarding course material or careers in Doctor® Venipuncture Kit. Section 2 contains medicine. vital information about taking a medical history, • Start with the Introduction section. You will learn sterility and asepsis and offers the opportunity to about the items contained in The Apprentice practice relevant basic skills. Doctor® Venipuncture Kit. Section 2 contains • Systematically study The Apprentice Doctor® vital information about taking a medical history, Venipuncture Course Sections 3, 4 and 5 in sterility and asepsis and offers the opportunity to order and perform all of the practical projects using practice relevant basic skills. your Venipuncture Trainer where applicable. For business and reseller information email us at Do not omit Section 5 on complications – it is [email protected]. of utmost importance that one has a thorough
9 Venipuncture Course and Kit |
OBJECTIVES OF THE COURSE
This course helps you master venipuncture and intravenous On completion of this course, students should have (IV) techniques used by medical professionals. gained the following skills:
The course explains the art and science of phlebotomy, • Collecting capillary blood setting up an IV-line, and related skills. Most importantly, • Drawing venous blood (various techniques) the Venipuncture Trainer and Kit give students the • Drawing arterial blood opportunity to practice these skills before entering a • Giving a subcutaneous injection clinical setting. • Giving an intra-muscular injection • An illustrated hands-on course is available online • The student will receive basic information regarding and on DVD-ROM. Download an APP for your mobile other specimens (excluding blood) received by the device. medical technology lab (e.g., urine, sputum and pus) • The kit includes real medical items you will need to • The student will understand how to recognize practice more than 30 step-by-step practical projects. and how to deal with common and less common • A simple but effective Venipuncture Trainer is complications of venipuncture included. Professional simulation arms are available for group training. • Take the IV kit with you wherever you go – it’s lightweight and mobile. • The Apprentice Doctor® Venipuncture Course and Kit is the perfect resource for all venipuncture and IV skills training and workshops.
The objectives of the course are to assist students in mastering basic injection, phlebotomy and IV skills. The course offers information on the theory and practice of phlebotomy, setting up an IV line and associated techniques. The course covers topics such as collecting various samples for the laboratory, donating blood, injecting local anesthetics, and much more.
On completion of this course, students should have a good understanding of:
• The importance of taking a medical history before performing any invasive procedures • The importance of adhering to basic principles of sterility and asepsis • The items used to perform a venipuncture procedure and putting up an IV line • The basic principles of venipuncture • Various techniques of drawing venous, arterial and capillary blood • Various types of injections (e.g., local and regional anesthetic injections) • The basic principles of putting up an IV line
10 INDEX Venipuncture Course and Kit | PREFACE 4 FOREWORD 5 WARNINGS 5 KEYS TO SYMBOLS 6 DISCLAIMER 7 REIMBURSEMENT POLICY 8 HOW TO USE THE APPRENTICE DOCTOR® VENIPUNCTURE KIT 9 OBJECTIVES OF THE COURSE 10
INDEX 11
SECTION 1: INTRODUCTION 15 Case study 1: An Avoidable Accident—an Unnecessary Death 16 Types of intravenous fluids 18 PROJECT 1A – FAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT 19 SAFETY PROTOCOL AND SAFETY ITEMS 22 PROPER SHARPS DISPOSAL AND ILLEGAL INJECTION DRUG USERS 24 PROJECT 1B – HOW TO USE A SAFETY NEEDLE/DEVICE 25 BASIC ANATOMY OF THE CIRCULATORY SYSTEM 28 Main Blood Vessels—Full Body 28 Veins and arteries of the head and neck 29 Arteries of the arm 30 Veins of the arm 31 Veins of the arm (close-up) 32 Veins of the hand 33 Arteries of the leg 34 Veins of the leg 35 Anomalous superficial arteries in the arm 36 Blood 36 Blood plasma 36 Whole blood 37 Blood cells 37 Packed red blood 37 Hemoglobin 37 Hematology 37
SECTION 2 : PREPARATION 39 Case study 2: Contracting One of the Most Feared Diseases in the World Today 40 SHORT NOTES ON MEDICAL HISTORY 41 Patient information 42 PROJECT 2 –TAKE A MEDICAL HISTORY 42 SHORT NOTES ON STERILITY AND ASEPSIS 43 PROJECTS 3A – 3I 43 PROJECT 3A – A TECHNIQUE FOR PROPER HANDWASHING 43 PROJECT 3B – CLEANING HANDS WITH AN ANTISEPTIC RUB 46 PROJECT – 3C HOW TO DON (PUT ON) CLEAN GLOVES 46 PROJECT – 3D HOW TO SAFELY REMOVE USED GLOVES 47
11 Venipuncture Course and Kit |
*PROJECT 3E – HOW TO CHANGE INTO THEATER ATTIRE 47 *PROJECT 3F – HOW TO SCRUB FOR A STERILE PROCEDURE 47 *PROJECT 3G – HOW TO GOWN FOR A STERILE PROCEDURE 47 PROJECT 3H – HOW TO DON STERILE GLOVES 48 *PROJECT 3I – HOW TO REMOVE CONTAMINATED GLOVES 48 PATIENT POSITIONING 49 TOURNIQUETS 51 PROJECT 4A – HOW TO APPLY A TOURNIQUET (DISPOSABLE) 51 PROJECT 4B – HOW TO APPLY A TOURNIQUET (TOURNISTRIP®) 53 PROJECT 4C – HOW TO APPLY A TOURNIQUET (REUSABLE) 54 PROJECT 4D – HOW TO APPLY A TOURNIQUET (BLOOD PRESSURE CUFF) 54 PROJECT 5A – IDENTIFY THE VEINS OF THE UPPER EXTREMITY 55 PROJECT 5B – IDENTIFY THE VEINS OF THE LOWER EXTREMITY 57 PROJECT 5C – OTHER IMPORTANT VEINS (FACE, NECK AND CHEST) 59 PROJECT 5D – MAP THE VALVES IN VEINS 61 PROJECT 6A – PREPARE TO GIVE AN INJECTION 63 PROJECT 6B – HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (ROUTINE VENIPUNCTURE) 69 PROJECT 6C – HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FOR BLOOD CULTURE) 71 PROJECT 6D – HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FROM BLOOD DONOR) 73
SECTION 3: VENIPUNCTURE SKILLS 75 Case study 3: My Life Changed Drastically in a Split Second 76 CAPILLARY BLOOD COLLECTION USING A LANCET 77 PROJECT 7A – DRAW CAPILLARY BLOOD (ADULT) 77 PROJECT 7B – DRAW CAPILLARY BLOOD (BABY) 79 PROJECT 8 – HOW TO GIVE A SUBCUTANEOUS INJECTION 81 Intradermal injections 84 PROJECT 9 – HOW TO GIVE AN INTRAMUSCULAR INJECTION 85 PROJECT 10A – SET UP THE VENIPUNCTURE TRAINER PHLEBOTOMY 88 PROJECT 10B – SET UP THE VENIPUNCTURE TRAINER FOR IV PROJECTS 89 PROJECT 10C – SET UP THE VENIPUNCTURE TRAINER FOR ARTERIAL BLOOD 90 Taking care of the Venipuncture Trainer 90 Refilling the IV fluid bag 90 THERAPEUTIC PHLEBOTOMY (LETTING BLOOD) 90 MAXIMUM ALLOWABLE TOTAL BLOOD DRAW VOLUMES 90 PROJECT 11A – DRAW VENOUS BLOOD USING A VACUUM TUBE 91 PROJECT 11B – DRAW VENOUS BLOOD USING A SYRINGE 96 PROJECT 11C – DRAW BLOOD USING A BUTTERFLY NEEDLE 99 PROJECT 11D – HOW TO SETUP AND START AN IV LINE 102 PROJECT 11E – HOW TO REMOVE THE IV LINE 106 SPECIAL GROUPS OF PATIENTS 107 The neonate patient 107 The pediatric patient 107 VETERINARY VENIPUNCTURE 108 The animal patient 108 AIDS TO ASSIST THE CLINICIAN 109 VeinViewer® 109 AccuVein® 109 Breastlight™ 109 Ultrasound 109
12 Venipuncture Course and Kit |
Radiography 109 PROJECT 12A – IDENTIFY THE BODY’S PULSE POINTS 110 PROJECT 12B – PERFORM A MODIFIED ALLEN’S TEST 112 PROJECT 12C – DRAW ARTERIAL BLOOD 114 BLOOD TRANSFUSIONS 117 Blood types (Blood Groups) 117 Agglutination 118 Blood donations 119 PROJECT 13 – DONATING BLOOD FOR THE BLOOD BANK 120
SECTION 4: RELATED TOPICS OF INTEREST 123 Case study 4: Despite All the Training and the Necessary Care, Accidents Do Happen 124 CENTRAL VENOUS LINE 125 ARTERIAL CATHETERIZATION 126 CORONARY ARTERIOGRAPHY 127 INTERVENTIONAL RADIOLOGY 127 KIDNEY DIALYSIS 128 KIDNEY DIALYSIS 129 PORTS 129
TOTAL PARENTERAL NUTRITION (TPN) 130 ANESTHESIA 130 Topical Anesthetic 130 Local Anesthesia 130 Infiltration Local Anesthesia 130 PROJECT 14 – INFILTRATING A WOUND WITH LOCAL ANESTHETIC BEFORE SUTURING 131 Local Anesthetic Block 134 Regional Anesthesia 134 General Anesthesia 135 Infusion Pumps 135 NEW DEVELOPMENTS 135 Microprobes for continuous monitoring 135 Needleless Injections 135 SHORT NOTES ON OTHER BODILY SECRETIONS 136 Saliva 136 Sputum 136 Breast milk 136 Semen 136 Sweat 137 SHORT NOTES ON OTHER BODILY EXCRETIONS 137 Urine 137 Urinalysis 137 Feces 137 SHORT NOTES ON OTHER BODILY FLUIDS 138 Cerebrospinal fluid (CSF) 138 Ascites 138 Effusion 138 Pleural 138 Joint effusion 139 Exudates and transudates 139 Pus 139
13 Venipuncture Course and Kit |
SECTION 5: COMPLICATIONS 141 Case study 5: A “Routine” Venipuncture Case 142 Vasovagal response and vasovagal syncope 143 Allergic responses 144 Contact dermatitis 144 Skin rash/Urticaria 144 Anaphylaxis (Anaphylactic Shock) 144 Needle penetration through the vein 145 Hematoma 145 Ecchymosis 146 Needle/cannula in the tissue 146 Tissue infiltration (extravasation) 146 Cannula/catheter blocked (occluded) 147 Catheter-related infections 147 Intra-arterial position of needle/cannula 148 Inadvertent intra-arterial injection of medication 148 Differentiation between arteries and veins 149 Superficial phlebitis 149 Septic thrombus 150
Deep vein thrombosis (DVT) 150 Embolism 151 Air embolism 151 Local tissue damage 153 Nerve damage 153 Arterial cannulation 153 Needle prick injuries 153 153 SECTION 6: CONCLUSION 155 ASSESSMENT MODULE 156 EPILOGUE 156 REFERENCES 156 CREDITS 157 GLOSSARY 160
14 1 Venipuncture Course and Kit | INTRODUCTION
CASE STUDY 1: AN AVOIDABLE ACCIDENT—AN UNNECESSARY DEATH
16 Venipuncture Course and Kit | INTRODUCTION
A 32-year-old nurse with an infectious smile cheerfully That evening, Helosini complained to her sister that her leg reported for duty, but she had no idea that this would be was turning blue and that she had flu-like symptoms. Nine her final, ill-fated day. days later, she was worse. She decided to go to her doctor, Helosini Pillay was a vibrant young woman who had just but changed her mind and went to a pharmacy instead completed her degree and started a new job at Lancet and purchased flu medication. Laboratories in Morningside Clinic. Helosini sat down to On Christmas Eve, Helosini was so sick that she went to perform a routine blood draw on a patient. She accidentally her doctor who diagnosed her with bronchitis. A few days bumped the trolley where she had placed the needle and later, Helosini’s sister, Yogeshini, found her unconscious syringe. The needle and syringe fell and pierce her right on the bathroom floor. Yogeshini rushed her sister to the calf. She reported it to her senior who ordered an HIV test hospital where it was confirmed that she had contracted on this patient. Results showed that the patient was HIV- malaria. In addition, she had developed a complication negative. However, a previous blood test indicated that he called Adult Respiratory Distress Syndrome (ARDS). Family had malaria. members were called as she was in a critical condition and Helosini asked if she might contract malaria from her gasping for breath. needle stick injury but was assured that she could only She never regained consciousness and two weeks later contract malaria from a mosquito or if she lived in an area she died. that was at risk for malaria. She went home thinking that everything would be fine. And so an expensive lesson is learnt. Routine use of safety needles would have prevented this tragedy.
The Venipuncture Trainer in this kit has been designed with effectiveness and affordability in mind. Students of phlebotomy will be able to use this versatile Venipuncture Trainer to practice basic skills over and over while experiencing a realistic feel similar to the real clinical situation. As an optional extra, The Apprentice Corporation has artificial arms available for sale. Keep in mind that no training system can replace the clinical phase of your training. Practice, gain confidence, then face real clinical situations under supervision and always learn from both your successes and your failures.
PHLEBOTOMY Venipuncture is the act of puncturing a vein with a needle or cannula (needle carrying a flexible plastic catheter) for Phlebotomy is the procedure of removing (drawing) drawing blood, for administering a therapeutic substance blood from the vascular system by puncturing a vein for intravenous feeding, or for therapeutic purposes. or sometimes an artery with a needle or by making an Although venipuncture is often performed for medical incision (rarely) to obtain a blood sample for: purposes or to administer a general anesthetic, it is in • Diagnostic purposes essence a minor surgical procedure – and thus the basic • To be analyzed by a medical laboratory principles of surgery apply. • Therapeutic purposes -- To treat polycythemia vera, a condition that causes Intravenous therapy (IV infusion) is the method an elevated red blood cell volume (hematocrit). by which therapeutic fluid/solution or medication is Phlebotomy is also prescribed for hepatitis B and administered intravenously through an infusion set. The IV C and for patients with disorders that increase the set includes: a plastic or glass bottle containing a solution, amount of iron in their blood to dangerous levels, and tubing to connect the bottle to a catheter or a needle such as hemochromatosis. Phlebotomy may be in the patient’s vein. performed on patients with pulmonary edema to decrease their total blood volume. -- Collecting blood from blood donors, commonly one unit of blood (500 mL) in a session.
17 Venipuncture Course and Kit | INTRODUCTION
SOLUTION SPECIAL TYPE USES (EXAMPLE) CONSIDERATIONS
Isotonic Dextrose 5% in water • Fluid loss • Use cautiously in renal and cardiac (D5W) • Dehydration patients • Hypernatremia • Can cause fluid overload Isotonic 0.9% Sodium Chloride • Shock • Can lead to overload • Hyponatremia • Use with caution in patients with • Blood transfusions heart failure or edema • Resuscitation • Fluid challenges • DKA (diabetic ketoacidosis) Isotonic Ringer’s Lactate/Lactated • Dehydration • Hypovolemia due to third spacing Ringers (LR) • Burns • Contains potassium, don’t use with • Lower GI fluid loss renal failure patients • Acute blood loss • Don’t use with liver disease (can’t metabolize lactate) Hypotonic 0.45% Sodium Chloride (1/2 • Water replacement • Use with caution normal saline) • DKA • May cause cardiovascular collapse • Gastric fluid loss from NG or vomiting or increased intracranial pressure • Don’t use with liver disease, trauma, or burns Hypertonic Dextrose 5% in ½ • Later in DKA treatment • Use only when blood sugar falls normal saline below 14 mmol/l (250 mg/dL) Hypertonic Dextrose 5% in normal saline • Temporary treatment • Don’t use in cardiac or renal patients for shock if plasma expanders aren’t available • Addison’s crisis Hypertonic Dextrose 10% in water • Hypertonic water replacement • Monitor blood sugar levels • Conditions where some nutrition with glucose is required
Table 1: Intravenous Fluid Comparison by Type
18 Venipuncture Course and Kit | INTRODUCTION
PROJECT 1A FAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT
Use the Content List and follow these steps to ensure that your Apprentice Doctor® Venipuncture Kit and Trainer is complete. Learn the names and functions of each item as you go.
VIDEO
WARNING This kit contains sharp items that can be potentially working on an HIV+ patient while practicing on the trainer. hazardous if they are not used correctly and safely. Keep Some items in the kit may contain LATEX and are not the kit and contents away from babies and children under suitable for persons with latex allergies. the age of 15. Adult supervision is required for students 15- Before proceeding, familiarize yourself with the warnings 17. It is essential that all students take extreme care while on the package and DVD-ROM and with the disclaimer on doing the practical projects. the leaflets inside the package. Prepare yourself for the clinical situation and imagine
19 Venipuncture Course and Kit | INTRODUCTION
REQUIREMENTS Venipuncture Kit and Trainer and a clean, uncluttered work surface. Follow these steps:
STEP 1 [CLICK TO PRINT KIT CONTENT PAGE]
Do not unwrap or open any items at this point in time! Unpack all of the items on your uncluttered working surface. Identify all the components of your Venipuncture Kit and Trainer using the Content List. Learn the names and functions of all items as you check them against the list.
CHECK LIST OF MEDICAL ITEMS INCLUDED IN THE KIT
The Apprentice Doctor® Venipuncture Course 1 IV Catheter 2 DVD-ROM
Lancets – Safety and Venipuncture Trainer 1 Regular 3
Connectors / Disposable Tourniquet Lumen stoppers 4 2
Syringe for SQ Injections 1 Butterfly Needles 2
Regular Syringes 6 IV Fluid Bag 1
Regular Needles 9 IV Lines 2
Safety Needles 3 Glass Vial 1
20 Venipuncture Course and Kit | INTRODUCTION
Plastic Vial 1 Alcohol Prep Swabs 10
Safety Vacuum Gauze Squares Container Device 1 10
Vacuum Container Hub Work Surface Cover and Needles 1 3
pairs Blood Vacuum Tubes 5 Gloves 5 pairs
pairs Cotton Wool 5 Sharps Waste Container 1
More information [CLICK HERE] Roll of Strapping 1
Reusable Tourniquet 1 * PLEASE NOTE: • Contents may vary slightly from the list depending on availability. • Kits are double checked for quality and completeness Tournistrip 1 by our factory. In the unlikely event of problems, please contact customer support personnel at [email protected] • Regarding the use of safety needles: The Apprentice Doctor® Venipuncture Kit contains Transparent Dressing 1 safety needles. For the sake of keeping the kit affordable, we have included regular needles, since there is nearly no risk of acquiring a bloodborne disease when using the kit according to the instructions. Safety and regular needles can be used for the projects while Ruler and Pen 1 working on the Venipuncture Trainer. However, in the clinical environment, safety needles should be used exclusively.
21 Venipuncture Course and Kit | INTRODUCTION
STEP 2 STEP 4 Open the Venipuncture Trainer and compare it with the Replace all the items in your Kit and proceed with the illustration below. Venipuncture Course, or close the kit and place it in a safe location out of the reach of children.
POINTS OF INTEREST • Approximately 80% of hospitalized patients receive IV therapy. • A large percentage of medications are administered by intravenous infusion. • IV Therapy is becoming more widely used in extended care facilities and in home care situations. • Central venous access has resulted in the widespread use of long-term IV therapy. The trainer is simple, effective, and functional. • Warm IV fluids are often used in restoring the body temperature of hypothermic patients. IV fluids should The Apprentice Doctor® offers realistic trainer simulation be warmed to approximately 43°C or (109.4° F) prior arms for group training. [ORDER ONLINE]. to administration. As most hypothermic patients are also dehydrated, warm intravenous fluids serve a dual purpose. STEP 3 • Contaminated IV fluids have at times resulted in the Buy red food colorant – available from grocery stores – and death of a patient or even multiple deaths. Ensure that add to the kit. you follow an acceptable antiseptic protocol when administering IV fluids. If in doubt about the sterility of the fluid (unusual color, change in transparency, etc.), do not use the fluid and report this to your hospital’s infection control official for further investigation.
BEFORE STARTING, YOU MUST FIRST READ THE FOLLOWING:
ASPECTS OF SAFETY Sharps injuries are ‘through the skin’ wounds caused by sharp medical items like needles, scalpels, or other sharp What is the most serious complication that may follow a objects such as glass medicine vials. Sharps injuries are simple venipuncture procedure? Is it a large hematoma? Is occupational hazards frequently encountered by medical it permanent nerve damage that causes the loss of normal professionals who handle needles. These injuries pose the sensation over the forearm and hand? Or is it a motor nerve risk of transmitting bloodborne pathogens such as the injury with partial paralysis of muscles in the arm or hand? hepatitis B virus (HBV), the hepatitis C virus (HCV), as well The truth is much graver – the ultimate complication is as the human immunodeficiency virus (HIV). Needlestick death (see case studies in the various sections.) injuries are common events in the healthcare environment; A great number of serious or even fatal accidents and Mario Saia et al¹ in 2010 reported an estimated 384,000 complications are avoidable, so do not skip this section or cases in the USA alone.¹ rush through it. This information is vitally important! Study Hollow needle injuries are especially dangerous and carry this section thoroughly before proceeding – you and your a very high risk of transmitting bloodborne diseases. patients’ lives depend on your carefully application of this Infected material coming into contact with a mucus information. membrane (e.g. blood splashing into the eye) also carries a risk of transmitting disease.
22 Venipuncture Course and Kit | INTRODUCTION
Centers for Disease Control and Prevention (CDC) All students, especially those in USA, should acquaint guidelines and recommendations regarding the use of themselves with the relevant legalities in the OSHA needles, cannulas, and intravenous delivery systems: Occupational Safety & Health Administration’s documents: • Use aseptic techniques to avoid contamination of sterile injection equipment. • Read OSHA’s Workers page, • Do not administer medications from the same syringe • Bloodborne Pathogens and Needlestick Preventions to more than one patient, even if the needle or and http://www.osha.gov/needlesticks/needlefaq.html cannula on the syringe has been changed. Needles, cannulas, and syringes are sterile, single-use items; In the USA, the Needlestick Safety and Prevention they should neither be reused for another patient nor Act of 2000 makes the use of ‘engineered sharps injury to access a medication or solution that might be used protection’ mandatory in the workplace. In practice, for a subsequent patient. it means that safety needles and safety devices are • Use fluid infusion and administration sets (i.e., compulsory in the USA and in a number of other countries. intravenous bags, tubing, and connectors) for one In order to reduce or eliminate the hazards of occupational patient only and then dispose of them appropriately. exposure to bloodborne pathogens, an employer must Once a syringe or needle/cannula has been used to implement an exposure control plan for the worksite enter or connect a patient’s intravenous infusion bag with details on employee protection measures. The plan or administration set, consider it contaminated.Use must describe how the employer will use a combination single-dose vials for parenteral medications whenever of engineering and work practice controls. Among other possible. provisions, the employer must ensure the use of personal • Do not administer medications from single-dose vials protective clothing and equipment and provide training, or ampules to multiple patients or combine leftover medical surveillance, hepatitis B vaccinations, as well as contents. signs and labels. Engineering controls are the primary • If multi-dose vials must be used, both the needle or means of eliminating or minimizing employee exposure cannula and syringe used to access the multi-dose and include the use of safer medical devices, such as vial must be sterile. needleless devices, shielded needle devices, and plastic • Do not keep multi-dose vials in the immediate patient capillary tubes. treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is [SEE ACT HERE: USA NEEDLESTICK SAFETY AND compromised or questionable. PREVENTION ACT OF 2000] • Do not use bags or bottles of intravenous solution as a common supply source for several patients.
Download CDC Posters on preventing injuries with IMPORTANT! sharps: If you are injured or pricked by a needle or other sharp [POSTER 1 HYPERLINK] object or get blood or other potentially infectious [POSTER 2 HYPERLINK] materials in your eyes, nose, mouth or on broken skin, [POSTER 3 HYPERLINK] immediately flood the exposed area with water and clean [STUDY CDC GUIDELINES FOR HANDLING any wound with soap and water or a skin disinfectant if SHARPS²] available. Immediately report this to your employer and seek immediate medical attention. Look at the WHO Publication on sharps injuries: Credit: U.S. Department of Labor Assessing the burden of disease from sharps injuries to health care workers at national and local levels.³
23 Venipuncture Course and Kit | INTRODUCTION
PROPER SHARPS DISPOSAL into a regular waste bin or bag. Hand a full sharps waste container to a medical professional at a hospital, a medical AND ILLEGAL INJECTION clinic, or to your family doctor for proper sharps waste DRUG USERS disposal. Globally, around 16 million people inject drugs and 3 Alternatively contact us per email and we will mail a self- million of them are living with HIV according to 2012 addressed box. Return with your sharps container for safe WHO statistics. disposal. Email to [email protected] According to the most recent CDC data (2008): • Injection drug users represent 12% of annual new HIV infections in the United States. • Injection drug users represent 19% of those living with HIV in the United States. Injection drug users often acquire infections like HIV and Hepatitis B as a result of needle sharing and the use of contaminated needles, often as a result of improper biohazard sharps waste management or the erroneous placement of needles in a regular waste bin or bag. Kindly play your part in minimizing the morbidity of this problem by NEVER discarding any used or unused needles or any other sharp or blood contaminated items
24 Venipuncture Course and Kit | INTRODUCTION
PROJECT 1B HOW TO USE A SAFETY NEEDLE/DEVICE
It is all about safety—for your patients AND YOU!
VIDEO
WARNINGS: INFORMATION • In this project you will work with sharp items. Take The Apprentice Doctor® has done a fair amount of great care to avoid injury to yourself and others. research to identify the best safety needle system for our • You will use safety needles in this project. The Venipuncture Kits. Based on research of The Health Care Autosafe®-Reflex® needle’s safety features will make Product Evaluation Center at the University of Virginia, a needle injury unlikely – but in the final analysis there the Autosafe®-Reflex® safety needles showed excellent is no substitute for caution. results and came out on top. Therefore we include • Follow the instructions accurately! Autosafe®-Reflex® Safety Needles in The Apprentice Doctor® Venipuncture Kits.
You will need: • A comfortable work area • The unassembled Venipuncture Trainer • A 5 ml syringe • An Autosafe®-Reflex® safety needle These needles are VERY easy to use – however, in order for them to be effective, one needs to use them correctly.
25 Venipuncture Course and Kit | INTRODUCTION
FOLLOW THESE STEP 7 INSTRUCTIONS EXACTLY: Withdraw the plunger of the syringe to fill the syringe with STEP 1 3-5 ml of air, just for practicing purposes. Look at the diagram of the needle with its various parts STEP 8 Pull the safety mechanism back and hold gently, just on the one side, in the activated position with your middle or index finger. STEP 9 Remove the protective sleeve of the needle.
STEP 10 Perform a simulation IMI (intramuscular injection) by injecting the Venipuncture Trainer. Penetrate the “skin” at 90° and insert the needle up to the level of the safety device. See PROJECT 9 – How to Give an Intramuscular Figure 2: Cross section of the Autosafe®-Reflex® safety needle Injection for more information.
STEP 2 STEP 11 Open a clean work surface cover. On it, place the Inject the air into the Venipuncture Trainer. unassembled Venipuncture Trainer, an opened 5ml Warning note: Normally one would carefully eliminate all syringe, and an unopened safety needle. air bubbles from the syringe and needle before injecting. NEVER inject air into a patient — neither by SCI, IMI, nor IVI. STEP 3 Wash your hands. Start now to develop this simple STEP 12 but effective habit. If you like, don clean gloves (gloves Remove your index finger from the safety mechanism. optional).
STEP 4 STEP 13 Withdraw the needle; you will notice the reflex mechanism Orientation is important when opening the Autosafe®- activates spontaneously and passively. The sharp needle Reflex® safety needle. Hold the needle with the paper tip will be covered by the safety cap, in a somewhat off- cover facing up. The needle is packed with its bevel facing center position. up, towards the paper cover. Kept in this orientation, the needle will be positioned correctly for performing clinical procedures like venipuncture. STEP 14 Remove the needle by disconnecting it from the hub STEP 5 of the syringe. Discard the used needle into the sharps waste container. Never try to recap a regular needle or Lift the edge of the paper cover and peel it backwards. reassemble a safety needle. In a clinical setting, you will Pinch the package at the fold (at the base of the package) discard the complete unit (syringe and needle). and fold the base down.
STEP 6 Fit the needle to the syringe, and withdraw the safety needle from the package while maintaining the needle’s orientation.
26 Venipuncture Course and Kit | INTRODUCTION
NOTE: POINTS OF INTEREST • In rare instances, after activating the Autosafe®- • According to the Centers for Disease Control and Reflex® needle’s safety device, you may need to Prevention (CDC), about 385,000 sharps injuries occur expose the needle again — for example when annually to hospital employees and WHO resources withdrawing medication from a vial using the safety estimate the frequency of needlestick injuries at needle. See this demonstration on how to safely about 3.5 million cases worldwide. [CLICK HERE] for expose the needle again: [VIDEO-CLIP] more information. • Look at the Autosafe®-Reflex® Vacutainer • As a consequence of sharps injuries, there are an Phlebotomy Device – it is equipped with an estimated 66,000 infections with HBV, 16,000 with Autosafe®-Reflex® needle. Do not open the device at HCV, and more than 1,000 with HIV worldwide. this stage – this device will be used in PROJECT 11 A • CDC guidelines for PEP (post-exposure – DRAW VENOUS BLOOD USING A VACUUM TUBE. prophylaxis) when a needle stick injury happens when treating a patient with one of these diseases (or passive carriers of these diseases): • Hepatitis B: Administer hepatitis B immune globulin and/or hepatitis B vaccine. • Hepatitis C: There is no current active PEP for HCV. • HIV: Administer three or more antiviral drugs when the donor is HIV positive.
• The prevalence of illegal drug injections in the USA is simply mind-boggling! It is estimated that between 920 million and 1.7 billion illegal injections take place each year in the United States. The illegal drug users often use and share contaminated needles and syringes. • Read the following WHO information on safe syringes for injection safety: [CLICK HERE]
To order AUTOSAFE®-REFLEX® SAFETY NEEDLES AND ASSOCIATED DEVICES [CLICK HERE]!
27 Venipuncture Course and Kit | INTRODUCTION
BASIC ANATOMY OF THE CIRCULATORY SYSTEM
Note: Student should already have a fair understanding of the basic anatomy and physiology of the cardiovascular system. Study the following illustrations before proceeding with the course:
THE MAIN BLOOD VESSELS OF THE BODY
[DOWNLOAD PDF]
28 Venipuncture Course and Kit | INTRODUCTION
VEINS AND ARTERIES OF THE HEAD AND NECK
[DOWNLOAD PDF]
29 Venipuncture Course and Kit | INTRODUCTION
ARTERIES OF THE ARM
[DOWNLOAD PDF]
30 Venipuncture Course and Kit | INTRODUCTION
VEINS OF THE ARM
[DOWNLOAD PDF]
31 Venipuncture Course and Kit | INTRODUCTION
VEINS OF THE ARM (CLOSE-UP)
[DOWNLOAD PDF]
32 Venipuncture Course and Kit | INTRODUCTION
VEINS OF THE HAND
[DOWNLOAD PDF]
33 Venipuncture Course and Kit | INTRODUCTION
ARTERIES OF THE LEG
[DOWNLOAD PDF]
34 Venipuncture Course and Kit | INTRODUCTION
VEINS OF THE LEG
[DOWNLOAD PDF]
35 Venipuncture Course and Kit | INTRODUCTION
ANOMALOUS SUPERFICIAL ARTERIES IN THE ARM The word anomaly is used when something is normal, but only occurs in a minority of the general population. The arteries of the extremities normally run a deeper course compared to the equivalent veins. Both the radial artery and the ulnar artery occasionally run an anomalous superficial course and may be mistaken for a vein by the well-intended clinician. The superficial ulnar artery (SUA) is present in almost 4% and the superficial radial artery (SRA) in about 0.2% of the population. An inadvertent arterial-puncture instead of a venipuncture could have catastrophic results. See the Complications Section on handling this type of situation in more detail. For more information [CLICK HERE] BLOOD
Blood is classified as a specialized connective tissue from balance. The total blood volume of an adult varies between an embryological point of view. Blood is the fluid that 5-6 liters for males and 4-5 liters for females. circulates through the heart, arteries, capillaries, and veins Whole blood is blood drawn from the body from which and is the chief means of transport within the body. It no constituent, such as plasma or platelets, has been transports oxygen from the lungs to the body tissues, and removed. carbon dioxide from the tissues to the lungs. It transports Blood fractionation is the process of fractionating whole nutritive substances and metabolites to the tissues and blood, or separating it into its component parts. This is removes waste products to the kidneys and other organs typically done with a centrifuge. of excretion. It has an essential role in maintaining fluid
Figure 3a: A typical hematology lab centrifuge apparatus Figure 3b: Centrifuged blood in tube
Blood can be separated into 3 layers by a process of centrifugation (fast spinning of blood filled tubes in a laboratory apparatus called a centrifuge). 1. The upper yellowish layer is blood plasma. 2. The thin, middle, buffy layer is white blood cells, as well as blood platelets. 3. The bottom layer is packed erythrocytes, or red blood cells. Blood serum is blood plasma without fibrinogen or the other clotting factors.
BLOOD PLASMA and fibrinogen), dissolved salts (ions), food nutrients, The liquid phase of the blood, obtained by sedimentation waste products, hormones, vitamins, and dissolved gasses or centrifugation of blood treated with an anticoagulant (oxygen and carbon dioxide). (anti-clotting agent). Albumin’s main function is to prevent water from leaving Plasma is mostly fluid, consisting mainly of water, as well the capillaries – thus albumin holds water inside the as three specific types of proteins (albumin, globulins, intravascular space.
36 Venipuncture Course and Kit | INTRODUCTION
Globulins are mainly the immune system’s antibodies. of hemoglobin molecules. This maximizes the cell’s Fibrinogen plays a major role in blood clotting. oxygen-carrying ability. The biconcave shape increases Blood serum is blood plasma without fibrinogen or the its surface area to ensure optimal gas exchange. other clotting factors. HEMOGLOBIN Hemoglobin has four protein chains, and each protein chain is called a BLOOD CELLS globin. Hemoglobin consists of four contorted protein globin chains, two If a drop of human blood is thinly smeared across a Apha and two Beta. microscopy slide, you can see various different blood cells. The pink roundish structures with white centers are the erythrocytes (red blood cells).
Figure 4: A normal blood smear Figure 4: A graphic illustration of hemoglobin
Blood cells include red blood cells, a variety of white blood A heme is ring shaped molecule with an iron ion (Fe+2). cells (lymphocytes, neutrophils, basophils, eosinophils, Oxygen has a high affinity to the heme ion. Each and monocytes), and blood platelets. hemoglobin molecule has four hemes; each heme Leukocytes include the following white blood cells: provides a place to carry an oxygen molecule. So each lymphocytes, neutrophils, eosinophils, and monocytes. hemoglobin molecule can carry four oxygen molecules. Blood platelets are small cell fragments that play an Every single red blood cell is packed with 280 million essential role in the blood clotting process. The buffy layer hemoglobin molecules. It follows that one red blood cell between the plasma and red blood cells contains all the could carry about one billion oxygen molecules! white blood cells, as well as the blood platelets. Hematology: Hematology is the study concerned with Packed red blood cells are red blood cells that have the diagnosis, treatment, and prevention of diseases of the been separated from whole blood for transfusions. Packed blood and bone marrow, as well as of the immunologic, red blood cells (RBCs) essentially contain the same amount hemostatic (blood clotting) and vascular systems. Because of hemoglobin as whole blood, but most of the plasma of the nature of blood, the science of hematology has been removed. profoundly affects the understanding of many diseases.
Erythrocytes (red blood cells/RBCs) Erythrocytes are biconcave in shape for two good reasons: • Flexibility. It’s a very flexible cell that can fold or bend to go through small capillaries. • Large surface area. RBCs are designed for one main purpose: to carry O2 from the lungs to the tissue cells and CO2 from tissue to the lungs. RBCs perform this dedicated function for ± 120 days and then the spleen and liver removes them from the bloodstream. A mature RBC has neither a nucleus nor any other organelles. It’s packed mostly with large numbers
37
2 Venipuncture Course and Kit | PREPARATION
CASE STUDY 2: CONTRACTING ONE OF THE MOST FEARED DISEASES IN THE WORLD TODAY
40 Venipuncture Course and Kit | PREPARATION
Imagine being extremely ill with a high fever, a splitting this clinic undiagnosed three weeks earlier. People who headache, diarrhea, and vomiting. You are also bleeding had been in contact with Marilyn were checked twice daily from the nose, the mouth, and all bodily orifices! The for symptoms, but fortunately none of her family members healthcare workers treating you are wearing clothes or friends contracted this vicious disease. that look like space suits. In one week, your chance of survival is a slim 20%. Ebola is spread through tainted blood and the only sure Sounds exaggerated? This is real–the hemorrhagic fever cure is by prevention. Patients with Ebola are kept under of the highly contagious Ebola virus! In the past 20 strict quarantine. years, more than 1000 confirmed cases of Ebola had a • All healthcare workers need to have a thorough mortality rate of 80% to 90%. There is no known drug or knowledge of sterility, asepsis, barrier techniques, cure for Ebola. as well as well as, the various skills associated with Marilyn Lahana of Parkmore, South Africa is believed aseptic technique. to have been the first diagnosed victim to contract the • Saving lives are not necessarily intricate cardio – or deadly Ebola virus. For three weeks, she bravely fought neurosurgical procedures – in most cases medical for her life in isolation at Johannesburg Hospital, while professionals save lives by performing simple routines medical officials desperately scrambled to find the source – like washing hands and donning clean gloves. of the virus. Marilyn Lahana was a nurse working at a private clinic in Johannesburg. Officials believe that she Your and your patients’ lives depend on you to strictly contracted the virus from a man from Zaire who died at follow procedures for sterility and asepsis – do not slip up!
SHORT NOTES ON MEDICAL WARNING! HISTORY Some syringes and medication vials contain a tiny amount of latex. Ensure that all items are factory marked: latex-free The taking of a comprehensive medical history by a if you treat a patient who is allergic to latex. A patient’s qualified medical professional is essential for diagnosing, severe latex allergy may become life threatening in a managing, and treating any patient. A full comprehensive matter of minutes! medical history preceding each and every venipuncture procedure is not only unnecessary but also impractical; however a short list of relevant questions will go a long way to avoiding complications and medico-legal problems. Routinely ask about: • Bleeding tendencies and anticlotting therapy. • Previous complications following phlebotomy/ venipuncture (e.g., phlebitis, thrombosis, DVT, difficult venous access, and accidental intra-arterial injections). • Infectious diseases (e.g., hepatitis, HIV). • Allergies specifically regarding cleaning agents (e.g., Iodine, strapping, plasters, and drugs or medications to be administered via the IV route). Specifically ask about latex allergy if you use latex gloves or a disposable latex tourniquet.
41 Venipuncture Course and Kit | PREPARATION
PROJECT 2 TAKE A MEDICAL HISTORY
Gather the relevant information and prevent avoidable mishaps!
See The Apprentice Doctor® Foundation Course for information on how to take a comprehensive medical history[CLICK HERE]
PATIENT INFORMATION When a physician orders a laboratory blood test, a lab requisition form needs to be filled out accurately and signed by the physician. It is important to have a double-check system on requisition forms and sample labeling to ensure that the correct blood samples are taken from the correct patient and that the correct results are allocated to the correct patient.
SAMPLE REQUISITION FORM An accurately completed requisition form must accompany each sample submitted to the laboratory. This information is essential to process the specimen correctly. The patient’s information is required: • Full names • Identification number • Date of birth • Gender • Full name of the requesting physician • Date and time of collection • Source of specimen (this information must be given when requesting histology, microbiology, cytology, fluid analysis, or other testing where analysis and reporting is site specific.) [PRINT A FORM] • Phlebotomist’s name A number of forms are available in the kit. • Indicate the test(s) requested • An example of a simple requisition form with the essential elements is shown below:
LABELING THE SAMPLE A properly labeled sample is essential so that the results of the test match the patient. NOTE: The information MUST match the information on the requisition form. It should show: • The patient’s full name • The patient’s identification number • Date, time and name (or initials) of the phlebotomist must be on the label of each tube Automated systems may include labels with bar codes. Examples of labeled collection tubes are shown below: Figure 5: Examples of labeled collection tubes
42 Venipuncture Course and Kit | PREPARATION
SHORT NOTES ON ASEPTIC TECHNIQUE
Study this section carefully as it can make the difference between frequent and occasional complications and possibly the difference between life and death! Follow an acceptable hands-hygiene protocol: • Handwashing techniques • Wash your hands with an acceptable method before and after every venipuncture procedure. • Alcohol rub • Hygienically preparing your hands with an alcohol-based hand sanitizer before and after procedures is a permissible way to prepare uncontaminated hands aseptically. Contamination may be any environmental dirt, bodily fluids (e.g., blood) secretions (e.g., saliva) or Figure 6: A surgeon scrubbing before surgery excretions (e.g., feces.) • Don clean gloves PROJECTS 3A – 3I
PROJECT 3A A TECHNIQUE FOR PROPER HANDWASHING
Learn to wash your hands – prepare them hygienically before examining a patient
VIDEO
43 Venipuncture Course and Kit | PREPARATION
INFORMATION STEP 2 It is recommended that students study the WHO Apply enough soap to the hands until you have a rich Guidelines on Hand Hygiene⁴ before starting this section foamy lather. Completely lather the surface of both hands of the course. and up the wrist. • The simple act of handwashing is probably the single most important way to reduce the transfer of harmful STEP 3 microorganisms from one person to another. Repeat the following actions at least five times: • For handwashing to be effective, you must adherence 3.1 Rub hands palm to palm. to proper technique. 3.2 Right palm over the back of the left hand with • Handwashing is also important for reasons of personal fingers interlaced and vice versa. hygiene, e.g., washing hands after using the bathroom 3.3 Palm to palm with fingers interlaced. and before meals. 3.4 Backs of fingers to opposing palms with • Staff working in the food and restaurant industries fingers interlocked. require a high level of hygiene including a 3.5 Rotational rubbing of left thumb clasped in protocol regarding handwashing in order to avoid right palm and vice versa. contaminating food with dangerous microorganisms. 3.6 Rotational rubbing, backwards and forwards SETTING: with clasped fingers of right hand and vice The bathroom or any room with a suitable faucet and sink versa. for washing hands. 3.7 Rotational rubbing of wrist by opposing palm and vice versa. REQUIREMENTS • A nail clipper or nail care set. STEP 4 • Soap (antiseptic or regular). Liquid soap is preferable, Rinse the hands well. Allow running water to flow over but a bar of soap will do. the hands. If possible let the water run from the fingertips • Clean single-use towels, e.g., disposable paper towels. to the palms and then towards the wrists. Rinse soap off completely. NOTE: 1. Handwashing can be subdivided into the following STEP 5 seven important steps. Dry hands thoroughly with a single-use disposable paper • Open faucet towel. Start at the fingers, work to the palms and back of • Wet the hands, and lastly dry the wrist areas. Use the same • Soap towel to turn off the faucet. Alternatively use your elbow • Wash to close the faucet. Do not use your clean hands. • Rinse • Dry • Close faucet STEP 6 Your hands are now hygienically prepared. If you intend to perform a clinical examination, don clean gloves. 2. Hands should be washed for at least 40-60 seconds (See PROJECT 3C) to be effective.
3. A healthcare worker’s nails should ALWAYS be kept neat, short, and hygienically clean!
PROCEDURE: STEP 1 Turn on the faucet and adjust to a moderate stream of water. Wet both hands up to the wrists.
44 Venipuncture Course and Kit | PREPARATION
HINTS: • Use disposable paper towels. Cloth towels are not suitable in a healthcare setting as they harbor and retain bacteria and become more contaminated with use. • Frequent handwashing will remove the skin’s natural surface oils, causing scabby and rough skin. To reduce this effect, wash hands in lukewarm rather than hot water. • Use a moisturizing hand lotion containing lanolin to help keep your hands feeling smooth and comfortable
POINTS OF INTEREST • An infection acquired in a hospital by a patient or a staff member is called a nosocomial infection. • In the United States, nearly 2 million infections occur among hospital patients (about one infection in 20 patients), and 99 000 of these patients die each year. Hospital-acquired infection can be life threatening and hard to treat due to multi-resistant bacterial strains. Hand hygiene is one of the most important ways to prevent the spread of infection. • In the United Kingdom, hospital-acquired infections result in approximately 10,000 deaths each year. • Waterless alcohol-based hand sanitizers are effective alternatives for routine sanitization of uncontaminated (without blood, bodily fluids and dirt) hands (see PROJECT 3B).
• Surgeons and operating room staff use a special technique called surgical scrubbing before an operation (see PROJECT 3F). This technique is similar to the above described handwashing technique with the following main differences: -- Surgical scrubbing requires meticulous scrubbing with a sterile brush. -- It requires more time (from 2 to 5 minutes). -- The wash area extends from the nails up to just above the elbows.
45 Venipuncture Course and Kit | PREPARATION
PROJECT 3B CLEANING HANDS WITH AN ANTISEPTIC RUB
Print out the World Health Organization’s (WHO) guideline diagram and follow the steps
VIDEO
PROJECT 3C HOW TO DON (PUT ON) CLEAN GLOVES
Print out the World Health Organization’s (WHO) guideline diagram and follow the steps
46 Venipuncture Course and Kit | PREPARATION
• Touching only the cuff, take the first glove out of the • Don the second glove – touch only the external original box. surface of the second glove with the already gloved • Try to touch only the wrist area of the glove, i.e., the hand. top end of the cuff. • Your gloved hands should not touch anything else • Don the first glove by sliding it over the fingers, palm, that is not indicated for glove use. and wrist. • With the bare hand, take a second glove from the box – again, only touching the glove’s cuff or wrist.
PROJECT 3D HOW TO SAFELY REMOVE USED GLOVES
Print out the World Health Organization’s (WHO) guideline diagram and follow the steps
• Pinch one glove at the wrist level to remove it, without touching the skin of the forearm, and peel away from the hand, thus allowing the glove to turn inside out • Hold the removed glove in the gloved hand and slide the fingers of the ungloved hand inside between the glove and the wrist. Remove the second glove by rolling it down the hand and fold into the first glove • Discard the removed gloves in a suitable biological waste container • Perform hand hygiene
PROJECT 3E * HOW TO CHANGE INTO THEATER ATTIRE
*See The Apprentice Doctor® Foundation Course for further information on how to perform these procedures. [CLICK HERE]
PROJECT 3F * HOW TO SCRUB FOR A STERILE PROCEDURE
*See The Apprentice Doctor® Foundation Course for further information on how to perform these procedures. [CLICK HERE]
PROJECT 3G * HOW TO GOWN FOR A STERILE PROCEDURE
*See The Apprentice Doctor® Foundation Course for further information on how to perform these procedures. [CLICK HERE]
47 Venipuncture Course and Kit | PREPARATION
PROJECT 3H HOW TO DON STERILE GLOVES
Print out the World Health Organization’s (WHO) guideline diagram and follow the steps
PROJECT 3I* HOW TO REMOVE CONTAMINATED GLOVES
*See The Apprentice Doctor® Foundation Course for further information on how to perform these procedures. [CLICK HERE]
48 Venipuncture Course and Kit | PREPARATION
PATIENT POSITIONING
PERFORMING VENIPUNCTUREON A VEIN OF THE UPPER EXTREMITY Position the patient comfortably with their arm at heart level or just below. Outpatients should be placed in the sitting position and hospital patients lying in bed, in the semi-Fowler’s or supine position. Inspection and palpation are essential components for selecting a suitable vein; therefore the intended venipuncture site must be exposed. Good lighting is required. If needed, position the light at an angle to enhance inspection of the veins. Place a clean linen-saver below the arm to protect bed sheets. Ensure that all the venipuncture equipment and items that you need are within easy reach.
Figure 8a: Patient in Semi-Fowler’s position
Figure 7: Patient in sitting position Figure 8b: Patient in supine position
49 Venipuncture Course and Kit | PREPARATION
The supine position is best when performing venipuncture PATIENT POSITIONING FOR on a vein of the lower extremity or neck. To distend the veins, you may position the bed in a slight Trendelenburg ARTERIAL BLOOD SAMPLING position for the external jugular vein and in a slight reverse Trendelenburg position for the veins of the lower extremity FROM THE RADIAL ARTERY The patient should be seated comfortably (patients in bed in the semi-Fowler’s position) and the arm comfortably extended towards you, wrist up, and extended with the skin over the radial artery taut. Let the forearm rest on a small pillow. Use a rolled towel under the back of the hand to facilitate the extended wrist position.
PATIENT POSITIONING FOR ARTERIAL BLOOD SAMPLING Figure 9a: Trendelenburg FROM THE FEMORAL ARTERY The femoral artery is generally not recommended for ABG sampling. Place the patient in the supine position, with the groin and leg extended and slightly abducted.
Figure 9b: Reverse Trendelenburg position
50 Venipuncture Course and Kit | PREPARATION
TOURNIQUETS - PROJECTS 4A – 4D
PROJECT 4A HOW TO APPLY A TOURNIQUET (DISPOSABLE)
A simple technique to facilitate easier venipuncture
INFORMATION is to minimize the flow of venous blood back to the heart while allowing the arterial blood to flow undisturbed to A tourniquet is a constricting or compressing device used the extremity. Blood will thus fill and distend the veins due to control (stop or reduce) venous or arterial circulation to to their fairly thin and collapsible walls. Then the veins are an extremity for a period of time. easier to see and feel, thus making venipuncture easier to perform without complications. Pressure exerted by IMPORTANT NOTE the tourniquet must be high enough to stop or impede REGARDING ARTERIAL the venous return to the heart, but low enough to allow free arterial blood-flow, about 45-65 mmHg (millimeters TOURNIQUETS: Mercury). A surgeon may use an arterial tourniquet under controlled From a hygienic point of view, a disposable tourniquet is conditions within specific time limits to stop the arterial the best option, as each one is discarded after a single-use. blood flow to a limb. However, in the following discussion Disadvantages may include cost and secondly you must be we will exclusively focus on the use of tourniquets to reduce careful of latex allergies, as these tourniquets are often made or stop the venous return of blood to the heart for a period of latex. Affordable latex-free disposable tourniquets (like of time. the one in your kit) are available and recommended. A venous tourniquet is usually applied 7-10 cm (3-4 inches) Reusable tourniquets should be properly laundered at above the intended venipuncture point on either the upper regular intervals and after any suspected contamination. or lower extremity. The idea behind applying a tourniquet Enquire about this at your hospital’s infection control section.
51 Venipuncture Course and Kit | PREPARATION
REQUIREMENTS STEP 5 You will need: Fold the end on the right side over on itself. Pull both • A volunteer test patient ends upwards, with the end on the right side being • One disposable (latex-free) tourniquet somewhat tighter. • A re-usable tourniquet • A blood pressure cuff (if you have one available) STEP 6 Tuck the double-folded end halfway under the other left FOLLOW THESE STEPS FOR end, leaving the free end, approximately 5 cm (2 inches) long, pointing away from you. Ask your volunteer patient DRAWING BLOOD FROM THE to clench a fist to help distend the veins. Inspect and CUBITAL FOSSA AREA: palpate the veins. STEP 7 STEP 1 When you are finished with the venipuncture procedure, Take a short medical history, especially regarding allergies simply pull the free end to release the tourniquet. (latex, Iodine and IV drugs, etc.). The tourniquet and gloves in this kit are latex-free POINTS OF INTEREST If a tourniquet is used for preliminary vein selection, do not STEP 2 leave the tourniquet on for more than one minute. If you Remove clothing from the arm up to the middle of the need more time, release it for two minutes then reapply. upper arm. Place the tourniquet about 7-10 cm (3-4 Recommended maximum tourniquet time for phlebotomy inches) above the elbow. procedures is one minute. WHO guidelines give the maximum time as two minutes. STEP 3 The following guidelines ONLY apply to practicing: Place the tourniquet under the patient’s arm with an end When practicing you may leave the tourniquet on for in each hand. Ensure that it lies flat on the skin surface longer – as long as one does not make it so tight as to stop the arterial flow as well – which is unlikely. For safety STEP 4 reasons when practicing do not leave the tourniquet on for Swap the two tourniquet ends to opposite hands so longer than 5 minutes. Take a break for at least 5 minutes that the end on the right is closer to you. Pull the ends before reapplying. upwards to form an ‘X’.
52 Venipuncture Course and Kit | PREPARATION
PROJECT 4B HOW TO APPLY A TOURNIQUET (TOURNISTRIP®)
The Tournistrip® is an easy-to-use disposable tourniquet that complies with single-use tourniquet protocol.
INSTRUCTIONS
Pull a Tournistrip® from the roll and tear along the perforated STEP 1 line. You can use the tabs on the box to help further reduce Remove Tournistrip® from box. cross infection.
STEP 2 Peel the removable section before wrapping the tourniquet Expose the adhesive panel on around arm. Tournistrip® (see peel here)
STEP 3 Place Tournistrip® around arm with Slip the slim end through the slot in the wider tab end. the printed side facing outward.
STEP 4 When tension is sufficient, stick the slim end down on the Hold the tab end between thumb exposed adhesive strip If necessary, lift Tournistrip® away from the adhesive and and forefinger and pull the slim end reapply. to tighten.
STEP 5 To remove, pull slim end up and away from adhesive section. Release Tournistrip®.
Order Tournistrips® [Click Here]
53 Venipuncture Course and Kit | PREPARATION
PROJECT 4C HOW TO APPLY A TOURNIQUET (REUSABLE)
Print out the World Health Organization’s (WHO) guideline diagram and follow the steps
The main concern with reusable tourniquets is the A good reusable tourniquet should have an easy possibility of transferring harmful microbes to a patient, application lock, as well as a quick release mechanism. especially if the cleaning recommendations are not A simple design with VELCRO® (like the one supplied in this followed to maintain the highest levels of hygiene possible. kit will do the job equally well). Reusable tourniquets if you follow the hygienic handling [SEE VIDEO CLIP ON HOW TO APPLY THESE recommendations – see TOURNIQUETS CLEANING TOURNIQUETS] GUIDE for more information.
The BOA® IV constricting band is an innovative reusable tourniquet that is simple to use and makes applying a tourniquet both effective and simple – visit www.NARescue.com for more information.
PROJECT 4D HOW TO APPLY A TOURNIQUET (BLOOD PRESSURE CUFF)
Apply a blood pressure cuff 7-10 cm (3-4 inches) above the intended venipuncture site. Inflate the cuff to about 60 mmHg. Proceed with the venipuncture procedure. Deflate as soon as the task is completed (1 minute—no more than 2 minutes if drawing blood for the lab).
54 Venipuncture Course and Kit | PREPARATION
PROJECTS 5A – 5D
PROJECT 5A IDENTIFY THE VEINS OF THE UPPER EXTREMITY
INFORMATION REQUIREMENTS Veins, by definition, are blood vessels that carry blood You will need: towards the heart. • Alcohol hand rub The veins of the arms are anatomically divided into two • A pair of clean gloves groups: superficial and deep. The two groups communicate • A tourniquet (anastomose) frequently with each other. The superficial • A skin marker pen veins are placed immediately beneath the integument • A volunteer (A person with a low BMI, male, athletic, between the two layers of superficial fascia. The deep middle-aged, or older with fair skin will show the veins veins often accompany the arteries. For the purpose of this more clearly.) project we will focus in on the superficial veins. • If no volunteer is available, use your own arm • Good lighting
55 Venipuncture Course and Kit | PREPARATION
FOLLOW THESE STEPS STEP 3 Ask the volunteer to lie down and let the arm hang down STEP 1 below the rest of the body to allow passive gravitation to Study the detailed illustration of the veins of the upper fill the veins with blood. Apply the tourniquet about 5-7 extremity (arm). [CLICK HERE] cm (2-3 inches) above the elbow joint STEP 2 STEP 4 Have a look at the simplified diagrams: Prepare your hands hygienically and don clean gloves. (Gloving is optional for this project.)
See PROJECTS 3A, 3B and 3C STEP 5 Use the simplified diagram to identify the veins of the ventral (front) side of your arm by inspection and by palpation. Use the tips of your middle three fingers. STEP 6 Use the skin marker pen to draw the veins on the arm.
STEP 7 Identify the veins of the dorsum of the hand (upper Figure 10a: The ventral arm veins side), as per the simplified diagram, by inspection and by palpation. Use the tips of your middle three fingers. STEP 8 Use the skin marker pen to draw the veins on the hand. Feel free to take a photograph of the venous pattern of your volunteer’s arm. You may also want to label the veins using the diagrams in Step 2.
POINTS OF INTEREST The anatomical patterns of veins vary more than those of the arteries of the body. Look at this excellent anatomical study and publication: Cubital Fossa Venipuncture Sites Based on Anatomical Figure 10b: The dorsal hand veins Variations and Relationships of Cutaneous Veins and Nerves by Kouji Yamada and coworkers.⁵ [Click Here] The flow of blood in the venous system is complex for several reasons: • The relatively low pressure within the veins. • The flow rate varies and is somewhat dependent on the contraction of muscles. • Gravity affects the flow rate and intravenous pressure. • The collapsible nature of the relatively thin venous walls. • Valves are present within the lumens of most veins. • Veins carry a large volume of blood: about 64% of the blood volume! Figure 10c: The cubital fossa veins
56 Venipuncture Course and Kit | PREPARATION
PROJECT 5B IDENTIFY THE VEINS OF THE LOWER EXTREMITY
INFORMATION STEP 3 Ask the volunteer to expose the leg area up to some REQUIREMENTS distance above the knee. The person should be standing, You will need: sitting, or lying down with the leg lower than the rest of • Alcohol hand rub the body to allow passive gravitation to fill the veins with • A pair of clean gloves blood. Apply the tourniquet somewhere at least 10-15 cm • A tourniquet (4-6 inches) above the knee joint. • A skin marker pen • A suitable volunteer (A person with a low BMI, male, athletic, middle-aged, or older with a fair skin will show the veins more clearly.) • If no volunteer is available, use your own leg • Good lighting
FOLLOW THESE STEPS STEP 1 Study the detailed illustration of the veins of the lower extremity (leg). STEP 2 Have a look at the simplified diagram:
Figure 12: Examining the veins of the leg STEP 4 Prepare your hands hygienically and don clean gloves. (Gloving is optional but strongly recommended.) See PROJECTS 3A, 3B and 3C
Figure 11: The anterior leg veins
57 Venipuncture Course and Kit | PREPARATION
STEP 5 the superficial veins into the deep venous system through Identify the veins, using the simplified diagram, by small perforator veins. Superficial, deep, and perforator inspection and by palpation. Use the tips of your middle veins have one-way valves that allow blood to flow only three fingers. towards the heart. A blood clot (thrombus) in one of the deep veins of the leg can become life threatening when a part of the blood clot breaks off (now called an embolus). The embolus may travel through the heart and into one of the pulmonary arteries where it will lodge in a blood vessel inside the lung. A clot (thrombus) in the superficial veins might cause discomfort and pain, but it is usually not a cause for pulmonary embolism.
IMPORTANT WARNINGS As a general rule, always use the veins of the upper extremities as your first choice for routine venipuncture. Venipuncture on the lower extremities, in particular the feet, is contraindicated in most situations because of the increased bacteria flora on the feet and the risks of possible infection and thrombosis. Venipuncture on the lower extremities shall not be performed on: • Patients who are diabetic or who suffer from thrombophlebitis, venous thrombosis, or edema. • Legs or feet with any type of symptom (burning, itchiness, pain, swelling, etc.). • Legs or feet showing the following clinical signs: tenderness, ulceration, swelling, tumors, or any change in color or temperature.
Figure 13: Identifying the greater saphenous vein • Legs or feet when injuries, areas of bruising, previous burns, or scar tissue are visible. STEP 6 • Phlebotomists and nursing staff are required to get Use the skin marker pen to draw the veins on the leg. Feel permission from the attending physician before free to take a photograph of the venous pattern of your using a vein of the lower extremity for venipuncture/ volunteer’s leg (of course, with permission). You may also phlebotomy. label the veins using the diagram in Step 2.
POINTS OF INTEREST There are two types of veins in the legs: superficial veins and deep veins. Superficial veins lie just below the skin and are usually visible on the surface. Deep veins are located much deeper, next to the muscles and arteries of the leg close to the femur and tibia. Blood flows from
58 Venipuncture Course and Kit | PREPARATION
PROJECT 5C OTHER IMPORTANT VEINS (FACE, NECK AND CHEST)
INFORMATION The external jugular vein has two pairs of valves: the lower pair is located at its entrance into the subclavian vein and the upper in most cases is about 4 cm above the clavicle. If you position a patient in the Trendelenburg position (body tilted about 15° with the head lower than the feet) you may notice the external jugular vein pulsating. This is caused by retrograde pressure from atrial systole (keep in mind that the entrances of the atriums are valveless and the venous valves are flimsy [SEE VIDEO CLIP].
REQUIREMENTS You will need: • Alcohol hand rub • A pair of clean gloves • A skin marker pen • A suitable same-gender volunteer (A person with a low BMI and a fair skin will show the veins more clearly.) • If no volunteer available, use your own neck in the mirror • Good lighting
59 Venipuncture Course and Kit | PREPARATION
FOLLOW THESE STEPS POINTS OF INTEREST STEP 1 • External jugular vein cannulation is a skill that every medical student should master. It is a useful Study the detailed illustration of the veins of the neck alternative in certain situations for: [CLICK HERE]. -- Repeated blood sampling. -- Administering intravenous fluid, medication, STEP 2 chemotherapy, radiological contrast, as well as Have a look at the simplified diagram: blood and blood products. -- The external jugular vein may be the site of preference for venipuncture with burn patients involving all the extremities. It is also useful in an emergency situation. -- The internal jugular vein’s course runs under the sternocleidomastoid muscle, so it is not visible under the skin as the external jugular vein is. It is commonly used to place central venous catheters/ lines.
Figure 14: The head and neck veins STEP 3 Ask the volunteer to expose the neck area. Place the person in the Trendelenburg position (head and neck about 15° down), tilt the head slightly to the opposite side, and apply light pressure just above the clavicle. You can also ask your volunteer to forcefully exhaling against resistance (closed lips) so you can see the veins more clearly. This will increase the intra-thoracic pressure and help to engorge the external jugular veins. Keep in mind that the course of the neck veins may vary to some extent; some patients have double external jugular veins. STEP 4 Prepare your hands hygienically and don clean gloves. (Gloving is optional but strongly recommended.) See PROJECTS 3A, 3B and 3C STEP 5 Identify the external jugular vein on both sides by inspection and palpation as it crosses the sternocleidomastoid muscle as shown in the diagram. Identify the anterior and posterior jugular veins if possible. STEP 6 Use the skin marker pen to indicate the course of the vein. With permission, take a photograph of the venous pattern of your volunteer’s neck. You may also label the veins using the diagrams in Step 2.
60 Venipuncture Course and Kit | PREPARATION
PROJECT 5D MAP THE VALVES IN VEINS
INFORMATION There are valves in most veins; exceptions include the portal, the hepatic, and the internal jugular veins. Venous valves are bicuspid (two) flap-like structures made of elastic tissue. The valves function to keep blood moving in one direction only. Once the blood has passed from the arteries through the capillaries, it flows at a slower rate because little pressure remains to move the blood along towards the heart. In the veins below the heart, blood flow is facilitated by muscular contraction. When the muscles contract, blood within the veins is squeezed forward in the vein and the valves open. When the muscle is at rest, the valves close, which helps prevent the backward flow of blood. This is called the muscle pump.
The direction of venous return in the extremities is from finger and toe tips towards the body
REQUIREMENT STEP 3 You will need: Occlude the vein distally (on the finger’s side) by • Alcohol hand rub applying firm pressure with an index finger. Press your • A pair of clean gloves second index finger next to your first index finger. • A skin marker pen Move the second index finger towards the elbow while • A volunteer (Look for a person with a low BMI,male, exerting mild pressure. This empties the blood from the physically fit, middle-aged or older, or with fair skin lumen as you move your finger along the vein. to show the veins more clearly.) • If no volunteer is available, use your own arm STEP 4 • Good lighting Stop at the proximal side of the section identified and then release the second index finger. The vein will METHOD 1 immediately refill up to the point where a venous valve is situated. Notice that the previously distended vein FOLLOW THESE STEPS remains flat up to the valve inside the vein. Lift the first index finger and note the flat section of vein filling up with venous blood. STEP 1 Prepare your hands hygienically and don clean gloves STEP 5 (gloving optional but strongly recommended). Mark the position of the valves with the skin marker pen See PROJECTS 3A, 3B and 3C and photograph the valve-mapped arm. STEP 2 Identify a suitable volunteer: someone with clear and prominent superficial veins on their arms. Ask this person to make a fist and extend the arm, with the palm up and slightly below elbow level. Locate a prominent section of vein of about 10 cm (4 inches) on the inside of the forearm.
61 Venipuncture Course and Kit | PREPARATION
METHOD 2 FOLLOW THESE STEPS
STEP 1 going towards the wrist. Exert mild pressure to empty Prepare your hands hygienically and don clean gloves. the blood from the lumen of the vein. (Gloving optional but strongly recommended.) See PROJECTS 3A, 3B and 3C STEP 4 Blood will immediately refill the vein up to the point where a venous valve is encountered and then you will STEP 2 notice the distended vein remaining flat up to the point Have a volunteer make a fist and extend the arm, with of the valve inside the vein. Lift your finger and notice the palm up and slightly below elbow level. Locate a how the flat section of vein fills up with venous blood. prominent vein on the inside of the forearm. STEP 5 STEP 3 Mark the position of the valves with the skin marker Starting near the elbow, run your finger along the vein pen. Take a photograph of the valve-mapped arm.
POINTS OF INTEREST • When drawing blood, injecting into a vein or putting up an IV line, insert the needle above or some distance below a valve. Avoid injecting straight into a valve to avoid damage or complications. • In some individuals, the valves show up as small nodular enlargements of the vein – and are easily identified. • Venous valve malfunction
Figure 16a and b: Example of varicose veins leg • Predisposing factors for developing varicose veins include: • Age—aging causes wear and tear on the valves in your veins. • Gender—women are more likely than men to develop this condition. • Hormonal changes—especially during pregnancy, pre-menstruation, or menopause. • Genetics—varicose veins tend to run in families. • Obesity. • Prolonged standing. Figure 15: Diagram of a normal and a varicose vein • Varicose veins affect about 20% of the population. Malfunction of the normal one-way valves in the veins They are more common in women (20-25%), than is the main underlying cause of varicose veins. This in men (10-15%). Pregnancy is often an initiating causes venous blood to accumulate in superficial veins event in women. Varicose veins tend to get worse and branches, causing the walls of the veins to distend with age. (enlarge) and stretch in a convoluted fashion. • Never attempt to use a varicose vein to perform venipuncture!
62 Venipuncture Course and Kit | PREPARATION
BLOOD SAFETY INSTRUCTIONS The following Projects, when performed on a patient in a real clinical setting, will expose you to blood—a potentially hazardous substance! For your own and your patient’s safety, these standard precautionary measures should be in place at the hospital or medical institution to minimize the spread of infectious disease: • Appropriate aseptic and sterile techniques protocol. • Appropriate hygiene practices, particularly hand hygiene routines [See PROJECTS 3A and 3B]. • Availability of protective barriers and usage guidelines—including the wearing of gloves, gowns, plastic aprons, masks, eye shields, and goggles [See PROJECTS 3C to I]. • Appropriate procedures for the handling and disposal of contaminated wastes. • Appropriate procedures for the handling and disposing of sharps. • Guidelines and procedures for the prompt handling of blood and body fluid spills. • Appropriate waste disposal measures must be in place to ensure that blood, other body fluids/substances, and other potentially infectious materials are disposed of safely. • An established protocol for preventing, reporting, and handling sharps injuries and other infective agent transfer incidents (e.g., body fluid splash on a mucous membrane).
PROJECT 6A PREPARE TO ADMINISTER AN INJECTION
Choose a suitable syringe and needle and draw up medication from various medicine vials
PLEASE TAKE NOTE: This project offers general guidelines and steps to follow in a clinical setting. The various medication vials (containers) are not included in the kit.
Figure 17: A dental needle (left) and a hypodermic needle (right). Note that the dental needle has a longer section pointing forwards and a shorter section pointing backwards. The back end is for penetrating the diaphragm of the dental cartridge and the front end for injecting.
63 Venipuncture Course and Kit | PREPARATION
CHOOSE THE CORRECT SIZE IMPORTANT NOTES: SYRINGE: Always keep your and your patient’s safety as your first priority! 0.5ML AND 1ML • Use insulin syringes only for insulin. (DEDICATED DIABETIC • Too high a dose of insulin may cause a hypoglycemic coma, or irreversible brain damage. It can even be lethal! SYRINGES) • Too low a dose given to a diabetic may lead to a Note: Milliliter (ml) indicates the same volume as cubic hyperglycemic coma. centimeter (cc) • Use safety needles whenever possible according The standard insulin syringe holds one ml (or one cc), to the manufacturer’s instructions and discard in a divided into 100ths, which is equal to one UNIT of insulin. It dedicated sharps safety container after use. is vital that you exclusively use a U100 insulin solution with • In all cases when preparing more than one syringe of a U100 syringe. There are some smaller insulin syringes different medications or if you are not administering that only hold 0.5ml but they are still marked properly for the medication straight away, clearly label the syringe U100 insulin even though they are smaller in size. above the volume markings the type of medication The syringe in the kit is a 0.5ml insulin syringe with a and the concentration (e.g., ketamine 100 mg/ml). protective cap over the needle and plunger. Remove these • Always take great care to avoid needle stick injuries orange colored caps to use. Orange is the color code for when working with sharps! U100 insulin. • If you need to recap a needle – use the one hand scoop technique (see below). 1ML SYRINGE (TB SYRINGE) • Never recap a blood-contaminated needle. Used for Heparin SQ or TB Intradermal skin testing. It holds 1ml and has 0.1ml markings on the side. NEVER draw up insulin in this syringe.
3ML – 5ML SYRINGES Commonly used for IM injections or for mixing or drawing up other medications. Use the smallest syringe that will hold the dose properly.
10ML – 12ML SYRINGE Used for mixing or drawing up other medications, for central line flushing, and to inflate/deflate Foley catheter balloons, as well as for urine specimen collection from a Foley’s port.
CHOICE OF NEEDLE GAUGE SIZES (ADULTS): Subcutaneous injections: 25-27 gauge, 10-16mm (3/8-5/8 inch) IM injection (need 2 needles): 21-25 gauge, 25-38mm (1- 1½ inch) Drawing up from vials: 18-21 gauge, 25mm (1 inch)
Figure 18: The one hand scoop technique for recapping a needle
64 Venipuncture Course and Kit | PREPARATION
YOU WILL NEED: • Carefully remove the needle cap from the syringe (or • Syringe with attached needle (10ml or 12 ml and remove the protective cover from the safety syringe, 18G-21G needle) • 10 ml glass vial of sterile water see PROJECT 1B). • Alcohol wipes • Sharps container • Sticker paper or a strip of strapping for labeling Important: DO NOT touch the needle! • A pen for labeling • Turn the vial horizontally and insert the needle into
HOW TO DRAW UP the vial. MEDICATION • Gently pull back the plunger and allow the medication In each of the projects to draw up medication in various ways, follow begin each time with these steps: to fill the syringe. Withdraw the required amount of GENERAL PREPARATION* medication as specified. Avoid drawing air by keeping • Clean the work surface with an antiseptic solution. • Open a clean work surface cover. the needle tip below the fluid meniscus of the • Gather all the items to be used with the outer package intact. medication. Withdraw the needle from the vial. • Prepare your hands hygienically. • To remove air bubbles, hold the syringe vertically with • Don clean gloves (optional). • Open the syringe on the work surface cover. needle pointing up. Tap the syringe gently to move • Partially open the needle at the hub end. • Connect the needle to the syringe and place on the any air bubbles toward the needle. cover • Tear open an alcohol wipe and drop it on the work • Gently push the plunger to remove the air and possibly surface cover bubbles mixed with a couple of droplets of medicine.
HOW TO DRAW UP Label the syringe by placing a sticker with the name
MEDICATION FROM A GLASS and concentration of the medication noted legibly.
VIAL Do not stick the label over the volume markings.
FOLLOW THESE STEPS • Prepare to administer the medication using the • General preparation – (*see above) • Hold the vial upright between your fingers and swivel appropriate route (See PROJECTS 8, 9 or 11D). If the vial two to three times in a circular motion to ensure that all medication is in the bottom of the vial and not IMI injection—appropriately discard the needle used in the top section. Do not flick your finger against the to draw up the medication and place a new needle vial as you may break the vial and injure your finger. • Identify the small dot on the vial and face it towards (preferably a safety needle) on the syringe. you. Hold the main body of the vial between the thumb and index finger of the one hand and the top part of the vial between the thumb and index finger of the other hand. • Crack the vial open by bending the top backwards in a single definite action, and place it upright on the work surface.
65 Venipuncture Course and Kit | PREPARATION
IMPORTANT NOTE • Insert the needle into the center of the rubber membrane of the vial. REGARDING WITHDRAWING • Turn the vial upside down and slowly inject air from MEDICATION FOR AN IM the syringe into the vial of medication. • Gently pull back on the plunger, allowing the INJECTION medication to fill the syringe, and withdraw the • Most training centers recommend a standard two- required amount of medication as specified. Avoid needle protocol when performing an IMI—the first drawing air by keeping the needle tip below the needle for withdrawing the medication and the fluid meniscus of the medication. Withdraw the second sterile needle for injecting the patient. needle from the vial. • Be careful when changing needles. You may use a • Hold the syringe with needle pointing upwards conventional needle to draw up the medication, but and tap the syringe gently to move any air bubbles use a safety needle when injecting the patient. towards the needle. • A single needle protocol for IMI injections is not • Push the plunger gently to remove the air and air recommended for the following reasons: bubbles, possibly mixed with a couple of droplets • The fine, sharp needle tip is easily damaged when of medicine. hit against the bottom of the glass vial. This is not • Prepare to administer the medication using the too uncommon and increases pain on subsequent appropriate route (See PROJECTS 8, 9 or 11D). If injection! IMI injection, appropriately discard the needle used • The first needle may touch a non-sterile surface and to draw up the medication and place a new needle become contaminated with microbes. on the syringe.
HOW TO DRAW UP HOW TO DRAW UP MEDICATION FROM A MEDICATION FROM A GLASS VIAL WITH A RUBBER PLASTIC CONTAINER • General preparation – (*see above) MEMBRANE • Open the plastic container (usually containing sterile YOU WILL NEED: water or normal saline solution for injection) by using a 180° twist-and-open action. • Syringe with attached needle • Carefully remove the needle cap from the syringe (or • Vial of medication remove the protective cover from the safety syringe – • Alcohol wipes PROJECT 1B). • Sharps container Important: Do not touch the needle! • Turn the vial horizontally and insert the needle into FOLLOW THESE STEPS: the vial. • General preparation – (*see above) • Gently pull back the plunger and allow the medication • Carefully remove the protective cap from the vial to fill the syringe. Withdraw the required amount of and swab the top of the vial thoroughly with a fresh medication as specified. Avoid drawing air by keeping alcohol wipe. Allow time to dry. the needle tip below the fluid meniscus of the • Determine the volume of medication required in ml medication. Withdraw the needle from the vial and (cc). Draw in an equal amount of air by pulling back remove any air and air bubbles in the syringe. on the syringe plunger. • Prepare to administer the medication using the • Carefully remove the needle cap from the appropriate route. If IMI injection – appropriately syringe (or remove the protective cover discard the needle used to draw up the medication from the safety syringe—PROJECT 1B) and place a new needle on the syringe. Important: Do not touch the needle!
66 Venipuncture Course and Kit | PREPARATION
SAFETY Plastic vials are safe from the point of view that it eliminates • Press down on the plastic activator to force diluent the possibility of a sharps injury to the clinician. into the lower compartment. On the down side, one can accidentally stick a needle in • Gently agitate to effect solution. an unused vial and unintentionally contaminate it, or stick • Remove plastic tab covering center of stopper. the needle right through the container and cause a needle • Sterilize top of stopper with a suitable germicide stick injury. (alcohol wipe). • Insert needle squarely through center of stopper until HOW TO DRAW UP tip is just visible. Invert vial and withdraw dose. MEDICATION FROM HOW TO DILUTE A CONTAINER WITH THE MEDICATION IN A 1:10 RATIO MEDICATION IN POWDER • Use a 10ml or 12ml syringe with 18G needle attached. FORM. • Open a 1ml medication vial (e.g., epinephrine). Withdraw the full volume of the vial into the syringe. (MANY ANTIBIOTICS COMES • Open 10 ml of solvent (e.g., sterile water or normal saline for injection vial) and withdraw 9 ml into the 10 AS A POWDER IN A VIAL.) ml (or 12 ml) syringe. SINGLE UNIT • Discard the 1 ml of water remaining in the vial. • Prepare to administer the medication using the • General preparation – (*see above) appropriate route. • Open the specific solvent (e.g., sterile water) and withdraw the required amount into a syringe. • Carefully remove the protective cap from the vial and swab the top of the vial thoroughly with a fresh NOTE: alcohol wipe. Allow time to dry. It is safer to administer a medication that has potentially • Let the syringe’s needle penetrate the rubber serious or even life threatening side effects by diluting it membrane of the powder vial. and injecting it slowly! • Squirt the solvent into the powder and mix it thoroughly by repeatedly injecting and withdrawing the medication a couple of times. • Gently pull back on the plunger of the syringe, allowing the medication to fill the syringe, and withdraw the required amount of medication as specified. Avoid drawing air by keeping the needle tip below the fluid meniscus of the medication. Withdraw the needle from the vial and remove any air and air bubbles in the syringe. • Prepare to administer the medication using the appropriate route (SEE PROJECTS 8, 9 OR 11D). If IMI injection – appropriately discard the needle used to draw up the medication and place a new needle on the syringe.
Directions for using a vial with a powder and a solvent compartment (e.g., the ACT-O-VIAL system)
67 Venipuncture Course and Kit | PREPARATION
POINTS OF INTEREST What are some procedures that have been associated with unsafe injection practices? STUDY THE CDC GUIDELINES FOR INJECTION Unsafe injection practices that put patients at risk for HBV, SAFETY: HCV, and other infections have been identified during What is injection safety? various types of procedures. Examples include: Injection safety, or safe injection practices, is a set of • Administration of sedatives and anesthetics for surgical, measures taken to perform injections in an optimally safe diagnostic, and pain management procedures; manner for patients, healthcare personnel, and others. A • Administration of IV medications for chemotherapy, safe injection does not harm the recipient, does not expose cosmetic procedures, and alternative medicine the provider to any avoidable risks, and does not result in therapies; waste that is dangerous for the community (e.g., through • Use of saline solutions to flush IV lines and catheters; inappropriate disposal of injection equipment). Injection • Administration of intramuscular (IM) vaccines. safety includes practices intended to prevent transmission of infectious diseases between one patient and another, The medications used in these procedures were in single- for example between a patient and healthcare provider, dose or single-use vials, multi-dose vials, and bags. What and also to prevent harm such as needlestick injuries. they had in common was the vials or bags were used for more than one patient and were entered with a syringe What is aseptic technique? that had already been used for a patient; or the syringe In this context, aseptic technique refers to the manner itself was used for more than one patient. of handling, preparing, and storing of medications and injection equipment/supplies (e.g., syringes, needles and The above is an excerpt from the CDC website on IV tubing) to prevent microbial contamination. injection safety.
What are some of the unsafe injection practices that For more information and answers on frequently asked have resulted in transmission of pathogens? questions go to the DCD website: http://www.cdc.gov/ The most common practices that have resulted in injectionsafety/providers/provider_faqs_general. transmission of hepatitis C virus (HCV), hepatitis B virus html (HBV), and/or other pathogens include: • Using the same syringe to administer medication to more than one patient, even if the needle was changed or the injection was administered through an intervening length of intravenous (IV) tubing; • Accessing a medication vial or bag with a syringe that has already been used to administer medication to a patient then reusing contents from that vial or bag for another patient; • Using medications packaged as single-dose or single- use for more than one patient; • Failing to use aseptic technique when preparing and administering injections.
68 Venipuncture Course and Kit | PREPARATION
PROJECT 6B HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (ROUTINE VENIPUNCTURE)
A simple but essential step to prevent infections
INFORMATION weaken these skin bacteria to the extent that it would be unlikely for them to cause problems. Isopropyl alcohol is The skin harbors, in large numbers, a variety of bacterial the most common substance used for this purpose when species, as well as other microorganisms. These microbes performing venipuncture/phlebotomy procedures. (also called flora) can be divided into two groups: Isopropyl alcohol is a colorless, flammable chemical resident flora (lives in and on the skin) and transient flora compound with a strong odor with the molecular formula (temporary visitor microorganisms). Resident and transient C3H8O. It is used in medical disinfecting pads (alcohol flora do not normally cause diseases on the skin but if they preps), which typically contain a 60–70% solution of enter the body they may cause diseases. For example, isopropyl alcohol in water. It kills bacteria by causing each Staphylococcus epidermidis lives quite innocently on the bacterium cell membrane to lose its structural integrity. skin in great numbers but may cause sub-acute bacterial Then the isopropyl alcohol enters the bacterium cell endocarditis (SBE) under certain conditions if they enter and denatures the proteins within, causing intracellular the blood stream. dehydration. This is why allowing the alcohol to completely It is impossible to sterilize (kill all known microorganisms evaporate spontaneously is so important in killing bacteria and spores) on a patient’s skin but one can reduce and before performing venipuncture.
REQUIREMENTS You will need: • Antiseptic soap for handwashing or alcohol hand rub • A clean work surface cover • A tourniquet (re-usable) • Clean gloves • Alcohol prep swabs
69 Venipuncture Course and Kit | PREPARATION
FOLLOW THESE STEPS: POINTS OF INTEREST STEP 1 The total number of microorganisms on a person’s skin is estimated at 1012 (1,000,000,000,000). Unfold the clean work surface cover and open it on your Common species include: working area. Place the following items on this cover: Staphylococcus epidermidis Clean gloves Staphylococcus aureus Alcohol prep swabs Micrococcus species Neisseria species STEP 2 Streptococci Prepare your hands hygienically (wash or alcohol hand Diphtheroids rub—PROJECT 3A/B). Choose a venipuncture site, apply Small numbers of other organisms a tourniquet, and select a suitable vein.
STEP 3 IMPORTANT: Adhering to a meticulous sterility and aseptic protocol will Tear open an alcohol prep sachet and place on the work dramatically reduce the number of infective complications surface. that your patients could experience. Insignificant Put on clean gloves and remove the alcohol-saturated square. deviations from the recommended protocol make a big difference! STEP 4 Ensure that the alcohol prep square is saturated with clear Cleanse in a circular fashion for 30 seconds beginning at alcohol. If the square is dry or semi-dry, cloudy or colored, the intended puncture site then make circular motions then discard it and use a new one. outwards (see the diagram below).
Figure 19: Correct and incorrect methods of cleaning an intended venipuncture site
Allow the skin to air dry. It is imperative to allow the alcohol to evaporate spontaneously. Give it enough time to dry (minimum 30 seconds) and don’t fan it dry with your hand.
STEP 5 The next step will be performing the venipuncture procedure (PROJECTS 11A, B, C and D) – for the purpose of this project you may now remove the tourniquet.
70 Venipuncture Course and Kit | PREPARATION
PROJECT 6C HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FOR BLOOD CULTURE)
Minimize the chances of contaminant bacteria of entering the blood culture bottle
This project is for your information only as there are no blood culture bottles supplied in the kit. Labs usually supply dedicated cleaning kits for the purpose of aseptically preparing the puncture site before taking blood samples for culturing. STEP 1 STEP 5 Prepare your hands hygienically (wash or alcohol hand Position patient appropriately, apply tourniquet to palpate rub—PROJECT 3A/B). Choose a venipuncture site, apply and identify appropriate vein. a tourniquet, and select a suitable vein. STEP 6 STEP 2 Perform hand hygiene for the second time. Use a 2% chlorhexidine gluconate in 70% alcohol solution, as well as 3-6 sterile swabs opened onto the sterile field. STEP 7 Alternatively a 2% iodine tincture or 10% povidone iodine Put on CLEAN gloves (do not touch the venipuncture site may be used in place of the chlorhexidine gluconate and after skin preparation. If palpation is absolutely necessary alcohol solution. then STERILE GLOVES must be used prior to palpation).
STEP 3 STEP 8 Remove the cap of each blood culture bottle and use a Using swabs saturated with 2% chlorhexidine in 70% non-touch technique to scrub the vial stoppers well with a alcohol, disinfect the venipuncture site in a scrubbing fresh chlorhexidine and 70% alcohol swab. Allow these to motion. Perform 2-3 scrubs using a fresh swab for each dry for 30 seconds. scrub, with the last scrub starting at the intended puncture site and spiraling out in a circular motion towards the STEP 4 periphery. Clean for a total of 1-2 minutes, and then allow the site to dry for approximately 30 seconds. Ensure that all the items and equipment for drawing blood (If tincture of iodine is used, remove with 70% ethanol after are ready and prepared. the procedure.)
71 Venipuncture Course and Kit | PREPARATION
STEP 9 better tolerated, doesn’t negatively affect wound In a real patient scenario, you will now perform the healing, and leaves a deposit of active iodine thereby venipuncture for blood culture/s using a vacutainer. creating the so-called “remnant” or persistent effect. The great advantage of iodine antiseptics is their wide scope of antimicrobial activity, killing all principal POINTS OF INTEREST: pathogens and, given enough time, even spores. • See conclusion made by researchers is this interesting • Using a sound skin preparation technique and article: [CLICK HERE FOR FULL ARTICLE] protocol the specimen contamination rate should be in the low single figures range (definitely < 9%) • Iodine is usually used in an alcoholic solution, called Chlorhexidine is a better alternative to iodine tincture tincture of iodine, as a pre- and post-operative because it has a comparable effectiveness and is safer, antiseptic. It is not recommended to disinfect minor cheaper, and preferred by staff. (Of course it should wounds, because it induces scar tissue formation not be used on patients who are sensitive or allergic to and increases healing time. Povidone-iodine is much Chlorhexidine.)⁶
72 Venipuncture Course and Kit | PREPARATION
PROJECT 6D HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FROM BLOOD DONOR)
Prevent bacterial contamination of donated blood
WHO GUIDELINES (2010)⁷ ARE AS FOLLOWS: If the site selected for venipuncture is visibly dirty, wash the area with soap and water, and then wipe it dry with single-use towels.
ONE-STEP PROCEDURE TWO-STEP PROCEDURE (recommended – takes about one minute): (if chlorhexidine gluconate in 70% isopropyl alcohol is not • use a product combining 2% chlorhexidine gluconate available, use the following procedure – takes about two in 70% isopropyl alcohol; minutes): • cover the whole area and ensure that the skin area is STEP 1 – use 70% isopropyl alcohol; in contact with the disinfectant for at least 30 seconds; cover the whole area and ensure that the skin area is in • allow the area to dry completely, or for a minimum of contact with the disinfectant for at least 30 seconds; 30 seconds by the clock. allow the area to dry completely (about 30 seconds);
STEP 2 – use tincture of iodine (more effective than povidone iodine) or chlorhexidine (2%); • cover the whole area and ensure that the skin area is in contact with the disinfectant for at least 30 seconds; • allow the area to dry completely (about 30 seconds).
Whichever procedure is used, DO NOT touch the venipuncture site once the skin has been disinfected.
73
3 Venipuncture Course and Kit | COLLECTING BLOOD
CASE STUDY 3: MY LIFE CHANGED DRASTICALLY IN A SPLIT SECOND
Dr. Louise Weimar wore a cream wedding gown and her prick injury. The pathologist simply remarked: “Good luck!” groom, Scottish engineer Mark Mynhardt, wore a kilt. She told her fiancé about her disease, fearing that this From an outsider’s perspective they looked perfect on the might be the end of their relationship, but to him it was happiest day of their lives. But behind the wedding music, a simple decision. She was the woman of his dreams and cake and champagne lay a devastating story of how an they married two weeks later. accidental needle stick changed a life. Sadly, Dr. Weimar had to approach a human rights lawyer Dr. Louise Weimar performed her medical duties at a for some form of compensation. remote public hospital. On a day like any other, she was drawing blood from a 3-month-old baby. After an Let’s survey some lessons learned: unsuccessful first attempt she reached for a second needle • Always use safety needles in all clinical and laboratory to re-attempt the procedure but just as she turned around, settings when working with blood or any other bodily the baby pulled loose from the nurse’s arms and bumped fluids/secretions/excretions. Dr. Louise’s hand right into the first needle. It penetrated • Discard used needles in an appropriate sharps waste the little finger of her right hand to the bone. Dr. Louise container immediately after use. followed protocol and reported the incident. A sample of • Start the recommended PEP (Post Exposure the baby’s blood was immediately sent to the lab to be Prophylaxis) protocol as soon as possible after tested for HIV. It was positive. exposure to an infective agent requiring PEP. Both the hospital authorities and the health department were unsupportive, and she started with the recommended antiretroviral medication far too late. Ironically, on December the 1st, International AIDS day, Dr. Louise was informed that she had contracted HIV from her needle
76 Venipuncture Course and Kit | COLLECTING BLOOD
CAPILLARY BLOOD COLLECTION USING A LANCET: WARNINGS: • During the following projects you will be working • Choose a place to practice where the fake-blood with sharp items. Take great care to avoid self-injury used in this project won’t stain any valuable items or injury to others. of clothing, carpets, etc. • Observe age recommendations (18 years and • Do not use any of the items in the kit for real older/15-17 adult guidance and supervision). patients – not even in an emergency!
PROJECT 7A DRAW CAPILLARY BLOOD – ADULT
A useful method of sampling a couple of drops of blood
VIDEO
The student is allowed to perform this project under supervision of a suitably qualified medical professional. If you have friend or family member who is a diabetic then offer to test their blood glucose level.
INFORMATION Blood from a finger stick differs from blood collected from Relative contraindications for finger prick blood collection: a vein in the fact that it is a mixture between venous, • General contraindications: Patients with general edema (mainly) capillary and arterial blood, as well as minute and patients with severe dehydration may not be good amounts of tissue fluid. candidates. If properly executed, blood collected from a finger (or • Local contraindications: Injury of the finger or hand, heel stick) will offer surprisingly accurate bio-chemical infection of the finger/nail area, scar tissue, previous information. Keep in mind that the following readings may burns, mastectomy with axillary lymph gland resection be slightly different: (on the side of the intended finger puncture site), • Lower concentrations of potassium, total protein, and Raynaud’s disease. calcium. • Patients with cold fingertips: Warm to increase the • Higher glucose. blood-flow before puncturing.
77 Venipuncture Course and Kit | COLLECTING BLOOD
REQUIREMENTS STEP 6 You will need: The puncture should be made perpendicular to the • A sterile lancet fingerprint ridges to prevent the drop of blood running • Alcohol prep swabs in the grooves. Stab the finger with the sterile lancet in a • Clean gauze squares single brisk stab movement. Puncture the flesh right up to • Gloves the shoulder of the lancet at 90° to the skin’s surface. • Clean work surface cover • Alcohol hand rub STEP 7 • A mini-blood receiver/container (not supplied in the Wipe away the first drop of blood which may contain kit) excess tissue fluid. • A suitable volunteer STEP 8 Collect drops of blood into the collection device by gently FOLLOW THESE STEPS massaging the finger. Avoid excessive pressure that may AS IF IN A REAL-LIFE squeeze tissue fluid into the drop of blood. CLINICAL SITUATION: STEP 9 Cap then rotate and invert the collection container to mix STEP 1 the blood collected. Open the above items on the clean work surface cover. STEP 10 STEP 2 Have the patient hold a small gauze pad over the puncture Greet the patient, introduce yourself and positively identify site for a couple of minutes to stop the bleeding. the patient. Do short medical history (allergies, bleeding tendencies, STEP 11 and anticoagulant medication). Verify the patient’s status Dispose of contaminated materials in their designated regarding fasting, dietary restrictions, medications taken containers. (and time), and other relevant information. Properly fill out Important note: All lancets are single-use only and and make appropriate notes on the lab requisition form must be disposed of in an approved sharps container including the specific tests requested. immediately after use. STEP 3 STEP 12 Prepare your hands hygienically. Label all appropriate tubes at the patient bedside and deliver specimens promptly to the laboratory. STEP 4 The patient should be comfortably positioned sitting or lying down. Extend the patient’s arm, keeping the hand POINTS OF INTEREST relatively open. A number of disposable spring-loaded skin puncture Choose a suitable puncture site. Use the pads of the devices are available that will ensure a safer procedure. The middle or fourth fingers of the non-dominant hand and spring-load mechanism should be pre-activated. The lancet somewhat to the side of the finger pad. will automatically puncture the skin when the auto-stab Avoid: mechanism is released, and will then immediately retract • The thumb, index finger, as well as the fifth fingers if back into the housing of the device. This virtually eliminates possible the possibility of accidental needlestick injury to the medical • The tip-area and central pad area of the finger professional performing the procedure. • Puncturing a finger that is cold or cyanotic, swollen, Regular venipuncture tubes generally hold 5-10 ml (adult) scarred, or covered with a rash and 2-4 ml (pediatric) of blood. Tubes for finger sticks or heel sticks generally hold one-half ml or less. STEP 5 Ensure that the fingertip is clean with no visible dirt. Wipe the fingertip with an alcohol prep swab. Wait 30 seconds to air dry.
78 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 7B DRAW CAPILLARY BLOOD – BABY
A useful method of sampling a couple of drops of blood
VIDEO
Figure 6: A surgeon scrubbing before surgery
INFORMATION Warning: This project is intended for your information only. Under no circumstances may you use a baby to practice this technique! A blood sample obtained from a heel puncture is a useful and simple way of collecting a blood sample from a newborn baby up to about 6 months of age.
It is commonly used for the following purposes in • Newborn bloodspot screening tests babies: • Full blood counts • Metabolic and genetic screening tests • Levels of certain drugs • Bilirubin levels (to monitor jaundice of the newborn) • Blood gases • Blood glucose and Lactate analysis • Urea and electrolytes
REQUIREMENTS • Receiving mini-blood container, capillary tube, and/or You will need: blood bottle • A sterile lancet (an appropriately sized automated • Clean gauze squares lancet devised for use on infants is recommended) • Clean gloves • Alcohol prep swabs • Clean work surface cover • Cotton wool • Alcohol hand rub
79 Venipuncture Course and Kit | COLLECTING BLOOD
FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION: STEP 1 Open the above items on the clean work surface cover. STEP 2 Check the patient for correct identity. Check the medical history with the baby’s parent (allergies, bleeding tendencies, medication, etc.). Verify the patient’s status regarding the physician’s specific orders. Properly fill out and make appropriate notes on the lab requisition form including the specific test(s) requested.
STEP 3 Figure 21: Permissable areas to perform a heel prick procedure Ensure that the baby is lying comfortably, warm and secure (for example, safely on a bed or on a person’s lap). Ask a parent or a nursing professional to assist by passively STEP 5 Gently but firmly compress the baby’s heel (avoid excessive restraining the baby. pressure). Release the tension, wipe away the first drop of Wash your hands. See handwashing guidelines and put on blood, and then re-apply the tension to allow the blood to clean gloves (PROJECT 3A, 3B and PROJECT 3C). collect in globules, which can then be collected into the Clean the site with warm water/saline and gauze or cotton blood bottle. wool. Do not use alcohol wipes to clean the skin of a baby. STEP 4 STEP 6 Cap then rotate and invert the collection container to mix Hold the baby’s heel with the non-dominant hand. It the blood collected. may be necessary to compress the foot beforehand to get a good flow of blood. With the foot flexed (see Fig. 14), prick the heel, preferably with a loaded automated STEP 7 lancet or with a disposable lancet, to a depth of 1-2mm in Apply pressure to the site with gauze and maintain the the plantar surface of the heel (see Fig. 15). The puncture pressure until bleeding has stopped. Tape a small piece should be made perpendicular to the heel-print ridges. If of gauze or cotton wool over the puncture site using you must use a regular lancet, then use a sterile single-use hypoallergenic tape. lancet to stab the heel at 90° to the skin’s surface in a single, brisk stabbing movement. STEP 8 Dispose of contaminated materials in designated containers. Important note: All lancets are single-use only and must be disposed of in an approved sharps container immediately after use. STEP 9 Take a consecutive blood sample from the alternate heel. Vary the puncture site positions. STEP 10 The person performing the skin puncture should wash Figure 20: How to hold the heel when performing a heel prick procedure their hands.
80 Venipuncture Course and Kit | COLLECTING BLOOD
STEP 11 • Damage to nerves, blood vessels, and bones Label all appropriate tubes at the patient bedside and • Osteomyelitis of the heel bone deliver specimens promptly to the laboratory. • Excessive scarring • Skin breakdown from repeated use of adhesive strips • Skin necrosis POINTS OF INTEREST • Excessive blood loss To avoid irritating, and even possible mutilating • Cellulitis and abscess formation complications the operator should adhere to a very strict • Hemolysis of the sample (will require a re-sampling) procedural protocol (as above). • Increased pain (compared to venipuncture) Complications that can arise in capillary sampling • Sore heels include:
PROJECT 8 HOW TO GIVE A SUBCUTANEOUS INJECTION
Deposit medication in the subcutaneous layer of the skin
VIDEO
*If you have an insulin dependent diabetic friend or family member, offer to administer their next insulin subcutaneous injection. Strictly follow the physician’s orders!
INFORMATION The skin is made up of different layers. Underneath the epidermis and dermis, which contain sweat glands and hair follicles, is a layer of fat. Subcutaneous injections are given into this area. As a general rule, suitable areas for subcutaneous injections are those areas with a substantial amount of fat below the skin, for example, the thighs, buttocks, and abdomen.
81 Venipuncture Course and Kit | COLLECTING BLOOD
CROSS SECTION OF THE SKIN
Some medicines work best when they are injected under To simulate a subcutaneous injection using the the skin into the fatty layer. These medicines require slower Venipuncture Trainer, see Step 12. absorption compared to medication taken by mouth or injected into a vein. Examples of medicines given FOLLOW THESE STEPS AS subcutaneously include growth hormone, insulin and IF IN A REAL-LIFE CLINICAL epinephrine (adrenalin). Medication for injection comes in various containers SITUATION: (bottle, vial, etc.), each with its own specifications on STEP 1 opening the container, maintaining sterility, withdrawing Greet the patient and positively check the identity of the medication, etc. See PROJECT 6A. patient. Three basic types of devices for giving subcutaneous Check the following on the medication ampule or vial injections are available: a syringe (for small volumes with a before proceeding: narrow gauge needle), an auto-injector and a pen device. • The correct medication name, amount (or volume, In this project we will use a syringe. e.g., 10 ml) and concentration, (e.g., 5 mg/ml). • The expiration date. Never use expired medication. REQUIREMENTS • Abnormalities regarding consistency and color of the medication in the container. If in doubt, send it back You will need: to the pharmacy. • Alcohol wipe • Clean work surface cover STEP 2 • Clean gloves Follow the steps described in Project 6A to draw up the • Ampule of medication medication for SQ injection. • Small syringe (0.5 ml) • 30 gauge needle (preassembled on syringe) STEP 3 • Cotton wool or gauze Choose the injection site for this dose and expose the • The Venipuncture Trainer area (if working on a real patient). There are several areas
82 Venipuncture Course and Kit | COLLECTING BLOOD
of the body suitable for giving subcutaneous injections, as • Some experts say that if you keep to the suggested shown in figure 17. Enquire about the patient’s previous injection sites, aspiration is unnecessary, specifically injection site. for subcutaneous injections as there are no major blood vessels in these specific subcutaneous injection STEP 4 site areas. (See safe subcutaneous injection sites Prepare your hands hygienically and don clean gloves diagram below). (sterile gloves are not required). STEP 5 Open an alcohol prep swab and wipe the intended area for SQ injection in a circular motion and allow to air dry. STEP 6 Spread the index finger and thumb of the non-dominant hand about 5 cm (2 inches) apart and place them on either side of the planned injection spot. Pinch (bunch-up) the skin in the chosen injection area between your thumb and index finger. Warnings: Stay clear of your own fingers. Take great care not to prick your own finger! Use a safety needle in a clinical setting. Note: In a home-care situation, no aseptic preparation Figure 23: Permissible areas for giving a subcutaneous injection of the skin is required, presuming reasonable personal hygiene. When a medical professional gives the SQ STEP 9 injection, skin prepping is advisable—especially in a clinic Press a piece of cotton wool or gauze lightly over the or hospital where medical professionals need to maintain injection site for a couple of seconds (optional). Do not a sterile chain, unlike the home-care situation. massage the injection site. STEP 7 STEP 10 Continue to hold the skin and insert the needle into Discard the used syringe and needle in the sharps waste the skin in the center of the skin fold so that the needle container. Do not recap or remove the needle! Remove is at an angle of 45°-90°. *Aspirate if your hospital/unit gloves and discard in suitable medical waste bin. recommends aspiration when giving a subcutaneous injection. STEP 11 Mark the puncture site, date, and time of the injection on a STEP 8 suitable chart or diagram. Push the syringe plunger to inject the medicine. It is recommended that you count slowly from 1 to 10 while STEP 12 injecting the medication. Simulate the project by following Steps 1-10 using the Remove the needle from the skin and release the skin. unassembled Venipuncture Trainer. Do not inject in the *Comments: blood vessel areas. • As a general rule, aspirating before injecting is a good Use 2ml of air or withdraw 2ml of fluid from the ‘In’ of one habit and is thus recommended. of the IV fluid bags to use as “medication” when doing the • How to aspirate: simulation exercise. With the needle in the injection site, gently withdrawing the plunger, exerting negative pressure before injecting the medication. This is done to make sure that you are not in a blood vessel, and thus administering an inadvertent IV injection and causing a possible medical emergency!
83 Venipuncture Course and Kit | COLLECTING BLOOD
POINTS OF INTEREST of time, ensure that you vary the injection sites to reduce Safe areas for giving subcutaneous injections: pain and irritation. In other words, don’t give the injection Abdomen: Uncover the abdomen from about 5 cm at the same spot every time. Instead, use a new spot each (2 inches) below the umbilicus up to the waist area. You time in an organized rotational way. A site rotation chart may give a shot below the waist, to just above the hipbone, for marking injection sites is recommended for patients and from where the body curves at the side to about who need subcutaneous injections on a regular basis (e.g., 5 cm (2 inches) from the middle of the abdomen. Avoid diabetics). It may be helpful to mark the injection site with the umbilicus. a small plaster as a reminder for next time. Thigh: Uncover the leg from the knee to the hip. The mid- section of the thigh, from mid-front to mid-side on the Injecting the medicine into the same area all of the time outside area of the thigh, is a safe site. Gently, grasp the will cause scarring or a fatty lump (lipohypertrophy) to area with index finger and thumb to ensure that you can form, causing medication to be absorbed more slowly. pinch one to two inches of skin. Upper Arm: Uncover the arm to the shoulder. Have the patient stand with hand on hip. Stand to the side, slightly Intradermal injections are often used for conducting behind the patient. Find the area halfway between the skin allergy tests. With the intradermal injection, a small elbow and shoulder. Gently grasp the skin at the back of thin needle of 25 or 27 gauge and 3/8 to 3/4 inch (1-2 cm) the arm between your thumb and first two fingers. You is inserted at a 10° to 15° angle to the skin of the forearm, should have 1-2 inches of skin. with the bevel facing upward. Various other areas – see Figure 23. Intradermal injections are also used by Plastic Surgeons to When a patient receives multiple injections over a period deposit fillers and Botox into the skin for cosmetic reasons.
84 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 9 HOW TO GIVE AN INTRAMUSCULAR INJECTION
Deposit medication in a suitable muscle
VIDEO
Figure 6: A surgeon scrubbing before surgery
INFORMATION • Medication causing little to moderate chemical irritation. It is not intended for medication that will Medication is injected well into the muscle layer below the cause a severe tissue reaction. various layers of skin. • Medication with low to moderate viscosity. Other considerations are the age of the patient (baby, child, or adult), the patient’s size, weight, and muscle mass (e.g., emaciated patients with small, friable muscles). Needle size (gauge and length) depends on factors such as the injection site, type of medication, and size of the muscle, as well as the patient’s weight and amount of subcutaneous fat. REQUIREMENTS You will need: • Alcohol wipe • Clean work surface cover Figure 24: An intramuscular injection • Clean gloves This route for injection is recommended for: • Container with medication • Medication requiring a relatively fast absorption • Syringe (5ml) speed for fast onset of action with a duration of • Two needles – preferably safety needles (Gauge 18 or 20) action of anything from hours up to several weeks • Cotton wool or gauze (variation dependent on the type and specifics of the • Adhesive bandage strip medication) • IV bag • A fairly small volume of medication (2-5 ml) depending • The Venipuncture Trainer on the muscle (deltoid – maximum 2ml and gluteus – up to 5 ml).
85 Venipuncture Course and Kit | COLLECTING BLOOD
SIMULATE A STEP 6 It is essential to aspirate before depositing the medication SUBCUTANEOUS INJECTION into the muscle. To do this, gently withdraw the plunger USING THE VENIPUNCTURE before injecting the medication into the muscle, in order to avoid an inadvertent intra-vascular injection and thus a TRAINER. SEE STEP 12. possible medical emergency. FOLLOW THESE STEPS AS If you aspirate blood, withdraw the needle and prepare a new syringe. IF IN A REAL-LIFE CLINICAL STEP 7 SITUATION: If no blood is aspirated, continue to hold the skin and STEP 1 push the syringe plunger to inject the medicine. It is Greet and positively check the patient’s identity. recommended that you count slowly from 1 to 10 for Check the following on the medication ampule or vial every milliliter (ml) being injected. before proceeding: • The correct medication, name, amount (or volume, STEP 8 e.g., 10 ml), and concentration (e.g., 5 mg/ml). When all of the medication has been injected, promptly • The expiration date. Never use expired medication. withdraw the needle and apply pressure to the injection • Abnormalities regarding consistency and color of the site using a gauze square to prevent bruising or a medication in the container. If in doubt, send back to hematoma; this will also minimize medication seeping into the pharmacy. the subcutaneous space. Certain medications may require massaging of the injection area for a minute or two, but STEP 2 for others this may be contraindicated. Apply an adhesive Follow the step-by-step instructions on withdrawing bandage strip if necessary. medication for an IM injection—see PROJECT 6A. STEP 9 STEP 3 Discard the used syringe and needle in a designated Prepare your hands hygienically and don clean gloves sharps waste container. Do not recap or remove the (sterile gloves not required). needle! Remove gloves and discard in a suitable medical waste bin. STEP 4 Choose the injection site for the dose and expose the area STEP 10 (if working on a real patient). There are several areas of Document the time, medication, dose, route, site, and the body suitable for giving intramuscular injections (IMI), patient’s response to injection. shown on the diagrams. STEP 11 STEP 5 Perform the project by following Steps 1-10 using the Swab the injection site with an alcohol pad for 30 seconds unassembled Venipuncture Trainer. Do not inject in the in a circular outward motion, up to 5 cm around. Allow blood vessel areas. the alcohol to air dry (30 seconds). Spread the index finger Withdraw 2ml of air or withdraw 2ml of fluid from the ‘In’ and thumb of the non-dominant hand about 5 cm (2 of one of the IV fluid bags as “medication” when doing the inches) apart and place them on either side of the planned simulation exercise. injection spot. Gently spread your index finger and thumb to tense the tissue. Ask the patient to relax and then to take a deep breath. As the patient inhales, make a quick dart-like motion to insert the needle at a 90° angle to an appropriate depth, ensuring that the needle tip enters the muscle properly. Warning: Stay clear of your own fingers. Take great care not to prick your own finger!
86 Venipuncture Course and Kit | COLLECTING BLOOD
POINTS OF INTEREST Relatively safe sites for IM injection are the deltoid, dorsal gluteal, ventrogluteal, and vastus lateralis (especially for children under two years of age).
Deltoid Muscle: The deltoid muscle is located in the Ventrogluteal Muscle: This muscle is located in the hip upper arm, just below the shoulder. To mark this site, place area. To mark this site, have the person lie on their back. the palm of your hand on the shoulder and spread your You should stand facing their hips. Place the palm of your thumb away from the four fingers in an upside down hand on the side of the hip, with your wrist lining up with V shape. Ensure that the middle of the patient’s arm is the thigh, the thumb is pointed towards the groin and the centered in your V. You will want to give the injection into fingers pointed towards the patient’s head. You should feel the middle of this V. the border of the bony iliac crest along the middle finger to small finger. Spread your index finger and middle finger into a V and give the injection between those fingers.
Figure 15a and b: Giving an intramuscular injection in the deltoid muscle
Vastus Lateralis Muscle: This muscle is located in the thigh. To properly mark this muscle, divide the front of the Figure 27a and b: Giving an intramuscular injection in the ventral gluteus muscle thigh into thirds from the top to the bottom of the thigh. The needle should go into the middle third. Dorsogluteal Muscle: This is the large buttock muscle. Divide one buttock into quadrants, halfway down the middle and halfway across. You will always want to give the injection in the outer, upper quadrant, almost towards the hip.
Figure 26a and b: Giving an intramuscular injection in the vastus later- alis muscle
Figure 28a and b: Giving a intramuscular injection in the dorsal gluteus muscle
87 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 10 A SET UP THE VENIPUNCTURE TRAINER FOR PHLEBOTOMY
How to prepare the trainer for performing various practical projects
VIDEO
INFORMATION REQUIREMENTS In the final analysis, phlebotomy is a clinical skill. The You will need: Apprentice Doctor® Venipuncture Kit is designed so you • Venipuncture Trainer can get acquainted and feel at ease with phlebotomy • Lumen stoppers/connectors skills before being confronted with real human or • IV line – adult animal patients in a clinical setting. The Venipuncture • Small IV fluid package Trainer might not look like a real arm or like the much • Syringe 5 ml more expensive plastic arm simulators (available from • Syringe needle 22 gauge the Online Store), but it is a fantastic affordable tool • Red colorant to practice phlebotomy and IV skills repeatedly. It • A shallow container, (e.g., a kidney dish, not resembles the real clinical feel of “in/out/missed the supplied in kit) vein” or “right through the vein” situations superbly well. Practice makes perfect. You will notice your “in Choose a suitable, easily cleanable work surface. the vein” rate increase dramatically as you continue practicing. You will be able to use the versatile trainer for practicing venipuncture on a large diameter vein, as well as a smaller diameter vein, drawing arterial blood, performing an intramuscular injection, a subcutaneous injection, and infiltrating a wound with local anesthetic before suturing. So let’s start setting up this effective yet simple training apparatus.
88 Venipuncture Course and Kit | COLLECTING BLOOD
FOLLOW THESE STEPS about halfway. When fake blood starts to flow from the tube, close the flow control, and then block the outflow (SEE THE ACCOMPANYING opening with a lumen stopper. DIAGRAM): STEP 7 STEP 1 You are ready to start with the phlebotomy projects. Inspect the Venipuncture Trainer. It represents a fake (PROJECTS 11-14) arm with two veins, covered by skin. The slightly wider diameter tube represents a regular vein and the smaller tube a smaller vein. Additional and replacement Venipuncture Trainers can be ordered online. [ORDER HERE] stand STEP 2 Inspect the IV fluid bag. Note the two ports marked as IV bag ‘In’ and ‘Out’.
STEP 3 “in” port Connect the syringe and needle. Draw up ½ to 1 cc of “out” port red colorant and inject the contents into the IV fluid bag, using the ‘In’ port. Mix the colorant within the IV bag. drip chamber STEP 4 Connect the adult IV line to the bag using the ‘Out’ port. Connect the other end to one of the tubes IV line (Venipuncture Trainer veins) using a connector. Ensure that the connection is secure and doesn’t leak. flow-control clamp STEP 5 Place or suspend the IV-fluid bag about ½ a meter (½ a yard) above the work surface. Suspend it from a hook connector or nail in the wall or place it on a shelf above the work IV Trainer surface. simulation veins STEP 6 Keep the lumen stoppers nearby. Place a shallow container at the outflow end of the Venipuncture Trainer. Open the infusion flow-speed mechanism. Press and release the drip chamber once or twice to fill it lumen stoppers
PROJECT 10 B SET UP THE VENIPUNCTURE TRAINER FOR IV PROJECTS
For PROJECT – 11D HOW TO SETUP AN IV LINE, you will have to modify the Venipuncture Trainer setup as follows: • Close or occlude the near side of both veins with the lumen stoppers. • Place a shallow container (e.g., a kidney dish) at the far, open ends of the veins to receive the IV fluid following a successful venipuncture procedure. • Proceed with PROJECT 11D.
89 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 10 C SET UP THE VENIPUNCTURE TRAINER FOR ARTERIAL BLOOD
For PROJECT 12C – DRAW ARTERIAL BLOOD you will have to modify the Venipuncture Trainer setup as follows: • Fill a 10 ml syringe with fake blood and connect to the smaller vein, and let it run through the tube. • Now tightly occlude one side of the smaller vein. • Ask another person to sit opposite you and then to press down on the plunger of the syringe. They can use a moderate pulsing pressure to simulate the pulsations of an artery. • Perform the simulation procedure for drawing arterial blood— PROJECT 12C.
TAKING CARE OF THE THERAPEUTIC PHLEBOTOMY VENIPUNCTURE TRAINER (BLOODLETTING) Put your Venipuncture Trainer away when you are finished Therapeutic phlebotomy (therapeutic bleeding) is a with projects: controlled removal of a relatively large volume of blood • Close the flow-speed mechanism. (usually 500 ml to one pint or more). The procedure is • Empty the fake blood inside the tubes into the plastic performed to reduce blood volume and consequently, red container and discard. blood cells and iron stores. Therapeutic phlebotomy may • Pack all of the components and place them into your be indicated as part of the treatment for: kit. • Hemochromatosis (including hereditary • Keep the kit in a secure location and out of reach of hemochromatosis) young children. • Polycythemia vera Important note: Keep in mind that the red colorant may • Porphyria cutanea tarda leak and stain clothes, tablecloths, carpets, etc. • Sickle cell crisis • A number of other conditions, but rarely Specific indications and parameters are in place for the REFILLING THE IV FLUID BAG conditions listed above. In the Middle Ages, bloodletting If the IV fluid runs dry, refill the bag using a 10 ml syringe was a common procedure for a variety of diseases. Today and an 18 gauge needle and homemade saline (one it is well established that bloodletting is not effective in teaspoon of salt in a glass of lukewarm water). Stir it well, treating most diseases and frankly, may be detrimental draw 10 ml into the syringe and inject it into the ‘In’ port of (the above list excluded). the IV bag. Repeat 10 times to add 100 ml. Add 5 ml of red food colorant to create fake blood. MAXIMUM ALLOWABLE TOTAL BLOOD DRAW VOLUMES The maximum allowable total blood draw volumes depends on the patient’s body weight, blood Hb (Hemoglobin) level, and the general condition at the time of the draw. [CLICK HERE] to see and print the Table for Maximum Allowable Total Blood Draw Volumes.
90 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 11A DRAW VENOUS BLOOD USING A VACUUM TUBE
One of a number of methods to draw venous blood
VIDEO
INFORMATION It is strongly recommended that the student read the WHO Certain areas are to be avoided when choosing a site: guidelines on drawing blood: Best Practices in Phlebotomy • Areas with extensive scars from burns or previous before proceeding with this project. surgery. It is difficult to penetrate skin through scar Notes on choosing a venipuncture site: tissue. • The most commonly used veins are the larger and • The arm on the side of a previous mastectomy. Test easily accessible median cubital or cephalic veins of results may be affected because of lymphedema. the arm, followed by the basilic vein on the dorsum of • A hematoma may cause inaccurate results. the arm or dorsal hand veins. • The arm on the side that is being used for intravenous • The veins of the foot are a last resort because of the therapy (IV) / blood transfusions, as the fluid may higher probability of complications. dilute the specimen. Collect from the opposite arm if • Other veins, like the external jugular vein, are rarely possible. used. • Cannula/fistula/heparin lock. In general, blood should • A good vein will be both visible and palpable. not be drawn from an arm with a fistula or cannula. However, occasionally you may have to depend only • Edematous extremities. Tissue fluid may cause on your sense of palpation. inaccurate test results. • To make it easier to see the veins, warm the arm for 10 • Extremities with extensive injuries (external wounds minutes with a hot pack or let the hand hang down. or fractured bones). • If you feel a pulse when palpating the blood vessel, • Extremities with a joint replacement. Use an alternative you may be looking at a superficial artery. Inspect the site/extremity. area further to identify a definite vein. • Avoid inserting the catheter into a bifurcation (where the vein splits) or near large valves.
91 Venipuncture Course and Kit | COLLECTING BLOOD
REQUIREMENTS • Correct procedures—check the requisition order form against the labels. You will need: Then: • Laboratory specimen labels (only in clinical setting) • Conduct a short medical history (allergies, bleeding • Pen for writing disorders, etc.). See PROJECT 2. • Laboratory forms • Position and prepare the patient. • The sharps waste container • Verify the following regarding the patient: fasting, • Alcohol wipe dietary restrictions, medications, timing, medical • Clean gloves treatment, and any other relevant information. • Clean work surface cover • Make notes on the lab requisition form. • A Vacutainer® holder (hub) • A Vacutainer® needle STEP 2 • Vacutainer® tubes Open a clean work surface cover. From the REQUIREMENTS • An Autosafe® Safety Phlebotomy Device (safety list above, gather the relevant items and equipment (open needle preassembled on hub/holder) outer plastic wrapping) and place on this cover. Set out • Cotton wool or gauze all of the tubes you will need by the order of the draw* • Strapping (adhesive bandage strip) and have any necessary tools (tourniquet, alcohol swabs, • A fully set up Venipuncture Trainer sharps waste container, and biohazard waste bag) nearby. Tear open the alcohol prep sachet. See PROJECT 10A A phlebotomist will also need leak-proof transportation Assemble the Vacutainer® by attaching the Vacutainer® bags and containers (not supplied in kit). needle to the Vacutainer® hub or use the Autosafe® Safety Vacutainer Phlebotomy Device (with needle preassembled IMPORTANT NOTE: to the hub). • Use either the Autosafe® Safety Phlebotomy Device or the standard Vacutainer® hub and needle. STEP 3 Perform hand hygiene. See PROJECT 3A – A TECHNIQUE • If you choose the Autosafe® Safety Vacutainer FOR PROPER HANDWASHING and PROJECT 3B – Phlebotomy Device, familiarize yourself with PROJECT CLEANING HANDS WITH AN ANTISEPTIC RUB. 1B – HOW TO USE AUTOSAFE®-REFLEX® SAFETY DEVICES • The BD Vacutainer® system is used in the Video clip STEP 4 Select the site, preferably at the cubital (antecubital) area demonstration – for more information visit the BD (i.e., the inner bend of the elbow). website: [CLICK HERE] Locate the anatomic landmarks. Inspect and palpate the
veins in the intended venipuncture site. If necessary, one may apply a tourniquet temporarily, about 4-5 fingers FOLLOW THESE STEPS above the intended venipuncture site in order to facilitate the inspection and palpation. Remove the tourniquet until AS IF IN A REAL-LIFE ready to proceed. CLINICAL SITUATION THEN Note: To make it easier to see the veins, warm the arm for SIMULATE DRAWING BLOOD 10 minutes with a hot pack or let the hand hang down. USING THE VENIPUNCTURE STEP 5 When ready for drawing the blood, apply the tourniquet TRAINER: about 4-5 finger widths above the selected venipuncture site. STEP 1 Greet the patient; introduce yourself and then pause to STEP 6 confirm the following: Ask the patient to form a fist to make the veins more • Correct patient—positively identify the patient. prominent.
92 Venipuncture Course and Kit | COLLECTING BLOOD
Important note: Don’t ask the patient to pump (repeatedly • The tourniquet must be released after a maximum of open and close) the fist. 2 minutes** irrespective of whether or not you have STEP7 completed the venipuncture task. **WHO guidelines. Some experts recommend a maximum Put on clean (non-sterile) gloves. tourniquet time of 1 minute. STEP 8 STEP 13 Disinfect the site using 70% isopropyl alcohol for 30 Withdraw the needle gently and then give the patient a seconds and allow it to dry completely (30 seconds). clean gauze or dry cotton-wool ball to apply to the site DO NOT touch the site again once the alcohol (or other with firm pressure for 2-3 minutes to achieve hemostasis antiseptic) has been applied! If you must touch it again to and avoid a hematoma. Ensure that the patient has feel the vein, touch a clean alcohol pad first to aseptically stopped bleeding and then apply tape and gauze to the treat your glove. venipuncture site. STEP 9 STEP 14 Anchor the vein by holding the patient’s arm and placing Discard sharps (e.g., the used needle/s and broken glass the thumb of the opposite hand below the venipuncture and syringe or blood-sampling device) into a puncture- site. resistant sharps container. Place other items like used DO NOT insert the needle where veins are branching as gloves and all items contaminated with blood or body this will increase the chance of a hematoma. fluids into the infectious waste. STEP 10 STEP 15 Enter the vein swiftly at a 15°-30° angle. Ensure that the Check the labels and forms for accuracy. bevel of the needle is pointing up. DO NOT bend the needle. STEP 16 Note: Angling the needle less than 15° increases the Perform hand hygiene. chance of the needle staying above the vein and an angle of more than 30° increases the chance of penetrating the STEP 17 deep wall of the vein. Simulate the project by following Steps 1-16 using the fully setup Venipuncture Trainer—see PROJECT 10A. STEP 11 Ensure that the tubes are filled with fake blood, that the IV Support the Vacutainer® tube holder, then push the fluid’s tubing flow-speed regulation device is set on ‘open’, Vacutainer tube into the hub and check for blood flow. and that the ends of the tubes have lumen stoppers in Allow the tube to fill and then remove it from the tube position. holder, all the time gently supporting the tube holder to prevent the needle from slipping out of the vein. When blood flow stops, remove the tube by holding the hub securely and pulling the tube off the needle. STEP 12 If tube used has additives mix the contents by gently inverting the tube 5-8 times (do not shake). Fill the remaining tubes and repeat the mixing routine after each tube has been filled. Once sufficient blood has been collected, release the tourniquet BEFORE withdrawing the needle. Note: • When filling additional tubes – determine what tests are ordered and what tubes will be necessary *BEFORE you begin drawing blood, follow the correct sequence of drawing blood for these tubes (SEE TABLE 3).
93 Venipuncture Course and Kit | COLLECTING BLOOD
POINTS OF INTEREST
Tubes Additives Tests Yellow SPS Blood Culture Tube Blue Sodium Citrate PT,PTT, APTT – All Coagulation Studies Electrolyte, Lipid Panel, Hepatic Red No Additive (Serum tube) Function, Digoxin, Bilirubin, HCG (pregnancy) Contains a gel at the bottom to separate Chemistries, immunology and serol- Red-gray or gold top blood from serum on centrifugation ogy Green Sodium Heparin or Lithium Heparin Ammonia Level Lithium heparin anticoagulant and a gel Light green Various chemical studies separator CBC, Hemoglobin, Hematocrit, ESR Lavender EDTA (Erythrocyte Sedimentation Rate) HLA tissue typing, paternity testing, Pale yellow Acid citrate dextrose DNA studies Gray Potassium Oxalate, Sodium Fluoride All Glucose Studies – Anticoagulant
Table 3: *Recommended order of draw for plastic vacuum tubes (may differ slightly from your hospital’s protocol).
DO DO NOT DO carry out hand hygiene (use soap and water or alcohol rub), and wash carefully, including wrists and spaces be- DO NOT forget to clean your hands tween the fingers for at least 30 seconds DO NOT use the same pair of gloves DO use one pair of non-sterile gloves for more than one patient per procedure or patient DO NOT wash gloves for reuse DO use a single-use device for blood DO NOT use a syringe, needle or lancet sampling and drawing for more than one patient DO disinfect the skin at the venipuncture site DO NOT touch the puncture site after disinfecting it DO discard the used device (a needle and syringe is a sin- DO NOT leave an unprotected needle gle unit) immediately into a robust sharps container lying outside the sharps container Where recapping of a needle is unavoidable, DO use the DO NOT recap a needle using both hands one-hand scoop technique (see figure xx) DO seal the sharps container with a tamper-proof lid DO NOT overfill or decant a sharps container DO place laboratory sample tubes in a sturdy rack before DO NOT inject into a laboratory tube while injecting into the rubber stopper holding it with the other hand DO immediately report any incident or accident linked to a DO NOT delay PEP after exposure to potentially needle or sharp injury, and seek assistance; start PEP contaminated material; (see below) as soon as possible, following protocols beyond 72 hours, PEP is NOT effective
Table 4: The rules of safety when performing phlebotomy
PEP (post-exposure) prophylaxis - for more information [CLICK HERE]
Credit: WHO, World Health Organization Always use the one-hand scoop technique for recapping a needle – see Figure 18
94 Venipuncture Course and Kit | COLLECTING BLOOD
ADDITIONAL SAFETY and others from accidental needle stick injuries. The importance of the safety syringe has increased; legislation RECOMMENDATIONS: requiring it or an equivalent has been introduced in many • If at all possible, use specially designed safety devices countries since needlestick injuries and re-use prevention to minimize the risk of accidental needle injuries became the focus of governments and safety bodies.
Don’t re-use the tube holder (Vacutainer® hub) – it is Important note: In the final analysis there are simply no intended for single-use only substitutes for taking CARE. Be careful at all times. You and your patient’s health and life depend on it! Safety syringes have a safety mechanism built into the syringe. The needle on a safety syringe can be detachable Also see: or permanently attached. On some models, a sheath is W.H.O. Injection Safety Toolbox [1] placed over the needle or the needle retracts into the barrel W.H.O. Injection Safety [2] following injection in order to protect healthcare workers Centers for Disease Control – Injection Safety [3]
VIDEO
95 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 11 B DRAW VENOUS BLOOD USING A SYRINGE AND NEEDLE
One of a number of methods to draw venous blood
VIDEO
INFORMATION REQUIREMENTS It is strongly recommended that the student read the You will need: WHO guidelines on drawing blood: Best practices in • Laboratory specimen labels phlebotomy before proceeding with this project. • Pen for writing As a matter of preference, or for specific reasons, a • Laboratory forms phlebotomist may prefer using a syringe and needle to • The sharps container perform a venipuncture. Using a syringe and needle will • Alcohol wipe necessitate that the blood specimen be transferred from • Clean gloves the syringe to the lab’s blood sample tube/s using specific • Clean work surface cover methods with the emphasis on avoiding accidental needle • Syringe (20ml) prick injuries and minimizing the risk of cross infection. • Needle – preferably a safety needle (20 gauge or larger) • Cotton wool or gauze • Strapping (adhesive bandage strip) • Fully setup Venipuncture Trainer—see PROJECT 10A A phlebotomist will in addition to the above items, also need leak-proof transportation bags and containers.
96 Venipuncture Course and Kit | COLLECTING BLOOD
MEMORIZE THESE STEPS TO STEP 4 Select the site, preferably at the cubital area. BE FOLLOWED IN A REAL- Locate the anatomic landmarks. Inspect and palpate the LIFE CLINICAL SITUATION veins in the intended venipuncture site. One may apply a tourniquet temporarily, if necessary, 4-5 fingers above the THEN SIMULATE DRAWING intended venipuncture site to facilitate the inspection and BLOOD USING THE palpation. Remove the tourniquet until ready to proceed. Note: Warming the arm with a hot pack or hanging the VENIPUNCTURE TRAINER: hand down may make it easier to see the veins. STEP 1 Greet the patient, introduce yourself, and then pause to STEP 5 When you are ready to draw blood, apply the confirm the following: tourniquet about 4–5 finger widths above the selected • Correct patient – positively identify the patient venipuncture site. • Correct procedure/s – check requisition order form against labels STEP 6 Then: Put on clean (non-sterile) gloves. • Do short medical history (allergies, bleeding disorders, etc.) See PROJECT 2 STEP 7 • Position and prepare the patient Ask the patient to form a fist so that the veins are more • Verify the following regarding the patient: fasting, prominent. dietary restrictions, medications, timing, medical Important note: Don’t ask the patient to pump his/her fist. treatment and any other relevant information • Make notes on the lab requisition form STEP 8 Disinfect the site using 70% isopropyl alcohol for 30 STEP 2 seconds and allow it to dry completely (another 30 Open a clean work surface cover then gather and open the seconds). relevant items and equipment. Assemble equipment (see DO NOT touch the site again once the alcohol (or other REQUIREMENTS above). Set out all of the tubes you will antiseptic) has been applied! If you must touch it again to need and have all the necessary tools (e.g., tourniquet and feel the vein, touch a clean alcohol pad first to aseptically alcohol swabs) nearby. Tear open the alcohol prep sachet. treat your glove. The needle should be 21g or wider in order to minimize STEP 9 hemolysis. ALL needles and syringes are single-use only. Anchor the vein by holding the patient’s arm and Briefly inspect the needle, especially the tip, to ensure it is placing the thumb of the opposite hand below the sharp and undamaged. venipuncture site. Remove the syringe from the packaging and insert the Do not insert the needle where veins are branching, as this nozzle of the syringe firmly into the exposed hub of the will increase the chance of a hematoma. capped hypodermic needle. Move the plunger within the barrel to ensure free movement. STEP 10 Note: Use safety needles in all clinical settings. When Enter the vein swiftly at a 15°-30° angle. Ensure that the simulating the procedure you may use a regular needle – bevel of the needle is pointing up. D NOT bend the but take great care not to injure yourself. needle. Hold/stabilize the barrel of the syringe and gently withdraw the plunger until the required amount of blood STEP 3 has filled the syringe. Perform hand hygiene. Note: Angling the needle less than 15° increases the See PROJECT 3A – A TECHNIQUE FOR PROPER chance of the needle staying above the vein and an angle HANDWASHING and PROJECT 3B – Cleaning hands of more than 30° increases the chance of penetrating the with an antiseptic rub. deep wall of the vein.
97 Venipuncture Course and Kit | COLLECTING BLOOD
STEP 11 STEP 15 Once you collect sufficient blood, ask the patient to relax Discard sharps (e.g., the used needles, syringes, as well the fist, and then release the tourniquet. as any glass items) into a puncture-resistant sharps Note: The tourniquet must be released after a maximum container. Place other items like used gloves and all items of two minutes according to *WHO guidelines, irrespective contaminated with blood or body fluids into the infectious of whether or not you have completed the venipuncture waste. task or not. Some experts recommend a maximum tourniquet time of one minute. STEP 16 Recheck the labels and forms for accuracy. STEP 12 Withdraw the needle gently and place clean gauze or a STEP 17 dry cotton-wool ball with strapping to the site. Apply firm Perform hand hygiene. pressure to achieve hemostasis and avoid a hematoma. Inspect the site after 2-3 minutes to ensure that the patient STEP 18 has stopped bleeding. Simulate the project by following Steps 1-17 using the fully setup Venipuncture Trainer—see PROJECT 10 A. STEP 13 Ensure that the tubes are filled with fake blood, that the IV **Always use a safety transfer device for transferring blood fluid’s tubing flow-speed regulation device is set on ‘open’, from a syringe to the vacuum tubes or the blood culture and that the ends of the tubes have lumen stoppers in bottles. [Click here] for more information on the method position. of transferring blood with a safety device. If no safety transfer device is available, place the vacuum POINTS OF INTEREST: tubes in a test tube rack before inserting the needle into Comments on safety and avoiding injury to you and the vacuum tube. Carefully penetrate the needle through your patient the tube’s stopper and let the blood passively fill the tubes. Students of phlebotomy should be aware of the most Warnings when transferring blood: recent information regarding the safety aspects related to • Do not hold vacuum tube in your hand! safety needles and other devices by visiting the following • Do not exert pressure on the plunger of the syringe. websites: This ensures that you avoid hemolysis or causing the needle or stopper to pop off thus creating a spray of *WHO (World Health Organization) http://whqlibdoc. blood droplets with the danger of exposing you and who.int/publications/2010/9789241599221_eng.pdf others to bloodborne pathogens. **OHASA (Occupational Safety and Health Administration) http://www.osha.gov STEP 14 USA: Safety holders (preferably disposable), safety If the tube used has additives, mix the contents by gently needles, safety blood transfer devices, and shields are inverting the tube 5-8 times (do not shake). Fill the mandatory, regardless of the blood collecting system remaining tubes and repeat the mixing routine after each used. See Occupational Safety and Health Agency tube has been filled. (OSHA) guidelines. Other countries: visit your country’s governmental Occupational Health and Safety Department.
98 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 11C DRAW BLOOD USING A BUTTERFLY NEEDLE
One of a number of methods to draw venous blood
VIDEO
INFORMATION The needle is held by the ‘wings’ and placed into the vein, generally at a fairly shallow angle. The wings allow the Winged infusion sets, commonly known as butterfly phlebotomist to grasp the needle very close to the end infusion sets or butterfly needles, are frequently used to to ensure accurate insertion into a vein. When the needle perform venipuncture procedures. They are especially enters the lumen of a vein a ‘flash of blood’ can be seen. The useful when doing venipuncture on patients with spastic, flash is a small amount of blood that flows back into the thin, or ‘rolling’ veins. Winged needles are most commonly tubing when the needle enters a vein. The phlebotomist used when the available veins are very small, fragile, and can then push vacuum tubes into the hub or use a syringe difficult to access or when veins are in a location that to draw blood. would make a standard evacuated tube system difficult to use. Winged needles are also used on very shallow veins because the design allows the needle to be inserted at a REQUIREMENTS much shallower angle (10-15°) compared to a standard You will need: evacuated tube system. Winged needles are nearly always • Laboratory specimen labels used when drawing blood from the hand, wrist, or other • Pen for writing places where veins are very close to the skin. • Laboratory forms Due to the fact that the winged needle is attached to a • The sharps container flexible tube, there is less chance of the needle slipping out • Alcohol wipe or perforating the deep end of the vein. This can happen • Clean gloves if either the patient or the phlebotomist moves during the • Clean work surface cover procedure, especially when drawing blood for multiple • Winged infusion set–21 gauge tubes. Winged needles are usually 21g (green label) or 23g • Syringe (10ml or 20ml) (blue label). Rarely, a 25g (orange label) is used, mostly in • Cotton wool or gauze square pediatrics or in very difficult cases; a needle of such small • Strapping (adhesive bandage strip) diameter may cause hemolysis, thus invalidating test • Fully setup Venipuncture Trainer—see PROJECT 10A results. Phlebotomist, in addition to the above items, will also need leak-proof transportation bags and containers.
99 Venipuncture Course and Kit | COLLECTING BLOOD
FOLLOW THESE STEPS AS STEP 6 IF IN A REAL-LIFE CLINICAL Put on clean (non-sterile) gloves. SITUATION THEN SIMULATE STEP 7 Ask the patient to form a fist to make the veins more DRAWING BLOOD USING prominent. THE VENIPUNCTURE Important note: Don’t ask the patient to pump the fist. TRAINER: STEP 8 Disinfect the site using 70% isopropyl alcohol and allow to STEP 1 dry completely (clean for 30 seconds and allow to dry for Greet, identify, position and prepare the patient, and then another 30 seconds). ask relevant medical questions. Check the requisition order Do not touch the site again once the alcohol (or other against labels. Verify the following patient information: antiseptic) has been applied! If you must touch it again to fasting, dietary restrictions, medications, timing, medical feel the vein, first touch a clean alcohol pad to aseptically treatment, etc. treat your glove. Make notes on the lab requisition form. STEP 9 STEP 2 Anchor the vein by holding the patient’s arm and placing the Assemble equipment (see REQUIREMENTS above). Set thumb of the opposite hand below the venipuncture site. out all of the tubes needed and have all the necessary DO NOT insert the Butterfly needle where veins are tools (tourniquet and alcohol swabs, etc.) nearby. The branching as this will increase the chance of a hematoma. butterfly needle should be a 21 gauge or wider in order to minimize hemolysis. ALL needles and syringes are single- STEP 10 use only. Open the outer packaging of all items to be used, Use the butterfly needle to enter the vein with a swift including the butterfly needle and syringe. movement at a 15° to 30° angle. Ensure that the bevel of Insert the nozzle of the Vacutainer® or the syringe firmly the needle is pointing up. DO NOT bend the needle. Keep into the hub end of the butterfly needle tubing. your eyes open for the flash-back of blood appearing in the tube lumen indicating a successful venipuncture. Note: Use safety butterfly needles in all clinical settings. When simulating the procedure you may use a regular STEP 11 needle but take great care not to prick yourself. Draw blood by using either a Vacutainer ™ or a syringe connected to the butterfly tubing (some winged STEP 3 needles have the Vacutainer ™ hub pre-attached). See Perform hand hygiene. PROJECT 11A or PROJECT 11B. See PROJECT 3A – A technique for proper handwashing Note: If you have to draw a tube for a coagulation and PROJECT 3B – Cleaning hands with an antiseptic rub specimen (citrate/light blue top) as the first specimen, STEP 4 then draw blood using a clear top* (no additive) vacuum tube before the citrate tube in order to fill the empty Select the site, preferably at the cubital (antecubital) area. tube space with blood, thereby ensuring the proper Locate the anatomic landmarks. Inspect and palpate the blood-to-additive ratio (discard this tube after use). veins in the intended venipuncture site. One may apply a *Preferably a clear top but any other color top tube will be tourniquet temporarily, if necessary, 4-5 fingers above the good. intended venipuncture site to facilitate inspection and palpation. Remove the tourniquet until ready to proceed. STEP 12 Note: Warm the arm with a hot pack or hang the hand Once you collect sufficient blood, ask patient to relax the down to make it easier to see the veins. fist, and then remove the tourniquet. STEP 5 Note: The tourniquet must be released after a maximum of two minutes* regardless of whether or not you have When ready to draw the blood sample, apply the completed the venipuncture task. tourniquet about 4-5 finger widths above the selected venipuncture site.
100 Venipuncture Course and Kit | COLLECTING BLOOD
*WHO guidelines. Some experts recommend a maximum tubing flow-speed regulation device is open, and that the tourniquet time of one minute. ends of the tubes have lumen stoppers in position. STEP 13 Gently withdraw the butterfly needle and give the patient POINTS OF INTEREST: Notes on safety: a clean gauze or dry cotton-wool ball to apply firm pressure Two examples of butterfly needles with built-in safety to the site to achieve hemostasis and avoid a hematoma. features are: Ensure that the patient has stopped bleeding, and then • The Punctur-Guard™ uses an internal blunt needle. apply tape and gauze to the venipuncture site. The mechanism is activated after blood is drawn. STEP 14 • The Angel Wing ™ is activated by sliding a safety shield Always use a safety transfer device for transferring blood over the needle after venipuncture. from a syringe to the vacuum tubes or the blood culture bottles. [CLICK HERE] for the method of transferring blood with a safety device. If no safety transfer device is available place the vacuum tubes in a test tube rack before inserting the needle into the vacuum tube. Carefully penetrate the needle through the tube’s stopper and let the blood passively fill the tubes. Warnings when transferring blood: • DO NOT hold the vacuum tube in your hand! Figure 29: The Angel Wing ™ Safety butterfly needle [For more informa- • DO NOT exert pressure on the plunger of the syringe tion] to avoid hemolysis or causing the needle or stopper Important note: to pop off, thus creating a spray of blood droplets • Always use a needle with safety features in a clinical with the danger of exposing you and other people to setting! bloodborne pathogens. • Safety needles minimize the risk of needle prick injuries but do not eliminate these risks completely. STEP 15 There is no substitute for being careful. If the tube used has additives, mix the contents by gently inverting the tube 5-8 times (do not shake). Fill remaining tubes and repeat the mixing routine after each tube has CUTTING DOWN A VEIN been filled. Venous cutdown is an emergency procedure in which the STEP 16 vein is exposed surgically and then a cannula is inserted directly into the vein. Common veins used for this purpose Discard sharps (e.g., the used needles and broken glass) are the saphenous vein at the ankle and the basilic vein and syringe or blood-sampling device into a puncture- in the cubital area. Venous cut down is indicated when resistant sharps container. Place other items like used peripheral veins are very difficult or impossible to access gloves and all items contaminated with blood or body due to obesity, vascular collapse, or thrombosis. fluids into the infectious waste. STEP 17 Recheck the labels and forms for accuracy. STEP 18 Thank the patient and perform hand hygiene. STEP 19 Simulate the project by following Steps 1-18 using the fully set up Venipuncture Trainer. See PROJECT 10B – SET UP THE VENIPUNCTURE TRAINER FOR IV TRAINING. Figure 30: How to cut down a vein Ensure that the tubes are filled with fake blood, the IV fluid’s Read more on how to perform the procedure at: [CLICK HERE]
101 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 11 D HOW TO START AN IV LINE
How to place a venous cannula into a vein
VIDEO
INFORMATION Mastering the skill of setting up an IV line requires, time, patience, and a lot of practice.
Figure 31b: Two examples of needle for introducing a peripheral venous catheter with their protective caps. The example on the top has a side port with cap for injecting medication.
Intravenous therapy or IV therapy is the infusion of a liquid directly into a vein. It is commonly referred to as a ‘drip’ because many systems of administration employ a drip chamber, which allows an estimation of flow rate and prevents air from entering the blood stream. (Air entering the blood stream can lead to an air embolism.) Intravenous therapy is used as a method of delivering medications to correct electrolyte imbalances for blood transfusions, and for replacing fluid to correct dehydration. The IV route is the fastest manner in which to deliver fluids and medications to the body. A peripheral cannula is commonly used for intravenous access. It consists of a short catheter inserted through Figure 31a: The components of an IV line [Photo with labels to be added] the skin into a peripheral vein. This is usually in the form of a flexible plastic “cannula over a needle” device. Once 102 Venipuncture Course and Kit | COLLECTING BLOOD
the tip of the needle and cannula are located in the vein • Cotton wool or gauze square the needle is withdrawn and discarded and the cannula is • Strapping then advanced inside the vein and secured into position • Transparent dressing with tape. • IV catheters 18 or 20 or 22 gauge • IV fluid stand (something to hang the IV bag from – about 3 feet/1 meter above your work area level) REQUIREMENTS • IV fluid bag You will need: • IV tubing • The sharps container • The Venipuncture Trainer (modified setup required). • Alcohol wipe See PROJECT 10B • Clean gloves • A linen saver (not supplied in the kit) • Clean work surface cover
MEMORIZE THESE STEPS TO STEP 3 Perform hand hygiene. BE FOLLOWED IN A REAL- See PROJECT 3A – A TECHNIQUE FOR PROPER LIFE CLINICAL SITUATION HANDWASHING and PROJECT 3B – CLEANING THEN SIMULATE DRAWING HANDS WITH AN ANTISEPTIC RUB. BLOOD USING THE STEP 4 Connect the IV tubing to the ‘Out’ port of the IV fluid bag. VENIPUNCTURE TRAINER: Prime the line by pressing the chamber once or twice, STEP 1 allowing it to fill about halfway. Open the control-flow mechanism and allow fluid to fill the tube until all air Greet the patient, introduce yourself, and then pause to bubbles are out of the tube. confirm the following: • Correct patient—positively identify the patient • Correct procedures—check and follow the physicians STEP 5 Select a suitable site for setting up an IV line. Start by orders, including specifics regarding IV fluid and looking for a suitable vein on the dorsal part of the hand. medications (if applicable) to be used. If no suitable vein is identified (or if you fail with the Then: venipuncture attempt) move proximally to the side of • Place the patient in the Semi-Fowler’s or supine the wrist, possibly the forearm, and then the cubital area. position. • Do a short medical history (allergies, bleeding Inspect and palpate the veins in the intended venipuncture disorders, etc.) See PROJECT 2 site. If necessary, you may temporarily apply a tourniquet • Make notes on patient’s clinical chart 4-5 fingers above the intended venipuncture site to facilitate inspection and palpation. Remove the tourniquet STEP 2 until ready to proceed. Assemble equipment and all the relevant items using Place a linen saver under the patient’s arm to protect the REQUIREMENTS above. Open the outer packaging of all bed linens as it is difficult to avoid a couple of drops of the items on the clean work surface cover. blood from occasionally flowing out of the vein. Note: Use safety catheters and safety needles in all clinical settings. When simulating the procedure, you may use a Warning: When setting up an IV line, it is of utmost regular catheter/needle but take great care not to prick importance to ensure that one is placing the cannula in a yourself with the sharp needle. vein, and not in an artery. When performing phlebotomy procedures, an intra-arterial draw might not be the end of the world, but as medication are often infused with an IV line, an intra-arterial infusion of medication may have catastrophic results!
103 Venipuncture Course and Kit | COLLECTING BLOOD
STEP 6 STEP 12 Choose your IV catheter needle size with care. The size Look for the flashback of blood in the catheter’s plastic will depend primarily on the size of the vein; however the applicator. Once you see this flash of blood, advance the patient’s age and gender may also influence your gauge catheter slightly, taking care not to go right through the selection. vein. Remove the needle while advancing the catheter in • Adults—an 18 or 20 gauge catheter will work well for one simultaneous movement. Take great care once the most cases. needle is removed to avoid needle prick injury. • Elderly and pediatric patients—use a smaller catheter (larger number, e.g., 22 or 24 gauge). STEP 13 • Emergency fluid replacement—use a larger catheter Remove the tourniquet. (smaller number, e.g., 14 or 16 gauge). If required, take the opportunity to draw blood before attaching the IV line. STEP 7 When ready to perform the venipuncture, apply the STEP 14 tourniquet about 4–5 fingers above the selected Remove the plastic connector cap/plug from the catheter’s venipuncture site. connector (if applicable). Apply finger pressure on the vein above the catheter to STEP 8 prevent the retrograde flow of blood. Apply a small gauze Don preferably sterile gloves, otherwise use clean square under the catheter to catch any escaping blood. examination gloves. See PROJECT 3C or 3H. STEP 15 STEP 9 Attach the IV tubing to the catheter. Secure the catheter Ask the patient to form a fist to make the veins more with tape and a transparent dressing. prominent. (Some clinicians will first ask the patient to form a fist first, and then don gloves while the veins are STEP 16 distending). Open up the IV line. If you were successful, you will see fluid dripping in the drip-chamber of the tubing. Important note: If you do not intend performing Observe the area for a couple of minutes. If the surrounding phlebotomy before attaching the IV line, you may ask the tissue swells, the drip is infiltrating the tissue. Stop the drip, patient to clench and open the fist a couple of times to apologize, and move to another site. facilitate vein distention. Important note: If you see a drop of IV fluid in the drip STEP 10 chamber moving in and out in a pulsatile fashion then Disinfect the site using 70% isopropyl alcohol for 30 seconds you are probably in an artery. Stop the drip immediately, and allow it to dry completely (another 30 seconds). remove the needle and apply pressure on this site for five DO NOT touch the site again once the alcohol (or other minutes. antiseptic) has been applied! If you must touch it again to To avoid grave complications, never inject medication into feel the vein, touch a clean alcohol pad first to aseptically an artery! treat your glove. STEP 17 STEP 11 Adjust the drip rate to whatever is appropriate for your Remove the protective cap from the needle section of patient. To keep the line open, turn the drip rate down to the catheter. Anchor the vein by holding the patient’s arm just a few drops a minute. and placing the thumb of the opposite hand below the venipuncture site. Insert the needle, bevel up, at an angle STEP 18 of 15°-20°. Some instructors advise students to imagine an Discard sharps (e.g., the used needles) into a puncture- airplane landing on a runway as they insert the needle. resistant sharps container. Place other items like used gloves and all items contaminated with blood or body DO NOT insert the needle where veins are branching as fluids into the infectious waste container. this will increase the chance of a hematoma.
104 Venipuncture Course and Kit | COLLECTING BLOOD
STEP 19 How to calculate IV flow rates: Thank your patient. Compliment pediatric patients for Intravenous fluid must be given at a specific rate. The being brave. Perform hand hygiene. specific rate is measured as milliliter per hour (ml/h) or drops/minute. To control or adjust the flow rate only drops STEP 20 per minute are used. Simulate the project by following Steps 1-19 using Common drop factors are: the Venipuncture Trainer. You will have to modify the 10 drops/ml (blood set), 15 drops/ml (regular set), 60 Venipuncture Trainer setup: drops/ml (micro-drop). Do not attach the tubing to the tubes on the trainer. Place To measure the rate we must know: a lumen stopper on one end of the tube/imitation vein 1. The number of drops and a shallow container below the open end. When you 2. Time in minutes. are convinced that you have successfully entered a vein on the Venipuncture Trainer, attach the free end of the The formula for working out flow rates is: IV tube to the catheter, and then open the flow-control mechanism. If you were successful, fluid will flow out of the Volume (ml) x drop factor (drops/ml) open end of the fake vein. If no flow is observed, close the = drops/min (flow rate) flow-control mechanism and try again. Keep practicing! Time (minutes)
POINTS OF INTEREST: Example: 3000 ml IV Saline is ordered over 24 hours. Using a drop If you fail, a bit of blame shifting is quite permissible. Blame factor of 15 drops/ml, how many drops per minute need it on the vein, on the weather or anything else, as you to be delivered? need to retain your patient’s confidence in your abilities for the next attempt! If you fail for a third time, apologize and ask for assistance from a more experienced medical 3000 (ml) x 15 (drops/ml) = 31.25 drops/minute professional—unless that person is you! 24 hrs. x 60 (gives us total minutes) The veins of elderly people tend to slip to one or the other side if you puncture it from the top. Secure the vein with a finger of your other hand and puncture the skin on the side of the targeted vein.
105 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 11 E HOW TO REMOVE THE IV LINE
How to remove a venous cannula from a vein
VIDEO
• Shut off the IV by closing the roller clamp of the flow • Maintain pressure over the site for 2-3 minutes to control mechanism. secure hemostasis. • Remove the tape and OpSite or Tegaderm™ from the • Discard all sharps into the sharps waste container and tubing and catheter. all other items in a biohazard waste bag. • Place non-sterile 2x2 gauze over the IV site, remove • Perform hand hygiene. the catheter from the arm, and secure the gauze in place with a piece of tape.
ALTERNATIVES TO IV • Intraosseous infusion is a temporary emergency measure indicated in life-threatening situations when INFUSION FOR ACCESSING intravenous access fails (3 attempts or >90 seconds). • Use the anteromedial aspect of the tibia. THE BLOODSTREAM: • Insert, pointing slightly inferior in order to avoid the Intraosseous infusion (commonly used in pediatric epiphyseal growth plate. patients) • Use an aseptic technique. • Crystalloids, colloids, blood products, and drugs can be infused. • Remove as soon as the child has been resuscitated and intravenous access has been established. • For more information [Click Here].
Figure 32: Performing an Intraosseous infusion
106 Venipuncture Course and Kit | COLLECTING BLOOD
SPECIAL GROUPS OF PATIENTS
THE NEONATE PATIENT THE PEDIATRIC PATIENT A neonate is a newborn infant, especially one less The basic principles of phlebotomy and venipuncture in than four weeks old. The neonate patient has specific the pediatric patient are similar to the adult patient yet challenges due to anatomical and physiological variables differ quite a bit. that differ substantially from an adult patient. This is The key to successful venipuncture lies with the restrainer why neonatologists need specialized knowledge and (parent or fellow medical professional). proficiency with difficult skills. Look at the recommended technique as suggested by WHO: Below is an excellent article about venous access in WHO guidelines on drawing blood: Best practices in neonates with the abstract below: phlebotomy⁷ Vascular access in neonates and infants—indications, Especially read the section on “Practical guidance on routes, techniques and devices, complications.⁸ By Möller pediatric and neonatal blood Sampling” pages 35-40. JC, Reiss I, Schaible T. This is a must read for any medical professional working with pediatric patients: Abstract: Difficult Venous Access in Children: Taking Control by Venous cannulation has been in regular use in neonates Laura L. et al.⁹ since the 1940s. This was at first through the umbilical Download this excellent article: [Click Here] vein, but the frequency of complications lead to other central and peripheral routes being used for infusion of fluid, nutrients and drugs. Today, peripheral venous access is preferred except for high volume fluid resuscitation, reliable infusion of irritant drugs and long-term parenteral nutrition. Intraosseous infusion provides a reliable alternative to peripheral veins for rapid infusion of fluid. Long, thin silastic catheters can be inserted through a peripheral venous cannulae for parenteral nutrition or other central venous infusions as an alternative to direct central venous cannulation using the Seldinger or other techniques. Broviac or Hickman catheters, inserted through a subcutaneous tunnel are only considered when central venous cannulation is likely to be needed for more than six weeks. The most common serious complication of vascular access is infection. Infection associated with central venous catheters is reduced by prophylactic vancomycin or teicoplanin. Other complications of central venous infusion are associated with cannulae malpositioning, bleeding and thrombosis. Distal hypoperfusion may follow arterial cannulation. Modern emergency and intensive care paediatrics is impossible without adequate venous and arterial vascular access; however, no other skill for neonatal intensive care causes more anxiety among primary care providers, is more difficult to teach and is associated with an increased risk of median nerve injury. For the complete article – [Click Here]
107 Venipuncture Course and Kit | COLLECTING BLOOD
VETERINARY VENIPUNCTURE
The animal patient The basic principles of performing venipuncture procedures on the animal patient are the same as for the human patient.
VIDEO
Generalized differences include: • Most animals do have fur or lots of hair covering the areas with veins suitable for venipuncture. Removal of fur or hair is often necessary to visualize the veins and successfully perform phlebotomy or set up an IV line. • The temperaments of animals are quite varied and different from the human patient. • Communicating with animals is quite different to communicating with humans. • The general and thus venous anatomy of various animal species may vary considerably. • The skin of certain species of animals, for example reptiles, may be thick and difficult to penetrate. • When treating wild animals, levels of aggression may be dangerous or life threatening. A sedative (i.e., administered by darting) may be a prerequisite before a successful venipuncture procedure may be safely performed. • Clinicians may need to take specialized protective measures to protect themselves from injury when treating animal patients.
In veterinary practice, vascular access has many variables and techniques specific to many different species that may be encountered. This topic is beyond the scope of this course. Veterinary students are referred to veterinary literature and books for detailed information on venipuncture in animals.
Figure 34: Hematoma cat patient following the neutering operation Two interesting article abstracts are included below:
108 Venipuncture Course and Kit | COLLECTING BLOOD
1. Vascular access: theory and techniques in the small animal emergency patient¹⁰
Abstract Acquisition of vascular access in the emergent small animal patient is one of the keys to successful management of a population of patients that are often unstable with regard to their major body systems. Venous and intraosseus cannulation allow for the administration of a variety of fluids and potentially life-saving medications. In addition, central venous and arterial access also serves as conduits for atraumatic blood sampling and intravascular pressure monitoring. A thorough knowledge of vascular access theory, the dynamics of fluid flow, vascular anatomy, catheter selection criteria, and placement techniques are critical to the proper and safe use of the vascular access options that are available to small animal clinicians today.
2. Vascular access techniques in the dog and cat¹¹ Abstract The rapid and reliable attainment of vascular access may prove crucial for the provision of an effective therapeutic solution in the critically ill or emergency small animal patient. Although in such cases it is more common to consider venous vascular access for the administration of medication and for the measurement of venous pressures, the attainment of arterial vascular access may prove just as important, allowing the direct measurement of arterial blood pressure and the sampling of arterial blood. This article provides guidelines on appropriate catheter selection for vascular access, placement techniques for both venous and arterial access, and procedures required for the long-term maintenance of these access sites.
Veterinary students will find The Apprentice Doctor® Venipuncture Course and Kit a valuable resource for attaining the basic venipuncture knowledge and skills required by their curriculum. Here are a number of clinical examples of Venipuncture procedures in the animal patient: [SEE VIDEO CLIP ON PAGE 108]
AIDS TO ASSIST THE CLINICIAN
VeinViewer® Ultrasound VeinViewer® is a medical imaging device that uses near- Ultrasound is useful in detecting problems with most of infrared light to produce a digital image of a patient’s veins the larger blood vessels in the body (e.g., the abdominal and project it directly on their skin. aorta and the carotid arteries). Using Doppler ultrasound See this YouTube video: [CLICK HERE] technology, the flow of blood through vessels can be observed and measured. This makes it possible to detect AccuVein® is a similar medical imaging device that uses a arterial stenosis and aneurysms. specific frequency of light to produce a digital image of a Ultrasound is also useful in demonstrating superficial or patient’s veins projected directly on their skin. deep veins and to differentiate between veins and arteries. See: [CLICK HERE] [CLICK HERE] Breastlight™ Anesthetists use ultrasound to guide them to correctly Breastlight™ was originally designed as a breast cancer place the needle when performing regional anesthesia. screening modality for examining the female breast for Radiography nodules. However, it is also quite useful to show blood Central lines are commonly placed in critically ill patients. Chest vessels or venipuncture purposes! radiographs are used to ensure proper positioning and to rule The frequency of light waves penetrates soft tissue readily, out complications during placement. The ideal location for the but shows blood vessels as dark lines. tip of a central line is at the cavoatrial junction, which is where For more information [CLICK HERE] the superior vena cava meets the right atrium. This allows for It is also more affordable than the previous two products. the infusion of large volumes of fluids or medications. Also see section on interventional radiology.
109 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 12A IDENTIFY THE BODY’S PULSE POINTS
How to identify the body’s pulse points and how to determine a person’s heart rate INFORMATION HINTS Each time the heart contracts (systole), a pressure wave is • Use the middle three fingers to feel for a pulse. Do not perpetuated throughout the arterial system of the body. feel with the thumb as you may in fact be sensing the A throb or pulse can be palpated anywhere in the human small artery pulsating in your own thumb. body where an artery crosses a bony prominence or firm • Firmly (but not with too much pressure) press down structure (e.g., a tendon). The pulsation occurs due to a with the middle three fingers in the area where you slight increase in the diameter of the artery coinciding want to feel for a pulse. with an increase in arterial pressure during systole. Arteries • You may have to move the position of these fingers have strong, muscular, elastic walls. slightly over the specific area before feeling the pulse. • Do not press too hard as this may block the artery and stop the pulsations. REQUIREMENTS • Some practice may be necessary before you can A suitable volunteer for checking the pulse points identify a clear pulse. A watch with a minute indicator (if you want to determine the heart rate) Take note of the following characteristics of the pulse: • The forcefulness of each individual beat indicates a weak pulse or a strong pulse. • Is the pulse regular or irregular? STEP 1 Look at this diagram showing a number of the more common pulse points of the body:
STEP 2 NOTE: Identify the wrist pulse points. Two arteries supply each The radial pulse point is situated on the thumb’s side of hand with oxygenated blood: the radial and the ulnar the wrist and the ulnar pulse on the little finger’s side, as arteries. See if you can identify these two pulse points. indicated in the illustration.
110 Venipuncture Course and Kit | COLLECTING BLOOD
Figure 35a – h: Various pulse points of the body
Note: A thorough knowledge of the regional anatomy will be helpful to locate these pulse points.
STEP 3 STEP 6 Identify the bony angel of the mandible. Place two fingers To determine the pulse rate, count the number of beats on this point. Move these fingers 3-5 cm (1-1½ inches) or pulsations in one minute. This number is the pulse rate forward and feel for the facial artery pulsating as it crosses and equals the heart rate for the specific person – it is the lower border of the mandible. measured in BPM (beats per minute). Place your fingers on the angle of the mandible again. Now go down 3-5 cm (1-1½ inches) towards the neck. STEP7 Press towards the midline in a direction slightly towards Practice by identifying a variety of these pulse points and the back. You should feel a strong pulse here; it is the checking the pulse rate of other people. internal carotid artery pulsating as it carries oxygenated blood to the brain. POINTS OF INTEREST: • An arterial line is a thin catheter inserted into an artery. WARNING It’s commonly used in intensive care medicine and Do not press too hard to find the carotid pulse in the neck. anesthesiology to monitor real time blood pressure and Do not press on both carotid arteries at the same time. This to obtain samples for arterial blood gas measurements. may cause fainting! • An arterial line is usually inserted in the wrist (radial artery) but can also be inserted into the upper arm STEP 4 (brachial artery), the groin (femoral artery), the foot Identify the brachial pulse – an important pulse point used (dorsalis pedis artery), or the inside of the wrist (ulnar for the purpose of taking routine blood pressure readings. artery). • The femoral artery is commonly used by diagnostic STEP 5 and interventional radiologists, as well as cardiologists Identify the pulse points as shown in the diagram above. to access the arterial system. The femoral pulse is reserved for self-examination. • For a more detailed discussion on the pulse rate— see Project 24 in The Apprentice Doctor® Foundation course.
111 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 12 B PERFORM A MODIFIED ALLEN’S TEST
Check the collateral circulation of the hand
VIDEO
INFORMATION In the majority of the population, two arteries—the radial and ulnar arteries—supply the hand with oxygenated blood. These arteries anastomose in the hand. In a minority number of people, this dual blood supply is absent. The Allen’s test and the modified Allen’s tests are used to test the collateral blood supply to the hand, specifically the patency (openness) of the radial and ulnar arteries. It is performed prior to radial arterial blood sampling or cannulation, as well as before coronary bypass surgery as the cardiothoracic surgeon may choose to harvest the radial artery to be used as a graft/conduit for bypass surgery.
112 Venipuncture Course and Kit | COLLECTING BLOOD
FOLLOW THESE STEPS TO INTERPRETATION: PERFORM THE MODIFIED When you release the occlusive pressure on the ulnar artery, you should notice a return of normal color to the ALLEN TEST: palm and nails within ±7 seconds. This indicates that the STEP 1 ulnar artery is patent and has good blood flow. With the middle two or three fingers (not the thumb), Negative Allen’s test: The normal color (flushing) returns locate the pulsating radial and the ulnar arteries on the within ±7 seconds. palm side of the wrist (see illustration). Keep in mind that Positive Allen’s test: The normal color of the hand does the ulnar artery is smaller and more difficult to locate. not return (flushing) within the specified time. A negative modified Allen’s test indicates that ulnar circulation is inadequate or nonexistent.
SIGNIFICANCE Despite the fact that some researchers question the validity of the Allen’s test, the following guidelines are still recommended: Negative: Allen’s test (normal pink color returns): You may use the radial artery for blood sampling, cannulation, or to harvest as a graft. The ulnar artery will be sufficient for supplying blood to the hand, even without a patent radial artery, should occlusion complications occur. Positive: Allen’s test (normal pink color doesn’t return): Don’t use the radial artery for blood sampling, cannulation, Figure 36: The radial and ulnar arteries or harvesting as a graft in order to avoid serious ischemic STEP 2 (insufficient blood supply) complications to the hand. Elevate the hand and ask the patient to make a tight Instead, use the radial artery of the opposite hand clenching fist for about 30 seconds. (remember to do an Allen’s Test first) or use another artery of the body for the specific clinical task or surgical STEP 3 procedure. Apply firm pressure over the ulnar and the radial arteries, occluding both of them. STEP 4 Still elevated, the hand is then opened. It should appear blanched. (Pallor can be observed over the palm, as well as the fingernails). STEP 5 Release the ulnar pressure and the color should return within ±7 seconds (between 5 and 15 seconds).
113 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 12 C DRAW ARTERIAL BLOOD
Sample arterial blood from an artery
VIDEO
INFORMATION REQUIREMENTS This project will describe sampling blood for ABG (arterial You will need: blood gasses) using the radial artery. • Laboratory specimen labels Other arteries that may be used for this purpose include • Pen for writing the ulnar artery, the brachial artery, and the femoral artery. • Laboratory forms Some medical/surgical emergencies like acute pulmonary • A sharps waste container edema, an acute exacerbation of COPD, and surgical shock • Alcohol wipe reduces the body’s ability to take in oxygen and eliminate • Clean gloves* carbon dioxide. Often the patient’s life depends on the • Clean work surface cover appropriate action based on the ABG results. ABG may also • Tourniquet be needed when weaning a patient from a ventilator or • Syringe (3ml or 5ml)** administering a general anesthetic to a very sick patient. • Needle (23g Use a safety needle if available.) The ABG test results include the following: the blood’s pH, • Cotton ball or gauze square the partial pressure of Oxygen (PaO2), the partial pressure • Strapping (adhesive bandage strip) Carbon Dioxide (PaCO2), Oxygen saturation (SaO2), and • Fully set up Venipuncture Trainer—see PROJECT 10C bicarbonate (HCO3) levels. For ABG sampling use: Drawing an arterial blood gas sample is not as difficult as Sterile gloves* (in most centers) you may think. Arteries pulsate, making them easier to Eye protection glasses* (recommended) locate and unlike some veins they don’t ‘roll’. An ice filled plastic bag*, paper cup* or kidney dish* for transporting the sample to the lab after the procedure *Not supplied in the kit **Most hospitals have ABG kits containing a special pre- heparinized syringe, as well as all the necessary items required for the procedure.
114 Venipuncture Course and Kit | COLLECTING BLOOD
FOLLOW THESE STEPS STEP 6 Position is important! The patient should be seated IN A REAL-LIFE CLINICAL comfortably (patients in bed should be in the semi- SITUATION THEN SIMULATE recumbent position) and the arm must be comfortably extended towards you, wrist up, and the skin over the DRAWING BLOOD USING radial artery taut. Let the forearm rest on a small pillow; THE VENIPUNCTURE use a rolled towel or linen under the back of the hand to facilitate the extended wrist position. Cover the rolled TRAINER: support with a ‘linen saver’. STEP 1 Assemble equipment (see REQUIREMENTS above). Open STEP 7 (OPTIONAL) Give local anesthetic. Don non-sterile gloves and prepare the the outer packaging of all the items to be used. skin aseptically. Infiltrate (e.g., 2% plain Lidocaine 0.2 – 0.3 ml) Note: Use safety needles in all clinical settings. When intradermally with a 25G needle to reduce the anticipated simulating the procedure you may use a regular needle pain associated with the procedure. Remove your gloves. but take great care not to prick yourself with the sharp needle. STEP 8 Perform hand hygiene, don sterile gloves, and disinfect STEP 2 the site with an alcohol wipe for 30 seconds and allow to Greet, identify, and inform the patient. Explain the dry completely (allow another 30 seconds). procedure shortly (unless comatose) and that they will experience a ‘small needle prick’, a ‘mosquito bite’, or STEP 9 whatever works for you. You can ask them to ‘please, keep With the fingertips of your gloved left hand, find the area your arm still’. of maximal pulsation of the radial artery. In addition to the pulsation, you should be able to feel the radial artery as a STEP 3 cord-like structure beneath your fingers. Perform hand hygiene. With the fingers of your left hand over the radial artery, See PROJECT 3A – A TECHNIQUE FOR PROPER visualize the course of the radial artery underneath your HANDWASHING and PROJECT 3B – CLEANING HANDS fingers in three dimensions. WITH AN ANTISEPTIC RUB. STEP 10 STEP 4 Hold the syringe with the attached exposed needle in Site selection: as a first choice, select the radial artery of the your right hand like a pencil. Approach the skin at 30°- non-dominant wrist. See PROJECT 12A – IDENTIFY THE 45°, in line with the radial artery, pointing in the direction BODY’S PULSE POINTS. towards the elbow. The needle should enter the radial artery immediately below the gloved fingers of the left Warning: Radial arteries are contraindicated in patients hand (careful not to slip and injure yourself). Keep the skin who have a fistula or shunt in place for dialysis or have had taut and enter the skin with a brisk movement is the skin the radial artery used as a coronary artery bypass graft on penetration that causes the most pain. the side of the intended sampling. STEP 11 STEP 5 Once in the soft tissue, slowly advance the needle to Perform a modified Allen’s test. See PROJECT 12B – where you think the radial artery is. Do not rush; it is easy PERFORM A MODIFIED ALLEN’S TEST. to go straight through the radial artery. You may feel a If you have a positive Allen’s test (normal pink color doesn’t slight ‘give’ as the needle penetrates the wall of the radial return): don’t use the radial artery for blood sampling or artery. Once the needle has entered the artery you should cannulation so as to avoid serious ischemic (insufficient see a flashback of blood pulsating into the syringe. If you blood supply) complications to the hand. don’t see blood you may have missed the artery or may have gone right through it. If so, withdraw the needle until Rather use the radial artery of the opposite hand (remember blood starts filling the syringe or you may have to try again to do an Allen’s Test first) or choose another artery. by re-aiming the syringe towards the pulsating artery.
115 Venipuncture Course and Kit | COLLECTING BLOOD
STEP 12 STEP 21 Instruct the patient not to move the arm or wrist. If they Simulate the project by following Steps 1-20 using the do, the needle may become dislodged. Blood gas syringes fully setup Venipuncture Trainer. See PROJECT 10C. fill automatically, stopping at ± 2 ml. If you are using a Unfortunately you won’t be able to feel a pulse on the regular syringe you will have to stabilize the syringe with simulator. your left hand and gently withdraw the plunger of the syringe with your right hand. Once the syringe has filled or once sufficient blood has been collected, hold it steady to POINTS OF INTEREST: prevent air aspiration and then withdraw the needle. Although arterial puncture is a fairly complication- free procedure, you may encounter the following STEP 13 complications: Immediately place a gauze pad or cotton ball over the Hematoma site and firmly apply pressure for 5-10 minutes. Use the Blood under pressure is initially more prone to leak from tourniquet over the cotton ball to apply pressure. an arterial puncture than from a venipuncture site. It is STEP 14 important to exert sufficient pressure over the puncture site for 5-10 minutes. Inspect the syringe for air bubbles and slowly eject using a gauze square. Mix the blood with the heparin by gently Hemorrhage rolling the syringe a couple of times between your fingers. Hemorrhage is especially a problem with patients receiving anticoagulant therapy or patients with blood coagulation STEP 15 disorders. A longer compression time will be necessary. Seal the needle or tip of the syringe with a rubber stopper Nerve damage to prevent the influx of air. Compression neuropathy secondary to hematoma may cause temporary numbness of the hand. Direct needle STEP 16 injury to a nerve may cause permanent numbness of part Place the syringe onto the ice (pack some ice cubes of the hand. Know your anatomy and avoid continuous over the syringe) and send it off to the lab immediately. blind and deep poking of the wrist area. ABG samples should be analyzed within 10 minutes of collection for accurate results. Aneurysm and AV (Arterio-Venous) Fistula These rare complications usually occur with repeated STEP 17 punctures. An aneurism will cause the artery to ‘balloon- Discard all sharps (e.g., the used needles, syringes) and out’ due to a weakened muscular wall. An AV fistula is a potential sharps such as glass items into a puncture- communication between an artery and a vein before the resistant sharps container. Place other items like used capillary bed. gloves and all items contaminated with blood or body Arteriospasm fluids into the infectious waste. Arterial spasm may decrease the pulse volume and cause pain but fortunately is temporary. STEP 18 Recheck the labels and requisition forms for correctness of Thrombus formation the patient’s name, the date, time, puncture site, etc. Injury to the artery can lead to clot (thrombus) formation. A large thrombus can obstruct the flow of blood and impair STEP 19 circulation to the hand. Monitor the site and extremity for a while for any Infection of the puncture site sign of circulatory problems, nerve damage, or other Use sterile/aseptic protocol as recommended by your complications. institution/hospital. STEP 20 Thank the patient and perform hand hygiene.
116 Venipuncture Course and Kit | COLLECTING BLOOD
The following factors will negatively influence the Note: The best way to be certain that a specimen is arterial integrity of the ABG: is by observing the blood pulsating into the syringe. • Air bubbles remaining in the specimen • Improper anticoagulant • Delay in cooling the specimen Note: Heparin is the only accepted anticoagulant for ABGs. • Venous blood mixed in ABG sample
BLOOD TRANSFUSIONS, BLOOD TYPE (BLOOD GROUPS) AND AGGLUTINATION
A person’s blood type is determined by certain proteins The ABO blood group system markers (antigens) on the surface of red blood cells (RBCs). In the ABO blood group system, there are four possibilities A total number of 30 human blood group systems are now A-antigen (A blood), B-antigen (B blood), both A and B recognized by the International Society of Blood Transfusion antigen (“AB blood”), and lastly neither A nor B antigens (ISBT). There are many types of blood; however, the most called “O blood”. A person with Type A blood produces important ones are ABO and the Rhesus factor. antibodies against the B antigens and vice versa. A person with O blood produces both A and B antibodies. See the illustration below (the antigens sticking out are represented by the colored shapes on the surface of the red blood cells).
Figure 37: The ABO antigens and antibodies
On average the general population has the following percentages of blood groups (percentages vary from country to country):
0+ A+ B+ AB+ 0- A- B- AB- 36% 28% 21% 5,0% 4% 4% 1,5% 0,5%
Table 7: Prevalence of Blood groups in the general population (approximate global averages)
117 Venipuncture Course and Kit | COLLECTING BLOOD
Genotype (Genetic type) Phenotype (Biochemical expression) AA or A0 A BB or B0 B AB AB 00 0 Table 8: The ABO Genotype and Phenotype
RH BLOOD GROUP SYSTEM AGGLUTINATION REACTION The Rh system (another type of protein that is exposed (CLUMPING TEST) on RBC is called “Rh-factor”) is the second most significant Should a medical professional infuse the wrong blood blood-group system in human blood. The most significant type to somebody by accident, the result will be that Rh antigen is the D antigen. You either have it or you blood will agglutinate (create clumps of red blood cells don’t. The person who has the D antigen is positive and followed by serious life threatening complications). It one who doesn’t is negative. So, someone could be Type is important to test the blood from the donor and the A, B, AB, or O, and then Rh positive or negative (e.g., A recipient by mixing a small amount in a test tube or on a Rh+ or B Rh-). An Rh+ person can donate blood ONLY glass slide to test for compatibility. Agglutination will be to another Rh+ person while an Rh- person can donate noted if the bloods are incompatible. Type O Rh- blood blood to both an Rh+, as well as an Rh- person. can be given to anybody because there’s nothing on Rh factor is especially important in pregnant women. the blood cells for the person to attack. A person with Let’s say a woman is Rh- and the Rh+ father gave the type O Rh- blood is considered a “Universal donor” and baby the genes to be Rh+ as well. This will be fine, as the any person in any other blood group may receive type baby’s blood isn’t mixing with the mothers or vice-versa. O Rh- blood. A person with type AB Rh+ blood carries When it becomes important is when she gives birth to both A, B, and D (Rh) antigens but neither A nor B nor the baby because there’s a break in the blood systems D antibodies and can therefore receive anyone’s blood and small tears cause some of the blood cells from the (types A or B or AB or O blood – Rh+ or Rh-) because they baby to cross over into the mother’s bloodstream during don’t have antibodies to fight antigens. Type AB is known birth, which causes the mother’s immune system to as a “universal recipient“. recognize those Rh antigens. The Rh-negative mother will produce Rh antibodies upon exposure to Rh-factor. If the next baby is Rh+ again, the mother’s anti-Rh antibodies can cross over to the baby’s system and attack the baby’s red blood cells, often ending in the demise of the baby. The RhoGAM injection was created to minimize Rh-factor incompatibility reaction with consecutive pregnancies. It is given to the mother within 72 hours of birth to kill the Rh+ cells that have crossed into her blood stream to prevent her from making Rh antibodies.
118 Venipuncture Course and Kit | COLLECTING BLOOD
Recipi- 0- 0+ A- A+ B- B+ AB- AB+ ent 0- 0+ A- A+ B- B+ AB- AB+
Table 9: Red blood cell compatibility
119 Venipuncture Course and Kit | COLLECTING BLOOD
PROJECT 13 DONATING BLOOD FOR THE BLOOD BANK
Become a blood donor (if you aren’t a donor already)! INFORMATION STEP 2 Study pages 25 – 30 (Practical guidance on Select the vein venipuncture for blood donation) of the WHO • Select a large, firm vein, preferably in the cubital fossa, document: from an area free from skin lesions or scars. WHO guidelines on drawing blood: Best practices in • Apply a tourniquet or blood pressure cuff inflated to phlebotomy. WHO Publication 2010⁷ 40–60 mm Hg to make the vein more prominent. • Ask the donor to open and close their hand a few Your mission is as follows: times. • Identify your closest blood bank. • Once the vein is selected, release the pressure device • Arrange a date and time to donate blood. or tourniquet before the skin site is prepared. • Observe the steps and method used by the phlebotomist to collect blood from you as a blood STEP 3 donor and compare it with the information below. Disinfect the skin • Ask questions and have a hands-on learning • If the site selected for venipuncture is visibly dirty, experience! wash the area with soap and water and then wipe it dry with single-use towels. REQUIREMENTS • One-step procedure (recommended—takes about one minute): You will need: • Use a product combining 2% chlorhexidine • The contact details of your local blood bank. gluconate in 70% isopropyl alcohol. • Transport to and from your local blood bank. • Cover the whole area and ensure that the skin area is in contact with the disinfectant for at COLLECTING BLOOD least 30 seconds. For collection of blood for donation use the procedure • Allow the area to dry completely or for a detailed in Section 2 for blood sampling (e.g., for hand minimum of 30 seconds by the clock. hygiene and glove use) as far as it is relevant and follow • Two-step procedure (if chlorhexidine gluconate in 70% the six steps given below: isopropyl alcohol is not available, use the following procedure—takes about two minutes): STEP 1 • Step 1: Use 70% isopropyl alcohol • Identify donor and label blood collection bag and test • Cover the whole area and ensure that the skin tubes area is in contact with the disinfectant for at • Ask the donor to state their full name. least 30 seconds. • Ensure that: • Allow the area to dry completely (about 30 • The blood collection bag is of the correct type. seconds). • The labels on the blood collection bag and all its • Step 2: Use tincture of iodine (more effective satellite bags, sample tubes, and donor match. than povidone iodine) or chlorhexidine (2%). • Records have the correct patient name and • Cover the whole area and ensure that the skin number. area is in contact with the disinfectant for at • The information on the labels matches with the least 30 seconds. donor’s information. • Allow the area to dry completely (about 30 seconds). • Whichever procedure is used, DO NOT touch the venipuncture site once the skin has been disinfected.
120 Venipuncture Course and Kit | COLLECTING BLOOD
STEP 4 AFTER A BLOOD DONATION Perform the venipuncture Donor care after the blood has been collected: • Perform venipuncture using a smooth, clean entry • Ask the donor to remain in the chair and relax for a with the needle. Take into account the points given few minutes. below which are specific to blood donation. • Inspect the venipuncture site. If it is not bleeding, • In general, use a 16 gauge needle, which is usually apply a bandage to the site. If it is bleeding, apply attached to the blood collection bag. A retractable further pressure. needle or safety needle with a needle cover is • Ask the donor to sit up slowly and ask how they are preferred, if available, but all should be cut off at the feeling. end of the procedure (as described in step 6 below) • Before the donor leaves the donation room, ensure rather than recapped. that they can stand up without dizziness and without • Ask the donor to open and close their fist slowly every a drop in blood pressure. 10-12 seconds during collection. • Offer the donor some refreshments. • Remove the tourniquet when the blood flow is established or after 2 minutes, whichever comes first. IMPORTANT NOTE! If you are not already one – consider becoming a regular STEP 5 blood donor. Monitor the donor and the donated unit • Closely monitor the donor and the injection site POINTS OF INTEREST throughout the donation process. Look for: Current FDA guidelines allow a maximum of 10.5 ml/ • Sweating, pallor, or complaints of feeling faint kilogram body weight of whole blood to be collected every that may precede fainting eight weeks. The majority of blood collection facilities use • Development of a hematoma at the injection 500 ml whole blood bags, with an additional 50 ml (10%) site allowed to be drawn for mandated screening tests. • Changes in blood flow that may indicate the needle has moved in the vein and needs to be Great advances have been made with minimizing the repositioned need for blood during surgery. See “Bloodless surgery” for • About every 30 seconds during the donation, mix the more information: [Click Here] collected blood gently with the anticoagulant, either manually or by continuous mechanical mixing. STEP 6 Remove the needle and collect samples • Cut off the needle using a sterile pair of scissors. • Collect blood samples for laboratory testing.
121
4 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
CASE STUDY 4: DESPITE ALL THE TRAINING AND THE NECESSARY CARE, ACCIDENTS DO HAPPEN
Michelle, an experienced phlebotomist, has been required protocol is followed and the patient is asked working in a kidney transplant unit for years. On this for permission to draw more blood samples—with the specific occasion, she receives a requisition order for necessary explanations and relevant forms to be filled drawing venous blood for kidney function tests. The out. Eventually, later in the day, the patient’s blood necessary items for drawing blood are collected but results arrive. the safety needle container is empty. “I will just use Michelle is summoned to the Infection Control Officer’s a regular needle for now and get new supplies in a office. They discuss the results of the blood tests after moment,” Michelle whispers to herself. The blood draw which the Infection Control Officer asks Michelle, “When proceeds quite smoothly until, for some unknown was your previous Hepatitis B inoculation?” An ice-cold reason, the patient suddenly and unexpectedly jerks shiver goes down the phlebotomist’s spine as she away. In an instant the needle slips out of the patients realizes that it is long, long overdue. arm and penetrates Michelle’s index finger. The Three months later, after a slow decline in health and
124 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
despite the best of medical attention by specialists in Warnings: their fields and the best treatment medical science • In all clinical settings use safety needles and don’t had to offer, the able phlebotomist succumbs to allow for any exceptions. complications of sub-massive viral liver necrosis and all Ensure that your Hepatitis B inoculations are up to date. ends in tragedy.
CENTRAL VENOUS LINE A central venous catheter (central venous line) is a catheter placed into the internal jugular vein or the subclavian vein or, less commonly, the axillary vein or femoral vein.
Figure 39b: An introducer and a central venous catheter
Figure 38: Central Venous Line Insertion
Depending on its use, the catheter is monoluminal, biluminal, or triluminal, dependent on the actual number Figure 39c: Placing a central venous catheter under sterile conditions of lumens (1, 2 and 3 respectively). The indication for the use of a central venous line is when frequent or persistent need for intravenous access is required for: • Monitoring of the central venous pressure (CVP) in acutely ill patients to quantify fluid balance • Long-term parenteral nutrition • Administering long-term medications • Infusing drugs that are prone to cause damage or phlebitis in peripheral veins (e.g., chemotherapeutic agents) • Frequent blood drawing for blood tests • Administering fluids • Determining the “mixed venous oxygen saturation” • Dialysis Figure 39a: Examples of a central venous catheters • Need for intravenous therapy when peripheral venous access is impossible
125 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
Central venous catheters usually remain in place for a • Thrombosis longer period of time than other venous access devices. • Other complications Possible complications include: • Air embolism (rare) • Pneumothorax • Hemorrhage and formation of a hematoma • Central-line associated bloodstream infections
ARTERIAL CATHETERIZATION
An arterial line is a thin, hollow tube that is inserted RISKS INCLUDE into an artery — the most common being the radial • Pain: Discomfort can result from the needle stick and or femoral arteries. It is often used in intensive care placement of the catheter at the time it is inserted. medicine and anesthesia to monitor the blood pressure Consider infiltrating the skin over the intended real time and/or to obtain multiple samples for arterial insertion site before catheterization. blood gas measurements. The arterial line must be • Infection: As is the case with all catheters inserted clearly marked to avoid accidental intra-arterial injection into the body, bacteria can travel up the catheter from of intravenous drugs. the skin and into bloodstream causing bacteremia or septicemia. The longer the catheter remains in the artery, the more likely it is to become infected. • Thrombus formation: If blood clots form on the tips of arterial catheters, the clots may block blood flow and, very rarely, may cause the loss of a hand or a leg. This complication can be minimized by regularly checking the flow of blood in the relevant extremity. • Bleeding: Bleeding may occur at the time of inserting the catheter. Patients on anticoagulation therapy are at high risk. The bleeding usually stops spontaneously, but in some cases the catheter may require removal Figure 40: Inserting a catheter into the radial artery followed by the application of pressure to the site.
COMMON REASONS FOR ITS USE ARE: • Severe hypotension or hypotensive shock • Life-threatening hypertension • Severe pulmonary problems
126 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
CORONARY ARTERIOGRAPHY
A cardiologist may catheterize the coronary arteries, A coronary angiogram is an X-ray of the coronary arteries usually via a femoral artery access to evaluate the coronary showing the coronary arteries. Radiologists inject a arteries or to perform an interventional procedure, such as contrast medium into the artery to assess the patency of placing a stent. the blood vessel.
VIDEO
INTERVENTIONAL RADIOLOGY
Interventional radiologists utilize minimally invasive, Many conditions that once required surgery can now be image-guided procedures to diagnose and treat diseases treated non-surgically by interventional radiologists, thus in nearly every organ system. The concept behind minimizing the physical and psychological trauma to the interventional radiology is to diagnose and treat patients patient, with reduced risk of infection and often drastically using the least invasive techniques available in order to reduced recovery time. minimize risk to the patient and improve health outcomes. Interventional radiologists pioneered modern minimally invasive medicine using X-rays, CT, ultrasound, MRI, and other imaging modalities. Interventional radiologists obtain images which are used to direct interventional instruments throughout the body. These procedures are usually performed using needles and catheters instead of making large incisions into the body as in conventional surgery.
127 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
KIDNEY DIALYSIS
Conventional chronic hemodialysis is usually done AV (arteriovenous) fistulas are recognized as the three times per week for about 3-4 hours per dialysis preferred access method for gaining access to the treatment, during which the patient’s blood is drawn bloodstream. Fistulas are usually created in the non- out through a tube at a rate of 200-400 ml/min. The dominant arm and may be situated on the hand, the tube is connected to a 15, 16 or 17 gauge needle forearm or the elbow by a vascular surgeon who inserted into the dialysis fistula or graft, or is connected surgically joins an artery and a vein together. Since this to one port of a dialysis catheter. The blood is pumped bypasses the capillaries, blood flows rapidly through through the dialyzer and then the processed blood is the fistula and this rapid flow of blood is necessary for pumped back into the patient’s bloodstream through withdrawing and replacing relatively large volumes of another tube connected to a second needle or port. blood during dialysis. During the treatment, the patient’s entire blood volume (about 5000 cc) circulates through the machine every 15 minutes.
Figure 41a: Placement of ‘In’ and ‘Out’ lines for renal dialysis Figure 41b: An AV fistula for renal dialysis
128 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
KIDNEY DIALYSIS
A port is most commonly inserted as a day surgery procedure in a hospital or clinic by a surgeon or an interventional radiologist under conscious sedation. Implantable ports are often used to give chemotherapy treatment and/or other medicines to cancer patients. Chemotherapy is relatively toxic to normal cells and can damage skin and muscle tissue, as well as small veins.
Figure 42a: A diagram of a venous access port Figure 42b: A clinical example of a venous access port
A PORT MAY SERVE THE FOLLOWING PURPOSES: • For the delivery of TPN (Total Parenteral Nutrition) When no longer needed, the port can be removed in • To deliver coagulation factors in patients with the operating room. severe hemophilia • For withdrawing and returning blood to the body in patients who require frequent blood tests • For withdrawing and returning blood to the body in hemodialysis patients • To deliver antibiotics to patients requiring them for a long period of time or frequently • For delivering medications to patients with immune disorders • To deliver radiopaque contrast agents which enhance contrast in radiography (e.g., CT imaging)
129 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
PARENTERAL NUTRITION (TPN)
Parenteral nutrition is given intravenously. TPN supplies all daily nutritional requirements. TPN Partial parenteral nutrition supplies only part of daily can be used in the hospital or at home. Because TPN nutritional requirements, supplementing oral intake. solutions are concentrated and can cause thrombosis Many hospitalized patients are given dextrose or amino of peripheral veins, a central venous catheter is usually acid solutions by this method. required. For more information: [CLICK HERE]
ANESTHESIA
LOCAL ANESTHESIA A local anesthetic is a drug that causes reversible local Topical anesthetics when used before venipuncture anesthesia (loss of sensation), inducing the blocking of penetrate mucosa with ease (mucosa will be fairly pain impulses to the brain with the aim of performing a numb within 1-3 minutes), but are slow to penetrate pain-free procedure. skin. Clinicians need to follow instructions precisely. The anesthetic cream is required to be in contact with the skin Topical anesthetics are usually in the form of a for 30-60 minutes! cream, gel, or spray and are applied to the skin or mucous membrane before penetrating it with a needle. Infiltration local anesthesia is widely used for minor Applications include ophthalmology, dentistry, the relief surgery on the skin and mucous membranes, as well as of symptoms (e.g., sun burn), and before venipuncture. for dental procedures. The local anesthetic is deposited diffusely in the region of intended surgery.
130 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
PROJECT 14 INFILTRATING A WOUND WITH LOCAL ANESTHETIC BEFORE SUTURING
Two methods of infiltrating a wound with a local anesthetic solution before debridement and suturing
VIDEO
INFORMATION REQUIREMENTS Most minor cuts and some not so minor lacerations can You will need: easily be sutured under local anesthetic as opposed to • The Venipuncture Trainer subjecting the patient to a general anesthetic. This is, in • Gloves most cases, a much more cost-effective option and can be • 5ml syringe done on an outpatient basis. • 20G needle Keep in mind the basic principles of assessing a wound for • Clean work surface cover suturing – remember the acronym “LACERATE”: • IV fluid bag • Alcohol hand rub Look at the Wound (Assess it) • A suitable volunteer (as usual) Anesthetic Considerations Clean the Wound Equipment (Set Up) Repair the Wound Assess the Results and Anticipate Complications Tetanus Immunization Status Educate the Patient Regarding Wound Care
131 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
METHOD 1 STEP 9 Repeat the same procedure on the other side of the FOLLOW THESE STEPS AS laceration. IF IN A REAL-LIFE CLINICAL STEP 10 SITUATION: Wait 2-3 minutes; test the effectiveness of the local anesthetic by poking the wound area with a probe or STEP 1 pinching it with a forceps. You are now ready to prepare Remember the basics: take a medical history, prepare your the wound for suturing. hands hygienically, and don clean gloves. Information: STEP 2 Do you want to learn all the basics about suturing, such as how to tie a surgeons knot and learn 12 different suturing Withdraw some of the fluid from one of the IV fluid techniques? Get your very own Apprentice Doctor® How bags from the ‘out’ port. This will be used as a fake local to Suture Wounds Course and Kit anesthetic solution.
STEP 3 STEP 11 Lift the skin, dry the trainer, and discard used needles in Draw a 5 cm (2 inch) line on the Venipuncture Trainer to the mini sharps waste container. Clean up and replace all represent the laceration. reusable items in your kit. Keep in a safe place and out of reach of children! STEP 4 Insert the needle into the tissue, about 5 mm (1/4 inch) away from the laceration, beside one end of the laceration.
STEP 5 Deposit a drop or two of local anesthetic and wait for 30- 40 seconds. Advance the needle parallel to the long axis of the laceration to the other end of the laceration or to the length of the needle.
STEP 6 Aspirate to ensure that you are not in a blood vessel, to avoid accidentally injecting the local anesthetic solution intravenously.
STEP 7 Inject the local anesthetic solution continuously just below the skin as you withdraw the needle. Note the skin rising as you deposit the local anesthetic fluid. With a real patient you will see blanching (the tissue will become whiter).
STEP 8 If the laceration is longer than the needle, repeat the same procedure along the next section of skin next to the laceration but ensure that you enter the skin in already locally anesthetized skin.
132 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
METHOD 2 For this method, use a thin 27G needle. A short dental syringe and needle will work just fine.
Figure 43a: A dental syringe Figure 43b: Repair of an ear laceration Penetrate the laceration through the raw edge of the wound. Starting at one side of the laceration, advance the needle into the adjacent tissue for about 1 cm (3/8 inch) at an angle of about 30°-45°. Repeat the same process of injecting local anesthetic solution every ±7 mm (±1/4 inch) on both sides of the wound. Follow with Step 9 as above. By avoiding the penetration of intact skin, the patient experiences significantly less pain compared to Method 1, although most people would think that injecting straight into the wound should be more painful.
133 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
POINTS OF INTEREST
Local and general adverse effects and complications Local anesthetic block – a local anesthetic solution is include: deposited in the region of a specific nerve stem to numb the sensory distribution area of that specific nerve. The LOCAL ADVERSE EFFECTS clinician needs to know the regional anatomy in detail. The local adverse effects of anesthetic agents include A nerve block should be effective within 3-5 minutes. An prolonged anesthesia (numbness) and paresthesia example of a local anesthetic block is the blocking of the (tingling or ‘pins and needles’ of the affected area). lingual and inferior alveolar nerves before performing a Permanent nerve damage after a peripheral nerve surgical/dental procedure involving the lower jaw, the block is rare. The vast majority of symptoms are likely to lower teeth, as well as the lip and chin on the side of resolve within four to six weeks. injection.
GENERAL SYSTEMIC IMPORTANT: It is wise to aspirate before depositing the local anesthetic to avoid intravascular injections. ADVERSE EFFECTS The clinician needs an understanding of the relevant pharmacology, physiology, anatomy, as well as the Central nervous system knowledge and skills to treat and manage complications. Dangerous side effects involving the central nervous system usually follow when the safety dosage margins NOTE: Great numbers of local anesthetic injections are of the specific drug were exceeded or when an given daily without aseptically preparing the mucosa. inadvertent intravenous or intra-arterial injection of the Despite the hordes of bacteria in the oral cavity, septic local anesthetic has occurred. It may either excite or complications related to these injections are extremely depress the central nervous system which may manifest rare. One researcher concluded: “…the application of an at lower blood levels as convulsions or coma, respiratory antiseptic to the mucosa before injection would appear arrest, and death at higher concentrations to be questionable except for patients in whom special hazards are known to exist.” Cardiovascular system Reference: [CLICK HERE] Complications related to the conductive system of the heart include heart palpitations (innocent and usually due to the vasoconstrictor’s effects), arrhythmias, and Regional anesthesia is anesthesia affecting only large a complete heart block (extremely rare but potentially parts of the body such as a limb or the lower half of the fatal if not treated promptly) body, as opposed to local anesthesia, which affects a fairly small part of the body such as a tooth or an area Allergic reactions of skin. An allergy may vary from hypersensitivity (e.g., skin rash Central regional anesthesia includes procedures and itchiness) to a life-threatening anaphylactic shock. like epidural anesthesia and spinal anesthesia, while A patient may be allergic to any one of the components peripheral techniques include procedures like plexus in a local anesthetic solution: blocks (e.g., brachial plexus blocks) and single nerve • The local anesthetic (The two main groups blocks. are esters and amides.) Regional anesthesia may be performed as a single • The vasoconstrictor shot or with a continuous catheter through which • The preservative medication is given over a prolonged period. Ask specifically about allergies to local anesthetics when Intravenous regional anesthesia (Bier block) is a specific preparing for suturing under local anesthetic. type of regional anesthesia in which the clinician injects Be prepared with all the emergency equipment to a local anesthetic solution directly into a vein, (e.g., of resuscitate a patient in the case of an allergic reaction. an arm) with the venous flow impeded by a tourniquet.
134 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
General anesthesia Infusion pumps Prerequisite before starting the administration of a External infusion pumps are medical devices that general anesthetic is a dependable venous access deliver fluids, including nutrients and medications (such route for injecting the induction agent, various other as anesthetic agents, antibiotics, chemotherapy drugs, medications, as well as possible emergency medications. and pain relievers) into a patient’s body in controlled Total Parenteral Anesthesia (TPA) is the term used when amounts. Many types of pumps, including large volume, the anesthetist administers a general anesthetic using patient-controlled analgesia (PCA), elastomeric, syringe, intravenous drugs, which are infused with an infusion enteral, and insulin pumps, are used worldwide in pump, instead of maintaining the anesthetic with healthcare facilities such as hospitals and in the home. volatile anesthetic gasses.
NEW DEVELOPMENTS
Scientists and bioengineers are developing amazing Needleless injections new technologies. Here are a few examples: In future, people who have a fear of needles one may barely perceive receiving a needleless injection—at Microprobes for continuous monitoring most they may feel the discomfort of a nail-scratch! Instead of frequently sampling blood and then sending it to the lab and waiting for results, certain biochemical How it works: substances can be monitored very accurately and in Commercially available needleless injection systems: real time using an indwelling microprobe. This has Have a look at this pain-free, needleless dental injection: especially useful applications in diabetics with real time [CLICK HERE] monitoring of blood glucose. And other pain-free injections: [CLICK HERE] [CLICK HERE] for more information
135 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
SHORT NOTES ON OTHER BODILY SECRETIONS
SALIVA BREAST MILK The term saliva is used for the watery substance freshly Breast milk may be analyzed for nutritional composition/ secreted from the ducts of the salivary glands. Saliva values. Measured nutritional components are glucose, is secreted by the six major salivary glands (the paired lactose, triglyceride, and protein. Deficiency of any of parotids, submandibular, and sublingual glands), as the measured or calculated parameters is suggestive well as the multiple hundreds of minor salivary glands of decreased nutritional quality of human breast milk. situated within the submucosa of the lips, cheeks, and It can also be analyzed for the presence of pollutants palate. such as heavy metals (Mercury) or organic pollutants (Persistent Organic Pollutants or POP). The laboratory testing of saliva samples is a fairly new and exciting field of clinical pathology, measuring various hormones, biochemical substances, drugs, etc. SEMEN It has a number of applications in forensic medicine as Basic semen analysis: Almost all laboratories will report well. on the following information using values established Saliva testing has many advantages over blood testing. by the World Health Organization. Saliva specimen collection does not require a blood • Concentration: This is a measurement of how many draw and there are no risks to patients. Saliva collections million sperm there are in each milliliter of fluid. are convenient and can be done at work or at home. There are various techniques for obtaining this When stored properly, saliva samples are stable for number; some prove to be more accurate than several weeks. others. Average sperm concentration is more than With an accuracy of 92-96%, saliva testing is as accurate 60 million per milliliter (>60 million/cc). Counts of as blood testing and, in some cases, more accurate. less than 20 million per milliliter (<20 million/cc) are Another advantage of saliva testing is the ability to considered sub-fertile. collect specimens over a period of time with ease. This offers providers more information than a single • Motility (sometimes referred to as the ‘mobility’): collection would. Compared to blood testing, saliva This describes the percentage of sperm that are testing is also more affordable. moving. Fifty percent or more of the sperm should be moving. SPUTUM • Morphology: This describes the shape of the sperm. The sperm are examined under a microscope and Sputum refers more to the mucous substance secreted must meet specific sets of criteria for several sperm by the mucous glands in the throat and upper airways characteristics in order to be considered normal. (nasal mucosa, trachea, bronchi, and bronchiole). Most commercial laboratories will report World Sputum needs to be coughed up and spit out by the Health Organization morphology. By WHO criteria, patient into a specimen collection container. Sputum 30% of the sperm should be normal. is usually sent to the microbiology lab and is especially useful in the diagnosis of tuberculosis (deep early • Volume of the ejaculate: Normal is 2 milliliters (2 morning sputum collected three consecutive days). ccs) or more. • Total Motile Count: This is the number of moving sperm in the entire ejaculate. There should be more than 40 million motile sperm in the ejaculate. • Standard Semen Fluid Tests: Color, viscosity (how thick the semen is) and the time until the specimen liquefies should also be measured.
136 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
SWEAT The sweat chloride test (sweat test) measures the over a circumscribed area of the body for about five concentration of chloride that is excreted in sweat. It is minutes. Sweat is collected on a piece of filter paper used to screen for cystic fibrosis (CF). and then sent to the laboratory for testing. Increased chlorine levels will make the diagnosis of CF ‘unlikely’, Sweating is stimulated by applying a colorless, odorless ‘possible’, or ‘likely’, depending on the specific level. chemical that causes sweating. An electrode is applied
SHORT NOTES ON OTHER BODILY EXCRETIONS
URINE FECES Urine tests are very useful for providing information to A doctor may order a stool collection to test for a variety of assist in the diagnosis, monitoring, and treatment of a wide possible conditions, for example to: range of diseases and conditions. Hormonal levels in the • Evaluate certain allergies, such as milk protein allergy urine test can indicate whether a woman is ovulating or in infants. pregnant. • Assist with identifying diseases of the digestive tract, Urine can also be tested for a variety of substances, liver, and pancreas. including illegal drug use in general, as well as in the world • Screen for colon cancer by checking for hidden of professional sport. (occult) blood. Urine may be submitted to the cytology lab to detect • Examine for the presence of parasites, such as cancerous cells or to the microbiology lab for microscopy pinworms or Giardia lamblia. and culturing to identify specific microbes involved in • Ascertain the cause of an infection, such as bacteria urinary tract infections. (e.g., Salmonella, Shigella, fungi, and viruses). • Assist with finding the cause of symptoms affecting the digestive tract, including prolonged diarrhea, URINALYSIS bloody diarrhea, increased flatulence, nausea, The urine can be tested very quickly using a strip of special vomiting, loss of appetite, bloating, abdominal pain, paper, which is dipped in urine just after urination. This will cramping, and fever. show if there are any abnormal products in the urine such • Check for poor absorption of nutrients by the digestive as sugar, protein, or blood. tract (malabsorption syndrome). If more tests are needed to get more details, the urine will be analyzed at a laboratory. A fresh stool sample is collected in a sterile container. Stool Normally urine is sterile, but skin contaminant bacteria samples should be taken to the laboratory within an hour may be added to the sample during urination. after collection. Infant stool samples are usually collected The patient should be instructed to wash genital areas with a rectal swab. before taking the sample, specifically taking the ‘mid- stream’ urine. Notes: A urine sample for the lab is collected in a standard lab • Wash hands thoroughly before and after sampling. collection container (100-150 ml required). • Use clean gloves and other barrier techniques if indicated!
137 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
SHORT NOTES ON OTHER BODILY FLUIDS
Cerebrospinal fluid (CSF) is a clear, colorless bodily fluid Diagnosis of the cause is usually done with blood tests, an produced in the choroid plexus of the brain and occupies ultrasound scan of the abdomen, and direct removal of the subarachnoid space, the ventricular system around the fluid by needle (paracentesis). Treatment may be with and inside the brain, as well as the central canal of the medication (diuretics), paracentesis, or other treatments spinal cord. directed at the cause. CSF can be tested for the diagnosis of a variety of Diagnostic blood tests should include a complete blood neurological diseases. It is commonly obtained by a count (CBC), basic metabolic profile, liver enzymes, and procedure called a lumbar puncture. Lumbar puncture coagulation profile. Most experts recommend a diagnostic is performed in an attempt to count the cells in the fluid paracentesis be performed; the fluid is then examined and to detect the levels of biochemical constituents like for its gross appearance, protein level, albumin, and cell protein and glucose. These parameters alone may be counts (red and white). Additional tests will be performed extremely beneficial in the diagnosis of subarachnoid if indicated, such as Gram stain and cytopathology. hemorrhage and central nervous system infections such as encephalitis and meningitis. Microbiological CSF culture The Serum-Ascites Albumin Gradient (SAAG) is probably examination may yield the specific microorganism causing a better discriminant than older measures for discerning the infection. the causes of ascites. A high gradient indicates the ascites By using more sophisticated methods, such as the is due to portal hypertension, while a low gradient points detection of the oligoclonal bands, conditions like multiple away from portal hypertension as the primary etiology. sclerosis may be recognized. Beta-2 transferrin is almost exclusively found in the EFFUSION is the escape of fluid from the blood or cerebrospinal fluid. It is not found in blood, mucus, or tears, lymphatic vessels into the surrounding tissues or into a thus making it a specific marker of cerebrospinal fluid and body cavity. the detection of leakage like CSF rhinorrhea. PLEURAL EFFUSION is excess fluid accumulating between the two pleural layers that surround the lungs. Pleural fluid is drawn out of the pleural space in a process called thoracentesis. A needle is inserted through the back of the chest wall in the sixth, seventh, or eighth intercostal space on the mid-axillary line into the pleural space. The fluid may then be evaluated for the following: • Chemical composition including protein, lactate dehydrogenase (LDH), albumin, amylase, pH, and glucose • Gram stain and culture to identify possible bacterial infections • Total and differential cell counts • Cytopathology to identify cancer cells and to assist in identifying possible infective organisms Figure 44: Cerebrospinal fluid fills the ventricles and surrounds the brain • Other tests as suggested by the clinical situation and spinal cord. – lipids, fungal culture, viral culture and specific immunoglobulins ASCITES is an accumulation of fluid in the peritoneal cavity. It is most commonly caused by severe liver disease, like cirrhosis or metastatic liver cancer, but its presence may also indicate other important medical conditions.
138 Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
JOINT EFFUSION is the presence of increased intra- • Clean the skin/mucosa with an appropriate articular fluid, a fairly common finding in the inflamed antimicrobial agent. If needed, remove excess knee joint, but any joint may be affected. It may happen as cleaning agent with a sterile gauze square to avoid a result of trauma, inflammation, hematologic conditions contamination. or infections. • Use a 5-10 ml syringe and a large bore needle and puncture the abscess at the point of maximum fluctuation or just below this point (within the limits EXUDATES AND of wisdom regarding the local anatomy). Aspirate TRANSUDATES enough pus; more is better than less. AN EXUDATE is any fluid that filters from the circulatory • Transfer to an aerobe as well as an anaerobe lab system into lesions or areas of inflammation. transfer medium/bottle. It is rich in the protein and cellular elements that ooze out • Mark as urgent, for immediate transfer to the lab. of blood vessels due to inflammation and is deposited • Proceed with the formal surgical incision and drainage in surrounding tissues. The altered permeability of blood procedure. (Needle aspiration is an insufficient vessels permits the passage of large molecules and cells method of evacuating all the pus in an abscess cavity.) through the blood vessel walls. • Alternatively, incise the abscess then use a pus swab to take the sample when pus emerges and then insert A TRANSUDATE is an accumulation of fluid that passed the swab in a dedicated transport medium. through a membrane due to increased pressure in the veins • Warning: Use safety needles and take extreme care and capillaries forcing the fluid through the vessel walls. not to inoculate yourself or someone else with this This process filters out most of the protein and cellular septic content! elements, thus yielding a watery solution. Transudates are caused by disturbances of hydrostatic or colloid osmotic COMMENT: pressure and not by inflammation. • Pus aspirated in a syringe is always preferable to a There is an important distinction between transudates and swab. exudates. Exudates have a higher protein content and thus • Sample pus, if possible, before initiating antibiotic a higher specific gravity, while transudates have a lower therapy. protein content and thus a lower specific gravity. • Contaminant bacteria (normal resident bacteria), such as Staphylococcus epidermidis (skin) and Streptococcus viridians (mouth and throat), grow easily and often overgrow the pathological bacteria in PUS the lab giving valueless results. Pus is a viscous, yellowish-white fluid formed in infected • The empirical treatment of an abscess is ‘incision and tissue, consisting of white blood cells, cellular debris, drainage’. necrotic tissue and masses of bacteria, both dead and alive. • External heat therapy increases the blood flow to the The following are recommended steps to take for area and assists with localizing the pus. sending a pus sample from a closed abscess to the • Antibiotics and analgesics play a supportive role in microbiology lab for MC&S (Microscopy, Culture and treating infections. Not even the strongest antibiotic Sensitivity). will clear a pus-producing abscess! • As far as possible, use a narrow spectrum antibiotic FOLLOW THESE STEPS: with proven sensitivity rather than treating the • Ensure sterile conditions and have relevant barrier infection blindly. techniques in place. • Test for fluctuation and determine the point of maximum fluctuation.
139
5 Venipuncture Course and Kit | COMPLICATIONS
CASE STUDY 5: A “ROUTINE” VENIPUNCTURE CASE
Judy has always had a problem with difficult veins. eventually arrives, ‘all hell breaks loose.’ The physician Questions like, “Are your veins hiding today?” and “Did demands action STAT*!! Emergency medications are called you leave your veins at home?” are common remarks by for and emergency procedures follow, after which an medical professionals when attempting to draw blood or urgent transfer to the Intensive Care Unit is done. Despite put up an IV line. Today is no exception as Candice, RN on the brave efforts of competent medical professionals, Judy duty, tries to draw blood from Judy’s arm veins. The nurse drifts deeper into the coma. Two days later, the consulting tries three unsuccessful attempts on the right arm and two neurosurgeon declares her brain dead. The autopsy on the left arm. Finally she successfully draws blood from findings report a massive pulmonary embolism as the the right foot. But the next day, the leg starts swelling. A cause of death. physician is called in, but while waiting for some hours for Although not recommended for routine venipuncture, the busy physician, Judy starts to have difficulty breathing the veins of the lower extremity are quite permissible. and slowly gravitates into a coma. When the physician This particular patient, however, had a history of
142 Venipuncture Course and Kit | COMPLICATIONS
repeated episodes of DVTs (deep venous thrombosis). Important to remember: This venipuncture was complicated by a phlebitis and • Always take a short medical history (or check the thrombus formation, triggering the cascade of events, medical history in the patient’s records) before leading to the fatal outcome. performing venipuncture or setting up an IV line. *STAT is short for statim, the Latin word for immediately. • Use the veins of the foot as a last resort, especially if any contraindications are noted. VASOVAGAL RESPONSE AND VASOVAGAL SYNCOPE
A vasovagal attack is a disorder that causes a rapid drop • Not drive home (and not drive at all) on the day blood in blood pressure and heart rate, resulting in decreased is drawn. blood flow to the brain, followed by fainting. It is most often evoked by emotional stress associated with fear or The emergency treatment to simply restore the patient’s pain. The clinician will notice the following signs: pallor, blood flow to the brain is to reposition the body. Use one of nausea, sweating, bradycardia, a rapid fall in arterial blood the following positions: pressure, and eventually, loss of consciousness. Symptoms include lightheadedness, nausea, the feeling of being extremely hot (accompanied by sweating), ringing in the ears (tinnitus), an uncomfortable feeling in the heart, and incoherent thoughts. It is not too uncommon to see a vasovagal attack or syncope (fainting) during or following venipuncture.
Clinicians should: • Anticipate the possibility of a vasovagal syncope and prevent injury to the patient by assisting and supporting the patient. • Reassure the patient frequently. • Not show off their equipment in front of the patient, especially sharp needles. • Have calming music in the background. • Have the patient comfortably seated, or if prone to vasovagal attacks, in the supine position. • Have simple monitor equipment available: a blood pressure meter and a basic pulse Oximeter. When reporting for venipuncture or donating blood, Figure 45: Various patient positions patients should: • Have a light meal before the procedure (unless they have specific instructions regarding fasting). • Sit down comfortably for a couple of minutes after the procedure (under supervision) before leaving. • Have a light refreshment after the procedure, especially after donating blood. • Leave with a responsible person, instructed to support the patient and what to do if syncope occurs. • Consider asking for a wheelchair instead of walking to their transport.
143 Venipuncture Course and Kit | COMPLICATIONS
ALLERGIC RESPONSES
A number of different allergic reactions may be SKIN RASH/ encountered during routine venipuncture procedures, urticaria following the infusion of medication or including the following: administration of a local anesthetic • Stop the infusion immediately and inform the CONTACT DERMATITIS medical professional in charge of the patient. This usually manifests as an increased redness of the • Treatment with IV or oral antihistamines and/or skin where a specific strapping was placed. cortisone will usually suffice as definitive treatment. • Remove strapping • Inform the patient regarding the specific • Apply a suitable cortisone-containing ointment medication so that they can avoid it and inform and give instructions on further use. medical professionals accordingly in the future. • Inform the patient regarding the specific brand • The patient should arrange for a Medical Alert of strapping. Ask them to avoid it in future and to bracelet engraved with relevant information. inform medical professionals when necessary.
ANAPHYLAXIS (ANAPHYLACTIC SHOCK) Anaphylaxis is a life threatening allergic reaction that is rapid in onset.
Figure 46: Anaphylactic shock diagram
144 Venipuncture Course and Kit | COMPLICATIONS
CAUSES Any medication may potentially trigger anaphylaxis. • If not qualified to treat the emergency—call for Other causes include severe latex allergy and food assistance! allergens. • Administration of epinephrine (adrenalin) is the first line of treatment, with antihistamines and steroids often used as an adjunctive treatment. Nebulized DIAGNOSIS salbutamol may be effective for bronchospasm that Anaphylaxis is diagnosed based on clinical criteria. does not resolve with epinephrine. • When two or more of the following signs occurs • It is recommended that an epinephrine solution be within minutes or hours of exposure to an allergen, given intramuscularly (e.g., the mid-anterolateral there is a high likelihood of anaphylaxis: thigh) as soon as the diagnosis is suspected. The a. Involvement of the skin or mucosal tissue injection may be repeated every 5 to 15 minutes if (an itchy rash and/or urticaria) there is insufficient response. You may consider an IV b. Respiratory difficulty as an alternative route, but ensure that you administer c. Low blood pressure 1/10 diluted epinephrine in sterile water SLOWLY. d. Gastrointestinal symptoms • Position the patient in the supine or Trendelenburg position. TREATMENT • Apply an oxygen mask or nasal cannula and supplement oxygen intake. Anaphylaxis is a medical emergency that may require • Monitor the vital signs, especially blood pressure and resuscitation measures such as airway management, oxygen saturation. supplemental oxygen, large volumes of intravenous • A 24-hour period of in-hospital observation is fluids, and close monitoring. recommended for patients once they have recovered due to the possibility of biphasic anaphylaxis.
NEEDLE PENETRATION THROUGH THE VEIN
Withdraw the needle somewhat, re-angulate the needle for the lab), move to a more distal site from the previous a bit more superficially, and enter the vein lumen. If attempt (not proximal), or move to another extremity. If unsuccessful, apply pressure and move to another site. As putting up an IV line, change to a more proximal site from a general rule, if performing phlebotomy (drawing blood the previous attempt (not distally).
HEMATOMA
If a hematoma forms under the skin adjacent to the Puncture the uppermost wall of the vein only. puncture site release the tourniquet immediately and Remove the tourniquet before removing the needle. apply firm pressure while withdrawing the needle. Move Ensure that the needle fully penetrates the upper most to another site. Older patients are prone towards forming wall of the vein as partial penetration will cause blood hematomas. leaking into the surrounding soft tissue. Considerations for preventing a hematoma: Apply pressure to the venipuncture site following Use the major superficial veins. phlebotomy.
145 Venipuncture Course and Kit | COMPLICATIONS
ECCHYMOSIS
Even in the best of hands mild bruising may occur occasionally, especially so in very fair skinned patients and older patients.
Management: • For mild bruising, a simple explanation to the patient will usually be sufficient. • For more severe bruising, apply a cold pack with pressure to help limit bruising. • A physical therapist can apply ultrasound to help break down a blood clot and diffuse ecchymosis.
Figure 47: Extensive ecchymosis in an elderly patient
NEEDLE/ CANNULA IN THE TISSUE
If performing phlebotomy and you land up in the tissue surrounding the vein, you have one of the following choices: • Go a bit deeper, if you are right above the vein. • Go laterally towards the vein, if you are on the side of a vein. • If you saw a flashback of blood and it disappears, you may have to withdraw the needle a bit as you may have gone right through the vein. • If no luck, move to another site or ask a more experienced colleague to assist.
TISSUE INFILTRATION (EXTRAVASATION)
If the needle lands up in the tissue during IV infusion Most infiltrations have only minor sequelae. However, of fluid/medication, the IV fluid will infiltrate into the certain drugs infused can cause serious complications surrounding tissue. The tissue will swell around the IV such as compartment syndrome, permanent nerve needle, becoming edematous and cool to the touch. damage, necrosis, soft tissue loss, scarring around The patient will complain about pain and discomfort. nerves, joints, and tendons leading to contractures and • Stop the infusion immediately! deformity. Severe tissue injuries may require extensive • Start the IV in a new spot on the patient’s body at surgical debridement, tissue grafting, surgical release of the correct rate for the given dosage. contractures to restore function, or even an amputation. • Observe the infiltrated area for 24 hours for possible complications. Treat these complications empirically.
146 Venipuncture Course and Kit | COMPLICATIONS
CANNULA/ CATHETER BLOCKED (OCCLUDED)
• Use appropriately fibrinolytic (thrombolytic) agents, (e.g., Cathflo) to dissolve small clots as per physician’s orders. • Adhere to the appropriate flushing procedure for any needleless connector system. • Flush the catheter immediately after a bolus of medication has been infused.
Inspect the tissue surrounding the IV site. Did the cannula slip out and is it infiltrating the tissue?
Figure 48: A blocked peripheral IV cannula Check the IV bag and line. Is the IV bag empty? Inspect the tubing and cannula for kinks. Prevention is better than cure! • Keep the IV fluid running; don’t close the infusion for If you can’t find a remediable reason, remove the IV long periods of time. Don’t let it run dry. cannula and place the IV line at a new site. • The IV fluid bag must be at least 1 meter (3 feet) above the patient for gravity to overcome the venous Warning: Do not force flush with saline! You may just pressure and guarantee a positive flow of IV fluid. cause a small embolus by doing this! Don’t allow the IV fluid bag to be at the level of the More information: [CLICK HERE] patient, or worse, lower than the patient, for any significant time. • Use appropriately anticoagulant preparations to prevent blood clots from forming as per physician’s orders.
CATHETER-RELATED INFECTIONS
Central venous catheter-related infections are common infection the CDC advises in their guideline that the and an estimated 80,000 central venous catheter catheter needs to be replaced every 96 hours (4 days). related bloodstream infections occur in intensive care See [SUPERFICIAL PHLEBITIS] for more information. units each year. Students should study the following CDC publication for detailed information including prevention guidelines.¹² [CLICK HERE]
Peripheral venous catheter infections are treated empirically – remove the catheter, elevate the limb and treat with local and/or systemic anti-inflammatory medication. Local or systemic antibiotics therapy is rarely indicated. Because of the risk of insertion-site
147 Venipuncture Course and Kit | COMPLICATIONS
INTRA-ARTERIAL POSITION OF NEEDLE/ CANNULA DURING PHLEBOTOMY
If you are drawing blood and you suspect an intra- • If you are more than halfway finished with the task arterial position: and then suspect that you are in an artery, complete • If you haven’t started withdrawing blood, remove the task, then remove the needle/cannula and the needle/cannula, apply pressure for at least five apply pressure for at least 5 minutes (or until the minutes, then move to a positively identified vein bleeding stops). and proceed with the phlebotomy procedure.
INADVERTENT INTRA-ARTERIAL INJECTION OF MEDICATION—INSTEAD OF INTRAVENOUS INJECTION
Some drugs can cause severe endothelial damage to pain in the extremity distal to the injection site, the arteries, but worse damage to the capillary bed stop immediately and presume an intra-arterial of the tissues within the arterial blood supply area. injection. Observe the hand/foot for any changes This can cause tissue damage or necrosis, resulting in in color. disfigurement or loss of function. In severe cases, it • If some medication has been injected, keep the can require the amputation of a hand, foot, or other arterial access; it may be required by the medical extremity. professional (experienced vascular surgeon or anesthesiologist) treating the complication. This complication is much better avoided than treated • Get urgent assistance from an experienced vascular afterwards. surgeon or anesthesiologist. • If you suspect an accidental intra-arterial injection • Treatment may require a combination of intra- and if you haven’t injected any medication, arterial flushing, local anesthetics, cortisone, and remove the needle/cannula, apply pressure for five sympathetic blocks. Later surgery may be necessary minutes and move to positively identified vein for if the following ensue: compartment syndrome, venipuncture. tissue necrosis, or scarring around nerves, joints, • If you start injecting and the patient experiences and tendons.
148 Venipuncture Course and Kit | COMPLICATIONS
CLINICAL DIFFERENTIATION BETWEEN ARTERIES AND VEINS
• Position: Veins are usually more superficial while intravenous fluid resists flowing into the blood arteries anatomically run a deeper course. Keep in vessel. You may also see the drop of fluid in the drip mind that there are exceptions; arteries may run a chamber growing bigger and smaller in a pulsatile superficial course in areas or as an anomaly. manner. (Attaching a ‘drip’ to the needle/line can • Color: Veins often have a bluish hue, especially assist one in differentiating between an intravenous noticeable in fair skinned people. and an intra-arterial position). • On palpation: Arteries pulsate (throb/thump). • On removal of a needle: Arteries are more Arterial walls are firmer and thicker than those of prone to bleed profusely due to the high pressure veins. (compared to veins). Therefore, after removing a • On puncturing: The pressure in arteries is much needle, always apply firm pressure on the spot for at higher than the pressure in veins, thus arterial least five minutes. Inspect the area, if it is bleeding, blood may squirt spontaneously into the syringe repeat the pressure. (but not always). • During an ultrasound examination: While exerting light pressure with the examination probe, WARNINGS: you will notice pulsating movement with arteries, NEVER inject any medication or fluids into a blood vessel while veins will simply collapse with mild pressure. unless you are 100% sure you are inside a VEIN! • On setting up an IV fluid bag/drip set: You will When setting up an IV line and if you suspect that the notice either a retrograde flow of bright red blood needle has entered an artery – stop the procedure, remove into the plastic tubing or you will notice that the the needle, and apply firm pressure as instructed above.
SUPERFICIAL PHLEBITIS
Superficial phlebitis, also called superficial throm ramify to smaller feeder veins as it progresses. On palpation, bophlebitis, is a condition where a vein close to the surface the vein will feel hard and warm with tenderness. The area of the body becomes tender, swollen, red, and develops will begin to burn and throb if acute inflammation ensues. a blood clot. This is differentiated from thrombophlebitis The patient may become febrile. of the deep veins of a limb (usually a lower limb), which The initial treatment for phlebitis, especially if associated is called deep vein thrombosis or DVT. with pain, is to stop the infusion and remove the peripheral Sometimes phlebitis may occur at the site where venous cannula (PVC). a peripheral intravenous (IV) line was started. The Elevate the affected limb and apply an anti-inflammatory surrounding area may be sore and tender along the vein. cream or gel to the area. In addition, anti-inflammatory Thrombophlebitis may be caused by damage to a vein’s medication and analgesics can be used when necessary. wall as a result of injecting substances that cause irritation or introduce bacteria into the vein from a contaminated needle/cannula as well as the prolonged insertion of a cannula for intravenous infusion. It usually starts with tenderness and redness along the superficial veins on the skin, showing as a red line as the inflammation follows the path of the superficial vein. It may
149 Venipuncture Course and Kit | COMPLICATIONS
SEPTIC THROMBUS
If a thrombus becomes septic, or invaded by pathogenic bacteria, the patient will become febrile with all the local and systemic signs and symptoms of infection (raised white blood cell count, etc.). In severe cases, septic shock may ensue. Treat empirically with relevant antibiotic therapy and supportive treatment. Blood cultures may be required.
DEEP VEIN THROMBOSIS (DVT)
It is not recommended to use veins, for either region to relieve pain. phlebotomy or setting up an IV line, in the lower • Compression stockings. Physicians frequently extremities of adults due to possible complications that recommend compression stockings to reduce DVT include, but are not limited to, phlebitis and/or DVTs – symptoms and to improve the venous return of especially in high risk individuals: blood to the heart. • Patients with a history of thrombosis • Anticoagulation medication (blood-thinning drugs). • Patients who will be immobile for an extended The anticoagulant drugs, heparin and warfarin, are period of time (e.g., orthopedic traction patients) used primarily to prevent the formation of new clots • The elderly and reduce the chance of pulmonary embolism. • Diabetics • Thrombolytic agents are used to help dissolve • People with blood disorders existing clots and reopen clogged veins. The most • Women who take oral contraceptives (birth control commonly used thrombolytic agents are urokinase pills) and streptokinase. • People who have just undergone major surgeries or • Surgery. Surgery is considered a last resort. Removal have just suffered a bone fracture of the thrombus (venous thrombectomy) or the insertion of a filter device into the inferior vena cava Signs and symptoms of deep vein thrombosis to trap any blood clots headed towards the lungs include: are procedures that may be considered. • Tenderness in the calf • Leg tenderness • Pain in the leg • Swelling of the leg • A warmer than normal leg • Redness in the leg • Bluish skin discoloration • Discomfort when the foot is flexed
Treatment of DVT includes: • Bed rest. Individuals with DVT usually require bed rest until symptoms are relieved. The leg should be elevated to a position above the heart to reduce swelling. Moist heat may be applied to the affected
150 Venipuncture Course and Kit | COMPLICATIONS
EMBOLISM
Lung embolism from a dislodged deep vein thrombus Definitive diagnosis is usually by a D-dimer blood test, is a life-threatening condition requiring treatment in an pulmonary artery angiography, or CT scan. intensive care environment by suitable qualified and Immediate full anticoagulation is mandatory for all experienced specialists in this field. patients suspected of having pulmonary embolism. Clinical signs and symptoms for pulmonary embolism are nonspecific and may include unexplained difficulty in breathing, fast respiratory rate, and chest pain.
AIR EMBOLISM
An air embolism is caused by air bubbles in the vascular negative pressure within the thorax system. Venous air embolism can result from the • Hypovolemia, which reduces central venous introduction of air through intravenous lines, especially pressure central lines, and generally must be substantial to block • Upright positioning of the patient, which reduces pulmonary blood flow and cause symptoms. central venous pressure Small amounts of air often get into the blood circulation accidentally during surgery and other medical Treatment: procedures, but most of these air emboli enter the The primary aim is to identify the reason for air entry veins and are stopped at the lungs. Thus, a venous air and prevent further air embolization. embolism that shows any symptoms is very rare. Supportive care includes the use of mechanical The risk of catheter-related venous air embolism is ventilation, vasopressors, and volume restoration. increased by a number of factors: • Breakage or detachment of catheter connections The following may be of value: • Failure to occlude the needle hub/catheter during • High-flow supplemental oxygen insertion or removal • Hyperbaric therapy • Dysfunction of self-sealing valves in plastic • Placing the patient in the Trendelenburg position introducer sheaths and other positional maneuvers may help in • Presence of a persistent catheter tract following the dislodging the air embolus removal of a central venous catheter • Closed-chest cardiac massage • Deep inspiration (inhalation) during insertion • Aspiration of air from the venous circulation or removal, which increases the magnitude of With air embolism, prevention is better than cure!
151 Venipuncture Course and Kit | COMPLICATIONS
NEEDLESTICK INJURIES
Needlestick injuries may involve the patient or the Also read: WHO Publication on Sharps injuries: medical professional. Assessing the Burden of Disease From Sharps Injuries to There are very specific legalities to be aware of, ways to Health-Care Workers at National and Local Levels. minimize you and your patient’s risk factors and steps to [Click Here] take if such an incident should occur. Kindly familiarize yourself with the most current In conclusion, a number of comments from the author: information on the subject. • Take great care to avoid this type of injury. Study the legalities: (USA) [OSHA Occupational • Use appropriate barrier techniques. Safety & Health Administration] • Use safety items and equipment at all times, if at all Medical professionals outside of the USA, contact your possible. country’s Health and Safety authorities for information • Accurately follow the guidelines of your unit or regarding legalities and other specifics. institution. For sensible guidelines and more information see: • If an accident occurs, immediately contact the [Click Here] hospital’s Infection Control Officer and follow the appropriate directives as soon as possible. Initiate the correct antiretroviral medication if applicable.
VIDEO
152 Venipuncture Course and Kit | COMPLICATIONS
LOCAL TISSUE DAMAGE
The skin surrounding the venipuncture site may (rarely) occur. break down, usually due to infection. • Recognize the signs and symptoms of nicking a nerve Applying a local antiseptic or antibiotic ointment may be and take appropriate action. all that is required. • If your patient complains of an electric shock sensation radiating down into the hand while the needle is being inserted, remove the needle immediately to NERVE DAMAGE minimize nerve injury. The two nerves with the highest risk of being injured during a venipuncture procedure are the radial and Danger areas: median nerves. Permanent nerve damage is a difficult • The distal part of the radial nerve just above the complication for the patient to come to grips with and thumb (radial nerve) carries a high medicolegal risk. • The inner/medial cubital fossa (median nerve) • The inner aspect of the wrist above the palm of the hand (median nerve)
Although it is considered safe to use the cephalic vein in the lateral aspect of the antecubital fossa area, risk of damage has occasionally been described to the lateral antebrachial cutaneous nerve of the arm following phlebotomy.
Figure 49: Diagram of the main nerves of the arm
Recommendations to minimize the risk of nerve injury: • Acceptable sites are the median cubital area and the dorsum of the hand. Identify the most prominent of the acceptable veins: median cubital, cephalic, and basilic. • If possible, avoid the basilic vein. Rather use the cephalic vein or median cubital vein as the basilic vein also runs near the brachial artery. • Avoid high-risk nerve injury areas. The three-inch area above the thumb and the three-inch area on the inner aspect of the wrist should always be avoided. Figure 50: Diagram of the main nerves of the arm • Avoid wrist veins. • Do not probe excessively. Arterial cannulation • Do not make an excessive number of attempts (two Brachial artery cannulation is associated with an increased or, at most, three attempts). risk of median nerve injury. • Use a good clinical technique • Stabilize the vein before inserting the needle • Insert the needle at an approximate angle of 15°-30° • Avoid hematomas and treat them promptly if they
153
6 Venipuncture Course and Kit | EVALUATION MODULE
ASSESSMENT MODULE
(Available online) [CLICK HERE]
The evaluation module consists of two sections: • Section 1. Short multiple choice questions (20 marks) • Section2. A selection of one practical project performed by the student and assessed by a designated evaluator (20 marks) CONGRATULATIONS AND FINAL REMINDERS
Congratulations – you have completed The Apprentice Dr. Anton Scheepers and the staff at the Apprentice Doctor® Venipuncture Course! Corporation wish you all of the best with your studies and May we remind you carefully close the sharps waste trust that we may have contributed in a small way to your container and to hand it to a medical professional at a success in practicing venipuncture! hospital, a medical clinic, or to your family doctor for Let us know if you liked the course, and in you didn’t, proper sharps waste disposal. inform us as well. Warning: [CLICK HERE] to access The Apprentice Doctor® Never discard the sharps into a regular waste bin or bag! Venipuncture Course and Kit evaluation questionnaire. Thank you for your time! EPILOGUE
In essence, the simple technique of venipuncture is a minor surgical procedure and all the rules common to surgery apply. On occasion, simple procedures may become complicated due to various reasons. The most serious complication following a simple venipuncture procedure is death—usually as a complication of a complication. Be alert and minimize the risks to your patients for developing complications and your risk regarding medicolegal consequences.
REFERENCES
1. Mario Saia,et al. Needlestick Injuries: Incidence and Cost in the United States, United Kingdom, Germany, France, Italy, and Spain. Biomedicine International 2010; 1: 41-49. 2. “Preventing Needle-stick Injuries in Health Care Settings.” CDC Publication 1999. 3. “Sharps Injuries: Assessing the burden of disease from sharps injuries to health care workers at national and local levels.” WHO Publication 2005. 4. “WHO Guidelines on Hand Hygiene in Health Care.” WHO Publication 2009. 5. Kouji Yamada et al. “Cubital Fossa Venipuncture Sites Based on Anatomical Variations and Relationships of Cutaneous Veins and Nerves.” Clinical Anatomy. 2008 21: 307–313. 6. Joan Barenfanger et al. Comparison of Chlorhexidine and Tincture of Iodine for Skin Antisepsis in Preparation for Blood Sample Collection. J Clin Microbiol. 2004 May; 42(5): 2216–2217.
156 Venipuncture Course and Kit | EVALUATION MODULE
7. “WHO guidelines on drawing blood: best practices in phlebotomy.” WHO Publication 2010. 8. Möller JC, Reiss I, Schaible T. Vascular access in neonates and infants—indications, routes, techniques and devices, complications. Intensive Care World. 1995 Jun; 12(2):48-53 9. Laura L et al. Difficult Venous Access in Children: Taking Control. JOURNAL OF EMERGENCY NURSING September 2009; 35:5 10. Beal MW, Hughes D. Vascular access: Theory and techniques in the small animal emergency patient. Clin Tech Small Anim Pract. 2000 May; 15(2): 101-9. 11. Rob White. Vascular access techniques in the dog and cat. In Practice 2002; 24: 174-192. 12. “Guidelines for the Prevention of Intravascular Catheter-Related Infections.” CDC Publication 2011.
CREDITS
Facilities for videos and photography: Patient models: Rhesa Van Der Merwe: Hospital Manager, Union Anton Scheepers and Clinton Hospitals Elna Van Der Hever Hans Van De Zee: Specialist Veterinary Surgeon, Jacquiline Sumerville Valley Farm Animal Hospital in Pretoria Régardt Scheepers Our gratitude to all the skillful veterinary practitioners and Ruan Klut staff at Valley Farm Animal Hospital. Stéfan Scheepers [CLICK HERE] to meet the team. Production: Final proof reading: Open Window School of Visual Communication Hub American Proofreading Company, Arthur Twigge (Coordinator) Peggy Wendel, Sr. Copy Editor, Chase Jordan Coetzee (Assistant videographer) www.ameriproof.com Dagan Read (Software development and final compiling) Graphic design: Natalie Scheepers (Photography - Dip Visual Maria Andor Communication) Package, DVD, EBook, Brochure, and various other Stephan Calitz (Games and other interactive graphic design aspects. components) Portfolio site: Wihann Strauss (Videographer and editing of http://www.behance.net/marcsiandor videos)
Illustrations: Professional RNs: Kevin Berry: Medical and General Illustrator Adelle Du Toit, RPN Drawing Conclusions: Annette Klut, RPN www.drawingconcusions.co.za Lili Van Der Zee, RPN
Linguistic care: Voiceovers: Eizabeth Scheepers Female: Jacqui Summerville Suehyla El-Attar Natalie Scheepers Voice123.com Male: Model: Craig Gildner Gizela Marais Voice123.com Box/package cover and DVD Stories (narration): Email: [email protected] Dave Pettitt Voice123.com
157 Venipuncture Course and Kit | EVALUATION MODULE
OTHER PRODUCTS BY THE APPRENTICE CORPORATION
After completing The Apprentice Doctor Venipuncture course, would you like to be able to confidently tie surgical knots and suture wounds?
THE APPRENTICE DOCTOR® HOW TO STITCH UP WOUNDS SUTURING COURSE & KIT
• Basic principles of wound care, hygiene and asepsis This training material is recommended for all healthcare • How to tie a surgeon’s knot and various other knots professionals whether prospective, in training or qualified: • How to suture wounds correctly and avoid common Medical students – Pre-medical students – Paramedics and mistakes EMT students – Dental students – Veterinary students – • Why eversion is important in suturing skin lacerations Nursing students – Surgery Interns/Registrars – Advanced • How to use the tools and instruments medical First Aid practitioners – Medics in the military – Practicing professionals use for suturing Healthcare professionals who would like to improve or refresh their suturing technique – Individuals with a keen The theory is clearly explained and well-illustrated. Suturing interest in the practical aspects of medicine, and High and knot tying skills are acquired as students perform School students interested in a career in medicine over 20 fun practical projects, and what’s more – this Order your kit online – today! [CLICK HERE] 18-piece suture kit contains all the necessary real medical instruments and items are included: imitation skin, needle holder, scissors, suture material, suture needles.
158 Venipuncture Course and Kit | EVALUATION MODULE
ATTENTION ALL FUTURE DOCTORS IN HIGH SCHOOL! Take your first Bold Step towards Reaching your Dream of Becoming a Great Medical Professional.
THE ACCREDITED APPRENTICE DOCTOR® HOW TO EXAMINE PATIENTS FOUNDATION COURSE AND KIT
• Get insight into the methods doctors use to make an “This is the most exciting introduction to the medical accurate diagnosis. profession that I have ever seen—I strongly recommend • Understand the human body from a doctor’s it to anyone who is considering a medical career.” – Dr. perspective. Lawrize Stofberg, Obs & Gynae, UK • Use real medical instruments and items (included in the kit) to practice what you learn on the CD-ROM. “This course is phenomenal! An excellent introduction to • Listen to numerous bodily sound samples and learn the exciting world of medicine! I highly recommend it for how to identify abnormalities like heart murmurs. anybody who is serious about making a well-informed • Increase your dedication and love for medical science career choice!” – Dr. Amanda Laubscher, Seattle, USA as well as the human body. • Make sure, beyond any doubt, that you are suited to “Thank you very much for the package received. I have become a doctor. thoroughly looked at it with a colleague of mine and find it • Discover which specialty would best suit you after you excellent!” – Prof. Detlef R. Prozesky, BSc MBChB MCommH become a doctor. PhD, Johannesburg, South Africa
What are people saying about The Apprentice Doctor® Order your kit online – today! How to Examine Patients Foundation Course and Kit? [CLICK HERE]
“... It took me 12 days to work my way through the course for To order AUTOSAFE®-REFLEX® SAFETY NEEDLES AND the first time. I am working my way through the material a ASSOCIATED DEVICES [CLICK HERE]! second time now. Thank you for this course! I simply couldn’t stop in the evenings and worked most nights until early morning hours. I am completely sold out on becoming a doctor.” – Simon Garrison, (16) Tonawanda NY, USA
159 Venipuncture Course and Kit | EVALUATION MODULE
GLOSSARY
KINDLY NOTE: The Apprentice Doctor® Venipuncture Course glossary does not include most of the common anatomical nomenclature (terminology). Students are referred to their anatomy resources for definitions of those terms.
ABG Arterial Blood Gas. typically causes a number of symptoms including an itchy ABO blood group The major human blood type system rash, throat swelling, and low blood pressure. which depends on the presence or absence of antigens A Anastomosis Refers to connections between tubular and B. structures such as blood vessels or between loops of Absorb To suck up or take in, as through pores. intestine. Acid-citrate-dextrose (ACD) An anticoagulant containing Anatomy The branch of science that studies the physical citric acid, sodium citrate, and dextrose. structure of animals, plants, and other organisms. Acquired immunodeficiency syndrome (AIDS) A disease Anemia The condition of having less than the normal caused by an infection of the human immunodeficiency number of red blood cells or hemoglobin in the blood. virus (HIV-1, HIV-2). Anesthetic A drug that causes unconsciousness or a loss Acute Of short duration. Rapid and abbreviated in onset in of local or general sensation. reference to a disease process. Anomalous Deviating from the norm or from what people Adsorb To attract and retain other material on the surface. expect. Adult Respiratory Distress Syndrome (ARDS) A life Antecubital fossa See cubital fossa. threatening inflammatory reaction of the lungs in response Antecubital vein See cubital vein. to various forms of injuries or acute infection. Anterior Towards the front of the body. Aerobic Referring to organisms requiring an oxygenated Antibacterial agent A synthetic preparation or drug that environment to grow and live. destroys or inhibits the growth of bacteria. It is used to treat Agglutination The process of cells clumping together, bacterial infections in patients. such as red blood cells or bacteria, with the formation of Antibiotic Antibacterial substances used to treat infection. clumps of cells. Antibody A molecule produced by immune cells with an AHF Antihemophilic Factor. See Factor VIII. affinity for a specific antigen. AIDS Acquired Immune Deficiency Syndrome, caused by Anticoagulant A natural or synthetic agent that prevents human immunodeficiency virus (HIV). the formation of blood clots. Air Embolism (Emboli) An air embolism is a potentially Antifibrinolytics Used to inhibit fibrinolysis (the process of fatal pathological condition caused by air bubble/s in a dissolving a blood clot). blood vessel and/or one or more of the heart chambers. Antigen A substance that is capable of producing a Albumin Main protein in human blood. specific immune response with a specific antibody. Allen’s test (Modified Allen’s test) Allen’s test is used to Antihemophilic factor Coagulation (clotting) factor test blood supply to the hand, specifically, the patency of number VIII. the radial and ulnar arteries. Antihistamine A drug that antagonizes the action of Allergen A substance capable of producing a histamine. It is used to treat allergies. hypersensitivity reaction (allergy). Anti-platelet agents Medications that, like aspirin, reduce Allergy An unusual sensitivity to a normally harmless the tendency of platelets in the blood to clump and clot. substance that provokes a strong reaction in a person’s Antiseptic A substance that discourages the growth of body. microorganisms. Ambulatory Mobile, walking around. Antiseptic rub An agent that reduces or prevents Anaerobic Organisms that can grow, live, and multiply in infection, especially by eliminating or reducing the growth the absence of oxygen. of microorganisms that cause disease. Anaphylaxis (Anaphylactic Shock) A serious allergic reaction that is rapid in onset and may cause death. It
160 Venipuncture Course and Kit | EVALUATION MODULE
Apheresis A technique in which blood products (e.g., minimize the chances of cross infection. platelets) are separated from a donor, the desired elements Basal state Early in the morning, approximately 12 hours collected, and the rest returned to the donor. after the last ingestion of food or other nutrition. Arterial catheterization The placement of a thin, hollow Basilic vein Large vein on the inner side of the arm. tube into the lumen of an artery to measure real time Basophil A subtype of leukocyte with a granular cytoplasm arterial pressure. The catheter can also be used to get staining with basophilic dyes. repeated blood samples to frequently measure the levels Betadine™ The trade name of a popular topical antiseptic of oxygen and/or carbon dioxide in the bloodstream. agent that contains iodine; povidone-iodine. Arterial line Catheter inserted into an artery. It may be Bicarbonate (HCO3) Bicarbonate is alkaline, and a vital used for withdrawing blood, measuring arterial pressure, component of the human body’s pH buffering system and rarely IV Infusion under pressure. (maintaining acid-base homeostasis). Arterial Referring to a blood vessel that is part of the Bleeding time A test that measures the time it takes for system carrying blood under pressure from the heart to small blood vessels to close off and stop bleeding. the rest of the body. Blind stick Performing a venipuncture with no apparently Arteriole A small branch of an artery that leads to a visible or palpable vein. capillary. Blood The fluid in the body that contains red cells, white Arteriovenous fistula The surgical joining of an artery cells, platelets, proteins, plasma, and other elements. and a vein under the skin for the purpose of hemodialysis. Blood bank A blood bank is a cache of blood or blood Artery Blood vessel carrying blood from the heart to the components, gathered through blood donation, then cells of the body. stored and preserved for later use in blood transfusion. Ascites An accumulation of serous fluid in the peritoneal Blood cells Cells normally found in blood (red blood cells cavity, causing abdominal swelling. or erythrocytes, white blood cells or leukocytes, and blood Aseptic Pertaining to protocols used by medical platelets or thrombocytes). professionals to prevent microbial contamination. Blood clot The conversion of blood from a liquid form to Aseptic technique Protocols used by medical professionals solid through the process of coagulation. to prevent microbial contamination. Blood clotting factor A number of different factors, which Aseptically Preventing infection from pathogenic work together when activated to form a blood clot. microorganisms. Blood count The determination of the proper number of Aspirate (aspiration) Exerting negative pressure with red blood cells, white blood cells, and platelets present in the plunger of a syringe before injecting to ensure the patients’ blood. an intravascular position of the needle or to avoid an Blood culture A test which involves the incubation of a inadvertent intravascular injection. Aspiration is the act of blood specimen overnight to determine if bacteria are removing liquid or gas by suctioning (e.g., blood or pus present. from a body cavity). Blood culture A microbiological culture of blood used to Auscultation Gathering information about the patient by detect infections that spread through the bloodstream. listening to bodily sounds, usually with a stethoscope. Blood donation Donated blood used for transfusions Autohemolysis Hemolysis of red blood cells of a person or to be made into specialized blood components or by his own serum. medications by a process called fractionation. Autopsy The medical examination of a dead body in order Blood donor A person who regularly donates blood. to establish the cause and circumstances of death. Blood film A sample of blood that is applied to a Autosafe®-Reflex® The branded commercial name of microscope slide and then studied under the microscope. safety needles designed to prevent or minimize needle Blood groups A specific antigen manifesting on specific stick injuries. persons’ red blood cell surfaces – for example A, B, or Rh Backflow Refers to the reflux of blood into the catheter antigens. lumen upon disconnection of a cannula or needle. Bloodletting The act of letting blood or bleeding, by Bacteremia The presence of viable bacteria circulating in opening a vein or artery, or by cupping or leeches, the bloodstream. Diagnosed with blood cultures. especially as applied to venesection. Barrier techniques Methods of using a variety of items Blood plasma The pale yellow or gray-yellow, protein- intended to protect the medical professional, as well as containing fluid portion of the blood in which blood cells the patient from transferring infection to either, and to and platelets are normally suspended.
161 Venipuncture Course and Kit | EVALUATION MODULE
Blood serum Blood serum is whole blood minus both the bound with carbon dioxide in the red blood cells. cells and the clotting factors. Carbon Dioxide (CO2) One of the mediators of the local Blood smear A sample of blood is applied to a microscope autoregulation of blood supply. When levels are high, slide and then studied under the microscope. capillaries expand to allow a greater blood flow to that Blood Stream Infection (BSI) Blood infection often tissue. believed to be introduced via an IV catheter. Carboxyhemoglobin Hemoglobin that has been bound Blood transfer device A safety device designed to transfer with carbon monoxide. blood from one container into another. Catheter Hollow tube of variable size used for intravenous, Blood transfusion The process of receiving blood or blood arterial, as well as body cavity/organ (e.g., bladder) access. products intravenously into the circulation. Transfusions Catheter introducer Needle device that is used to insert a are used in a variety of medical conditions to replace lost catheter into the artery or vein. The catheter slides off the blood or blood components. introducer needle, which is then disposed of. Blood types See blood groups. Catheter Malposition/Migration Movement of a Blood vessel All the vessels lined with endothelium catheter which can cause trauma within the vein or artery through which blood circulates. and interrupt IV therapy. Bloodborne pathogen Microorganism present in blood Catheter Related Sepsis (CRS) Blood infection believed that can cause disease. to be introduced through an IV catheter. Bloodborne pathogens Any disease-producing Cathflo Activase (Alteplase) A medication used for the microorganisms that are spread through direct contact restoration of function to central venous access devices with contaminated blood. (CVADs) as assessed by the ability to withdraw blood. Blunt cannula A non-sharp plastic or metal needle. Also CBC Complete Blood Count. refers to a needleless system where the blunt cannula CDC (Centers for Disease Control and Prevention) A accesses a pre-slit injection port. United States federal agency that protects public health Bodily secretions Bodily fluids produced by exocrine and safety by providing information to enhance health glands such as the salivary and tear glands. decisions. CDC promotes health through partnerships Bolus Dosage of medication, usually administered within with state health departments and other organizations. a short period of time, given via IV push, either directly into Central Line See central venous line. a vein or through a port on the IV tubing. Central Venous Catheter (CVC) A small, flexible plastic Breast milk Milk produced by the breasts (or mammary tube inserted into a large vein in the neck, chest or groin glands) of mammal females (including human females) for where the tip of the catheter resides in the superior vena infant offspring. cava. Bruise A reddish-purple traumatic injury of the soft tissues, Central venous line Also called a central venous catheter which results in breakage of the local capillaries and or central venous access catheter. It is a catheter placed leakage of red blood cells. Also called a contusion. into a large vein in the neck, chest, or groin, which is used Bruit The term for the unusual sound that blood makes to administer medication or fluids, obtain blood tests, and when it rushes past a partial obstruction due to turbulent directly obtain cardiovascular measurements such as the flow in an artery. central venous pressure. Butterfly A small needle with two plastic wings attached Centrifuge A laboratory apparatus that separates mixed which are squeezed together to form a tab that is used to samples into homogenous component layers by spinning manipulate the needle. them at high speed. Butterfly needle See winged infusion set. Cephalic vein One of the larger arm veins that empty into Cannula A flexible tube for insertion into a duct, vein, or the axillary vein. cavity in order to drain away fluid or to administer drugs. Cerebrospinal fluid (CSF) Cerebrospinal fluid is a clear, Capillaries An extensive network of microscopic blood colorless bodily fluid produced in the choroid plexus of vessels that supply oxygen and nutrients to cells and the brain. remove CO2 and waste products. Chelate Combining with a metallic ion into a ring complex. Capillary Any one of the minute vessels that connect the Chemotherapy Treatment of disease with chemical arterioles and venules. Together, capillaries form a network reagents that have a specific and toxic effect upon the in nearly all parts of the body. disease-causing microorganism or cancer cells. Carbamate hemoglobin A hemoglobin compound
162 Venipuncture Course and Kit | EVALUATION MODULE
Chlorhexidine Antiseptic agent commonly used to in the coronary arteries. eliminate, reduce, or weaken microorganisms. Cortisone A steroid hormone secreted by the adrenal Circulation The movement of blood in a circuitous course. cortex. Synthetic cortisone medications used to treat Circulatory system The circulatory system is composed allergic responses and other medical conditions. of the heart, arteries, capillaries, and veins. Coumadin Trademark name for warfarin, an anticoagulant. Citrate Citrate chelates (binds) calcium ions, preventing Crystalloid solutions IV fluids containing varying blood clotting. It is, therefore an effective anticoagulant. concentrations of electrolytes. Citrate phosphate dextrose (CPD) A type of CT scan (CAT scan) Computed Tomography or Computed anticoagulant. Axial Tomography. A medical imaging procedure that Citrate phosphate dextrose adenine (CPDA-1) An utilizes computer-processed X-rays to produce “slices” of anticoagulant used for the preservation of whole blood specific areas of the body. and red cells. Cubital fossa (antecubital fossa) The cubital fossa (or Cleaning The removal of all visible foreign material from elbow pit) is the triangular area on the anterior view of objects using water, detergents, or mechanical means. the elbow of a human. It contains the radial and median Clot A semisolid mass of blood found outside of the nerves, the brachial artery, the tendon of the biceps circulatory system. muscle, as well as several more superficial veins. Coagulate The process of clot formation. Cubital vein The cephalic vein when it crosses the cubital Coagulation factors Group of plasma protein substances fossa. It communicates with the basilic vein in the cubital (Factor I thru XIII) contained in the plasma, which act fossa via the median cubital vein. together to bring about blood coagulation. Cutaneous Referring to the skin and its appendages. Collateral circulation Blood which is carried through Cytoplasm The cell contents excluding the nucleus with secondary channels after the primary vessels of a particular all the organelles suspended in it. area has been obstructed. D5W Dextrose 5% in water. Colloid solution IV fluid containing large proteins and D-dimer blood test D-dimer is a fibrin degradation molecules that tends to stay within the blood vessels. product (or FDP), a small protein fragment present in the Coma A coma is a state of unconsciousness lasting more blood after a blood clot is degraded by fibrinolysis. than six hours, in which a person cannot be awakened and Dead space (residual volume) The residual volume fails to respond normally to painful stimuli, light, or sound. withheld in an IV device. Refers to the amount of fluid The comatose person lacks a normal sleep-wake cycle and remaining in a connector, not delivered to the patient. does not initiate voluntary actions. Deep Vein Thrombosis (DVT) A thrombus that formed in Comatose Unconscious (in a coma). one of the deep veins, usually of the leg. Complete blood count (CBC) The number of red blood Defibrinated blood Blood that has been deprived of cells, white blood cells, and platelets present in a blood fibrin. sample (per cubic millimeter). Dehydration The lack of water in the body resulting from Complications A disease or problem that arises in addition inadequate intake of fluids or excessive loss of water and to the initial condition during or following the medical or electrolytes through sweating, vomiting, or diarrhea. surgical treatment of a patient. Dermatitis Inflammation of the skin from any cause, Conduction anesthesia A comprehensive term which resulting in a range of symptoms such as redness, swelling, encompasses a great variety of local and regional itching, or blistering. anesthetic techniques. Dextrose A carbohydrate (sugar) solution used in Contact dermatitis Inflammation of the skin due to intravenous drips. contact with an allergen, resulting in a range of symptoms Dialysis The process of cleansing the blood by passing it such as redness, swelling, itching, or blistering. through a special machine. Contagious May be transmitted from one person to Dialyzer The dialyzer is the heart of the hemodialysis another person. machine used to replace the functions of the kidneys in Contamination The introduction of pathogenic organisms kidney failure patients. into a wound. Differential A count of the different types of leukocytes Contusion A bruise or injury without a break in the skin. in a stained blood smear. The proportion is expressed as a Coronary arteriography A test that uses X-rays to help a percentage. doctor/radiologist/cardiologist find narrowing or blockage
163 Venipuncture Course and Kit | EVALUATION MODULE
Disinfectant A substance capable of killing a wide range Epidemiology The science concerned with the study of of microorganisms. factors influencing the distribution of disease and their Disinfection Process that eliminates many or all infectious causes in a defined population. micro-organisms except bacterial and fungal spores. Epidermis The upper or outer layer of the two main layers Displacement The volume of fluid displaced in a catheter of cells that make up the skin. when a needleless intravenous (IV) connector is connected Epithelium The outermost layer of skin, mucous or disconnected. membranes, as well as the lining of the digestive and Distal Further away from the torso. Further away from the respiratory systems. IV solution bag. Erythrocytes Red blood cells, which primarily carry Distended Expanded, swollen, or inflated. oxygen and collect carbon dioxide using hemoglobin. Dorsal Referring to or situated on the back of the body, Etiology The cause or origin of a disease or disorder. the upper parts of the hands (opposite side of the palms), Excretions A body’s waste products (e.g., carbon dioxide, and feet (opposite side of the soles). sweat, urine and feces). Drip chamber Clear, plastic tube (chamber) used as a Extension Set IV tubing used to provide additional length reservoir and measuring device on IV lines just below the or access to the primary IV line. solution bag. Extracellular space The space outside the cells consisting D5W Short for 5% dextrose in water. of the intravascular and the interstitial spaces. Ebola (Ebola hemorrhagic fever) A viral disease Extravasation The leaking of blood or other fluid from a transmitted by contaminated blood or body fluids, often vessel into surrounding tissue as a result of injury, burns, or recognized by the leakage of blood and bodily fluids, inflammation. usually resulting in death. Extremities Limbs of a person or animal, or the parts of a Ecchymosis A diffuse collection of blood outside the limbs that are farthest from the body (e.g., hands or feet). blood vessels within the tissue. Exudate A fluid rich in protein and cellular elements that Edema The swelling of soft tissues as a result of excess oozes out of blood vessels due to inflammation and is fluid accumulation. deposited in nearby tissues. EDTA (Ethylenediaminetetraacetate) A calcium Exudates (verb) Fluid leaking from a blood vessel, tissue, chelating (binding) agent that is used as an anticoagulant or organ. for laboratory blood specimens. Factor VIII An important clotting factor known as Effluent An outflow, usually of fluid. antihemophilic factor (AHF). Effusion The oozing of fluids from blood or lymph vessels Faint Sudden loss of consciousness. into body cavities or tissues as a result of inflammation. Fasting Abstaining from all food and liquids, with the Electrolytes Ions in cells, blood, or other bodily fluids exception of small sips of water, usually overnight. with many physiological functions like assisting with Feces The body’s solid waste matter, composed of maintaining normal pH levels, nerve impulse conduction, undigested food, bacteria, water, and bile pigments, and muscle contraction. discharged from the bowel through the anus. Embolism The blockage of a blood vessel due to an Fibrin Sleeve A buildup of platelets on the exterior of and embolus, usually a blood clot formed at one place in the indwelling catheter that can lead to thrombus formation. circulation and then lodging in another area. Fibrin The protein chains formed during normal blood Embolus A dislodged and displaced blood clot, or some clotting that is the essence of the clot. other substance, causing obstruction in blood vessels at Fibrin Tail A fibrin formation that hangs off the tip of the a distant site. catheter like a tail. EMLA cream A topical anesthetic cream used locally Fibrinogen The protein from which fibrin is formed. on children for mildly invasive procedures such as Fibrinolytic (Thrombolytic) Fibrinolytic or thrombolytic venipuncture. drugs are used to dissolve (lyse) blood clots (thrombi). Endothelium The layer of cells lining the closed internal Finger prick See finger stick. spaces of the body such as the blood vessels and lymphatic Finger stick A procedure in which a finger is pricked with vessels. a lancet to obtain a small quantity of capillary blood for Eosinophil An eosin (red) staining leukocyte with a testing. nucleus that usually has two lobes connected by a slender thread of chromatin.
164 Venipuncture Course and Kit | EVALUATION MODULE
Fistula An intentional or pathological shortcut between a used to reduce or prevent blood clotting. vein and an artery. An opening or passage between two Heparin cap Injection port. organs or between an organ and the skin. Heparin Lock The function of administering heparin into a Flashback The appearance of a small amount of blood catheter after use to reduce intraluminal clotting of blood. when inserting the needle of a syringe or the tubing of a Used for intermittent therapies where the catheter is not butterfly or cannula in a vein indicating that venous access being utilized for fluid delivery. has been successful. Hepatitis Inflammation of the liver. Flexion In the bent position. Hepatitis B A sometimes recurring or fatal form of hepatitis French size Term used to describe external diameter of that is caused by a virus and transmitted through contact catheter. Numerical increase = size increase. with infected blood, blood products, and bodily fluids. Gauge Typically refers to the inside diameter of a needle or Hepatitis C Inflammation of the liver, caused by a virus. catheter. Numerical increase = size and flow rate decrease. Symptoms include fever, jaundice, abdominal pain, and General anesthesia A medically induced coma and loss weakness. of protective reflexes resulting from the administration of Hickman catheter A hollow silicone (soft, rubber-like general anesthetic agents. material) tube inserted and secured into a large vein in the Germicide An agent that kills pathogenic microorganisms. chest for long-term use to administer drugs or nutrients. Glucose The sugar measured in blood and urine specimens HIV Human Immunodeficiency Virus known to be to test for diabetes. responsible for producing Acquired Immunodeficiency Graft An implant or transplant of any tissue or organ. Syndrome (AIDS). Harvesting The collection and preservation of tissues or Hub Female connection of an IV device or catheter into cells from a donor for the purpose of transplantation. which the male luer is inserted. Hb Blood hemoglobin level. Normal hemoglobin values Huber needle A needle bent at an acute angle used for are 14-18 g/dl in adult males and around 12-16 g/dl in accessing implanted ports. adult females. Humoral Pertaining to humoral (or hormonal) control or Heel prick (heel stick) A procedure in which an infant’s relating to the immune response that involves antibodies heel is pricked with a lancet to obtain a small quantity of circulating in bodily fluids. capillary blood for testing. Hyperalimentation Total parenteral nutrition (TPN). Hematocrit The ratio of the total red blood cell volume to Hyperbaric oxygen therapy The medical use of oxygen the total blood volume, expressed as a percentage. at a level higher than atmospheric pressure. Hematology The branch of medicine devoted to the Hyperbaric Referring to pressures higher than normal. study of blood, blood-producing tissues, and diseases of Hyperglycemia An abnormally high glucose in the blood. the blood. Hypersensitivity A state in which the body reacts with an Hematoma A hematoma is a localized collection of blood exaggerated immune response to a foreign substance. outside the blood vessels within the tissue. Hypertonic crystalloid A crystalloid solution that has Hematopoiesis (hemopoiesis) The formation of the a higher concentration of electrolytes than the body’s cellular components of blood in the blood-forming tissues plasma. of the body, mostly the red bone marrow. Hypodermic needle A needle that attaches to a syringe Hemoconcentration A decrease in the fluid content of the for the purpose of injections or withdrawal of fluids such blood (plasma), resulting in an increase in the hematocrit. as blood. Hemodialysis The removal of certain components of the Hypoglycemia An abnormally low glucose level in the blood by virtue of the difference in their rates of diffusion blood. through a semipermeable membrane. Hypotonic crystalloid A crystalloid solution that has a Hemoglobin An iron-containing protein in red blood cells lower concentration of electrolytes than the body’s plasma. that transports oxygen around the body. Immunoglobulins Antibodies formed by cells of the Hemolysis The breaking of the red blood cells membrane immune system that are present in blood and saliva. releasing free hemoglobin into the circulating blood or Implant Object or material, such as tissue, partially or blood sample. totally inserted or grafted into the body of a recipient. Hemostasis To stop bleeding either by vasoconstriction, Implantable Port Subcutaneous (below the skin) injection coagulation, or by surgical means. port having no exterior components when not in use. Heparin A natural anticoagulant formed in the liver and In vitro Outside the living body.
165 Venipuncture Course and Kit | EVALUATION MODULE
In vivo Inside the living body. same concentration of electrolytes as the body plasma. Infection Control Officer The person in a hospital in IV line See intravenous line. charge of the prevention and management of hospital IV Setup Equipment and items required for starting an IV infections and related issues. infusion. Inferior Towards the lower aspects of the body. IV Skills (Intravenous skills) The ability to perform Infiltration Fluid seeping into the tissue. Local anesthetic phlebotomy and to put up an intravenous line. injected diffusely into tissue. IVH Intravenous hyperalimentation. Infusate IV solution to be administered. Joint A part of the body where bones are connected (e.g., Infusion pumps A programmable medical device used the knee, elbow, or skull). for infusing controlled amounts of fluid or medication into Keep Vein Open (KVO) Refers to a slow continuous a patient’s body – usually into the bloodstream. IV infusion for keeping the vein open and the cannula Injection cap Access point of a catheter where the IV line unobstructed. administration line is connected. Kidney dialysis Kidney dialysis is a process for removing Inspection The act of gathering visual information about waste and excess water from the blood, and is used a patient, done by a medical professional. primarily to provide an artificial replacement for lost kidney Intermittent Therapy Administration of IV therapy which function in people with renal failure. occurs at intervals. Lactated Ringer’s (LR) See Ringer’s Lactate Interstitial fluid Fluid surrounding the cells of the body Laminar flow hood Safety cabinets with air flow in such a (excluding blood). direction as to carry any harmful materials or fumes away Interventional radiology A medical sub-specialty of from the worker. radiology that utilizes minimally invasive image-guided Lancet A small sharp blade for puncturing the skin for procedures to diagnose and treat diseases in nearly every collecting small amounts of capillary blood. organ system. Lateral Away from the midline of the body. Intra-arterial Pertaining to the inside of an artery or the LAV Luer activated valve. arterial system. Leukocytes (leucocytes) White blood cells or leukocytes Intracellular fluid The fluid within the cells. are cells of the immune system involved in defending the Intradermal injections An injection of medication into body against both infectious disease and foreign materials. the skin’s dermis layer (below the epidermis). Lipids (Interlipids) Emulsified fat for IV infusion for Intramuscular injection (IMI) An injection of medication nutritional therapy. into one of the large muscles of the body. Lipohypertrophy Medical term that refers to a lump Intrathecal injection An injection into the sub-arachnoid under the skin caused by accumulation of extra fat at the space. site of many subcutaneous injections of insulin. Intravascular volume The volume of blood contained Local anesthesia The prevention of sensory impulses, within all the blood vessels (arteries, veins, and capillaries). especially pain impulses, in a localized area of the body Intravenous fluids Chemically prepared solutions that are from reaching the brain by depositing a local anesthetic administered to a patient via an IV route. solution in the area or near a sensory nerve stem supplying Intravenous (IV) Therapy Infusion therapy given to a the area. patient via intravenous access. Luer lock A secure connecting and locking mechanism Intravenous line A tube with a needle or cannula placed between a male luer fitting and a female luer fitting. The directly into a vein and used to correct electrolyte female fitting screws into threads in the sleeve on the male imbalances, to deliver medications, for blood transfusion, fitting. or as fluid replacement to correct conditions such as Luer slip Conical male luer that achieves a friction dehydration. connection when inserted into a female hub and turned a Iodine Usually used in an alcohol solution, called tincture quarter turn clockwise. of iodine, as a pre- and post-operative antiseptic and Lumen The internal space within catheter artery, vein, occasionally for preparing the skin aseptically before intestine, or tube. venipuncture. Lymph Fluid found in lymphatic vessels and nodes derived Irrigation To push fluid though an IV line, usually with from tissue fluids. normal saline solution. Isotonic crystalloid A crystalloid solution that has the
166 Venipuncture Course and Kit | EVALUATION MODULE
Lymphedema A type of swelling that occurs in lymphatic and can lead to vein thrombosis. tissue when excess fluid collects in the arms or legs because Needle A thin, sharp metal tube attached to a syringe for the lymph nodes or vessels are blocked or removed. injecting a patient or the sharp usually semi-curved metal Lymphocytes Mononuclear, non-phagocytic leukocytes structure at the one end of a suture thread. that are found in the blood and lymph; the body’s Needlestick injury Accidental injuries sustained by immunologically competent cells. medical professionals while working with sharp needles. Macrophage Any of the many forms of mononuclear Injuries may be clean (before injecting) or contaminated phagocytes found in tissues and originating from stem (after injecting a patient). cells in the bone marrow. Negative air pressure Pressure less than that of Magnetic resonance imaging (MRI) A medical imaging atmosphere. technique used in radiology to visualize internal structures Neonate A newborn child, especially one less than one of the body in detail by using nuclear magnetic resonance month old. (NMR) to produce “sliced” images of the body. Neutrophil A polymorphonuclear granular leukocyte Malaria An infectious disease caused by a parasite having a nucleus with 3-5 lobes connected by slender transmitted by the bite of carrier mosquitoes. threads of chromatin and cytoplasm containing fine Mandible Lower jaw. inconspicuous granules. MCH (Mean Corpuscular Hemoglobin) The average Normal saline solution An isotonic crystalloid solution hemoglobin content in a red blood cell. that contains 0.9% sodium chloride dissolved in sterile MCHC (Mean Corpuscular Hemoglobin Concentration) water. The average hemoglobin concentration in red blood cells, Nosocomial infection An infection whose origin is from expressed as a percentage (g/dL). the hospital environment. MCV (Mean Corpuscular Volume) Average volume of red Occluded The stopping of flow of intravenous fluid or blood cells (erythrocytes), expressed in cubic micrometers. blood due to a blockage (e.g., a blood clot (thrombus), Medial (mesial) Towards or closer to the midline of the pressure tourniquet, or kinking of the plastic tube or body. cannula). Medial cubital vein The communicating vein between Occlusion Blocked artery, vein, IV catheter, or tubing. Also, the cephalic and basilic veins in the cubital fossa commonly refers to an occlusion alarm on a pump that sounds when used for venipuncture. the IV setup becomes blocked. Median antecubital vein See medial cubital vein. OHASA Acronym for Occupational Health and Safety Act. Medical history The systematic questioning of a patient Oncology Scientific and medical study of cancer. by a medical professional to gather information for Order of draw The order in which blood sample tubes diagnosing a condition or disease. should be drawn using a multi-sample technique. Medication A drug used to treat a disease or condition or OSHA Occupational and Health Safety Administration, to alleviate a symptom (e.g., pain). part of the United States Department of Labor. Mesial See medial. Osmosis The movement of water across a semipermeable Micron Filter IV filter used to capture and eliminate air and membrane from an area of lower solute concentration to contaminates in the IV system. an area of higher solute concentration. Microorganism A microscopic organism or microbe. Oxygen-carrying solutions Chemically prepared Some types can cause a variety of diseases, wound, and solutions that can carry oxygen to the cells. blood infections. Oxygen saturation (SpO2) Oxygen saturation or (O2 sats) Milliliter A thousandth of a liter; it equals a cc (cubic measures the percentage of hemoglobin binding sites in centimeter). the bloodstream occupied by oxygen. Monocyte A mononuclear, phagocytic leukocyte with an Oxyhemoglobin Hemoglobin that has been bound with oval to kidney shaped nucleus. oxygen in the lungs for the purpose of transport of oxygen Mononuclear A cell containing only one nucleus. to cells of the body. Multi-sample adapter A device used with a butterfly and PCA Patient-Controlled Analgesia (pain medication). Vacutainer ™ holder to allow for the withdrawal of multiple Packed red blood cells In transfusion medicine, packed tubes of blood during a venipuncture. red blood cells are red blood cells that have been separated Mural Thrombosis A fibrin buildup on the wall of the from whole blood for transfusion purposes. vessel often caused by trauma during catheter insertion
167 Venipuncture Course and Kit | EVALUATION MODULE
Pallor Paleness; increase in the absence of skin color; the Piggyback Accessing a primary IV line at a secondary port absence of color in skin. (Y-site). Palmar Referring to the palm surface or side of the hand. Pipet A glass or transparent plastic tube used to accurately Palpate To examine or feel with the hand. measure small amounts of liquid. Palpation The act of gathering information about the Plasma Blood plasma is the liquid component of blood, patient with the medical professional using the sense of making up around half of the total blood volume. It consists touch. of about 90% water, the balance being proteins, minerals, Parafilm™ A thin film of paraffin used primarily in the clotting factors, hormones, and immunoglobulins. laboratory to seal open containers such as test tubes. Plateletpheresis The selective separation and removal of Parenteral nutrition (PN) Parenteral nutrition is feeding platelets from withdrawn blood. a person intravenously, bypassing the usual process of Platelet-rich plasma (PRP) Platelet-rich plasma has been eating and digestion. used as an adjunct to wound healing for several decades. Patent (patency) Generally referring to an open, clear (not Platelets See thrombocytes. occluded) IV catheter. Pleural Pertaining to the thin transparent membrane that Pathogen Any microorganism that produces disease. lines the chest wall and doubles back to cover the lungs. Pathogenesis The development and progression of a Plunger Piston-like part of a syringe for exerting pressure disease. for injecting or negative pressure for aspirating. Pathogenic Having the capability of producing disease. Polymorphonuclear A white blood cell with a nucleus so Pediatric Referring to the medical care of children deeply lobed so as to appear to have multiple nuclei. including the prevention and treatment of children’s Ports A port is a small medical appliance that is installed diseases. beneath the skin with a catheter connecting the port to a PEP (Post-exposure prophylaxis) Steps to take to vein. Under the skin, the port has a septum through which prevent or minimize the risk of infection after a patient or drugs can be injected and blood samples can be drawn healthcare worker has been exposed to a known pathogen many times. (e.g., HIV). Posterior Towards the back of the body. Peripheral blood Blood circulating in blood vessels Povidone-iodine A topical antiseptic occasionally used in outside of the heart and major blood vessels. phlebotomy. Peripheral Line Any IV line placed on the periphery of the Primary Line Main IV tubing. Secondary lines will be body (e.g., arm, leg, hand, or foot). piggy-backed into the main line. Peripherally Inserted Catheter (PIC) Catheter that is placed Priming The elimination of air in the IV setup by infusing on the periphery of the body (e.g., arm, leg, hand, or foot). solution prior to IV administration. Peripherally Inserted Central Catheter (PICC) Catheter PRN Adapter Injection port. that is placed on the periphery of the body, generally from P.r.n. (Latin: pro re nata) Means ‘as needed’ or ‘as the the arm with the catheter tip positioned in the superior situation arises’. Used when prescribing medication only to vena cava. be used if necessary. Peritoneal dialysis Dialysis through the peritoneum. Prone Lying face down, as opposed to supine. Peritoneum The membrane lining the abdominal and Prophylaxis A preventative treatment; medication pelvic wall. prescribed with the intent to prevent complications that PH A scale from 0-14 indicating the level of acidity or may develop following a surgical procedure. alkalinity (< 7 is acidic, 7 = neutral and > 7 is alkaline). Protocol Guidelines written to prescribe safe and effective Phagocytosis A phagocyte is any cell capable of ingesting clinical practice. Intended to be followed by all clinical particulate matter. personnel and set as a benchmark for what and when Phlebitis Inflamed, irritated vein. specific procedures or steps of procedures should happen Phlebotomist One who practices phlebotomy. and in what order it should happen. Phlebotomy Needle puncture of a vein for the purpose of Proximal Nearer to the head and torso or nearer to the IV drawing blood (venipuncture). fluid bag. Physician A doctor who diagnoses and treats diseases Pulse points Specific areas or points on the human body and injuries using methods other than surgery. where an arterial pulse or throb can be palpated on mild Physiology The branch of biology that deals with the digital (fingertip) pressure. internal workings and functions of living organisms.
168 Venipuncture Course and Kit | EVALUATION MODULE
Pus The yellowish or greenish fluid that forms at sites of Semen The liquid that contains sperm produced by the infection, consisting of dead white blood cells, dead tissue, male sex organs. bacteria, and blood serum. Semipermeable Permitting the passage of certain QNS Quantity Not Sufficient molecules and hindering others. Radiography The use of X-rays to view the internal Sepsis A localized or systemic state of inflammation structures of a human or an animal body. caused by disease forming bacteria and their products Radiology The branch of medicine that deals with the use (e.g., toxins). of X-rays and radioactive substances such as radium in the Septic See sepsis. diagnosis and treatment of diseases. Serum Referring to blood, the clear liquid portion of blood Red blood cells See erythrocytes. that separates out after clotting has taken place. Regional anesthesia Anesthesia that affects a large part Sharps injury An injury occurring when a sharp object of the body such as a limb or the lower half of the body. penetrates the skin or mucous membranes. Residual Volume The volume withheld in an IV device. Sharps Objects or devices with acute rigid corners, edge, Refers to what amount of fluid resides in a connector and points, or protuberances capable of cutting or penetrating is not delivered to the patient. the skin (hypodermic needles, scalpels, blades, lancets, Reverse isolation An isolation procedure for protecting broken glass, etc.). patients whose immune response has been greatly Sodium The most common electrolyte found in animal reduced from contracting disease. blood serum. Reverse Trendelenburg Patient lying on the back with the Solute Particles that are dissolved in the sterile water bed angulated so the feet are about 15°-30° lower than the (solvent) of an IV fluid. head. Solvent The liquid portion of an IV solution that the solute Rh system A specific type of human blood group dissolves into. The most common solvent is sterile water. responsible for hemolytic disease of the newborn. Sputum A mucus or phlegm-like substance coughed up Ringer’s Lactate An isotonic crystalloid solution containing from the respiratory tract. the solutes sodium chloride, potassium chloride, calcium SQ See subcutaneous injection. chloride, and sodium lactate, dissolved in sterile water. Standard precautions The routine use of safe work RN (Registered Nurse) A nurse who has graduated from a practices and protective barriers to minimize the spread of nursing program at a college or university and has passed infectious diseases and prevent sharps injuries. a national licensing exam. Stat Abbreviation for the Latin word statim, meaning Safety-engineered needles Needles designed to prevent immediately. or minimize needle stick injuries. Sterile procedure Referring to an invasive procedure Saline Solution of salt and water used as a carrier for all IV where a special sterile and aseptic protocol is followed to drugs and hydration. Normal saline is a 0.9% solution with minimize the risk of causing and transmitting infection. the same osmotic pressure as that of blood. Subcutaneous injection (abbreviated as SQ or SC) An Saliva The clear liquid consisting of water, mucin, protein, injection of medication into the subcutaneous layer of the and enzymes, secreted into the mouth by the salivary skin (below the dermis and epidermis). glands. It moistens food and starts the breakdown of Submucosa A layer of loosely meshed microscopic fibers starches. and associated connective tissue cells beneath a mucous SASH Saline flush→Antibiotic→Saline flush→Heparin. membrane. Sclerosis The hardening of an artery or vein, usually seen SuperficialRelating to, affecting, or located on or near the in the elderly. surface of something. Scrubs The shirts and trousers or gowns worn by nurses, Superior Towards the upper aspects of the body. surgeons, and other operating room personnel when Supine Patient lying on the back and with the face ‘scrubbing in’ for surgery. Scrubs are now commonly worn upwards. by any hospital personnel in any clean environment. Suturing The closure of a wound by joining the edges. Secondary Line IV line used to access a main/primary line Swan-Ganz® Catheter A catheter with a balloon at the tip, at a secondary port (Y-site). passed via one of the major veins into the right side of the Seldinger Technique Over the wire insertion method used heart and the arteries leading to the lungs, which monitors for catheter insertion. the heart’s function, blood flow, and intravascular pressure in these vessels.
169 Venipuncture Course and Kit | EVALUATION MODULE
Sweat The clear salty liquid that passes through minute angulated so the head is about 15°-30° lower that the feet. pores to the surface of the skin when somebody is hot as a Ultrasound A technique that uses high-frequency sound result of strenuous activity, fear, anxiety, or illness. waves for medical diagnosis and treatment (e.g., to create Syncope Fainting. images of internal organs). Syringe A medical device commonly used for injecting Urinalysis The analysis of the physical, chemical, and medication into the body or withdrawing fluid (e.g., blood microbiological properties of urine, carried out to help or pus) from the body. The basic parts of a syringe are the diagnose disease, monitor treatment, or detect the barrel, plunger, and tip. presence of specific substances. Therapeutic phlebotomy (letting blood) A therapeutic Urine The yellowish liquid containing waste products that procedure to remove blood from the bloodstream is excreted by the kidneys and discharged through the primarily for medical reasons. urethra. Therapeutic Promoting healing or a healing agent. Urticaria A skin rash, usually occurring due to an allergic Third space The third space is space in the body where reaction, marked by itchiness and small pale or red fluid does not normally collect in larger amounts, or where swellings. any significant fluid collection is physiologically non- Vacutainer® The brand name and often generically term functional (e.g., peritoneal, pleural space, etc.). used to describe the equipment used to draw or aspirate Thrombocytes Very small, irregularly shaped, clear cells blood from a vessel by venipuncture. derived from fragmentation of precursor megakaryocytes. Vacutainer® holder A cylindrical shaped holder that Platelets are involved in hemostasis leading to the accepts a Vacutainer® tube on one end and a Vacutainer formation of blood clots. needle on the other. Thrombocytopenia Decrease in the number of blood Vacutainer® needle The needle used to attach to a platelets below normal values. Vacutainer holder. Thrombosis A buildup of blood fibrin and platelets in the Vacutainer® system The combination of a Vacutainer circulatory system which can lead to embolism or clotting. holder, needle, and sample tube which allows for a more Thrombus A blood clot that forms in a blood vessel and automated method of drawing blood. remains at the site of formation. Vacutainer® tube Blood sample tubes containing a Tissue infiltration Intravenous fluid seeping into the vacuum. surrounding tissue instead of flowing into a vein. Vacuum tube A sterile glass or plastic tube with an Topical anesthetic The numbing of the surface of a evacuated closure to create a vacuum inside the tube mucous membrane or the skin in an attempt to avoid or facilitating the draw of a predetermined volume of liquid. reduce pain experienced by the patient on needle pricking Valve A membranous structure in a hollow organ or vessel or minor surgical procedures. such as the heart or vein that ensures the unidirectional Total body water The total amount of water contained flow of blood passing through it by closing intermittently. within the cells, around the cells, and in the bloodstream. Vascular graft Harvesting an artery or vein and Total Parenteral Nutrition (TPN) IV fluids used as a transplanting it to another site. complete nutritional replacement for a period of time. Vascular Pertaining to or composed of blood vessels. Tourniquet A band applied around an arm or leg in order Vasoconstriction A decrease in the inside diameter of to temporary reduce or stop the venous or arterial blood blood vessels leading to a decrease in blood flow. flow in a limb. Vasovagal response The vasovagal response is the Tournistrip® The registered trade name of an easy to use, development of inappropriate cardiac slowing and single-use tourniquet. arteriolar dilatation. Transplant An organ or tissue taken from the body for Vasovagal syncope Fainting due to a vasovagal response. grafting into another part of the same body or into another Vein A blood vessel that carries blood towards the heart. individual. Venesection Surgically opening of a vein for the purpose Transudate A transudate is a bodily fluid that passes of collecting blood. through a membrane, filtering out most of the protein and Venipuncture The puncturing of a vein for any cellular elements, thus yielding a watery solution. medical purpose (e.g., to take blood, to feed somebody Transudates A fluid that passes through the pores or intravenously, or to administer a drug). The act of inserting interstices of a membrane. a needle or catheter into a vein. Trendelenburg Patient lying on their back with the bed
170 Venipuncture Course and Kit | EVALUATION MODULE
Venous access Insertion of a cannula into a vein allowing entrance to the circulatory system to infuse medication or solutions, or to draw blood. Ventral Referring to or situated on the front of the body, the palms of the hands, and soles of the feet. Venule A very tiny vein continuous with the capillaries. Veterinary Pertaining to diseases of animals and their treatment. Vial A small glass, plastic vessel, or bottle used to store medication as liquids or powders. Warfarin A synthetic anticoagulant. White blood cell count The number of white blood cells (leukocytes) found in the peripheral blood and measured per cubic millimeter. White blood cell See leukocyte. WHO Acronym for World Health Organization. Whole blood Whole blood is a term used in transfusion medicine, meaning human blood from a standard blood donation. Winged infusion set A type of needle used in venipuncture (phlebotomy) often used with people who have difficult venous access. Y Site Injection port that branches off primary lines. Used for piggybacking medications into primary set.
171