ch 9 + 10

Reference Ranges/_____

• Tests confirm health or screen, diagnose, and monitor disease

• Test results are compared w/ specimens of ___ people

• Consist of range of values with high & low limits

intervals

• healthy

Resting state of body early in the morning after fasting __ hours

• ___-___ specimen is ideal for establishing reference ranges on inpatients + effects of diet, exercise

• is influenced by age, sex, conditions of body like dehydratiom, diet, circadian variations, more

Basal state

• 12

• Basal-state

• __ effects RBC, WBC, creatinine clearance, hormones

• ____ effects Increased: RBC, Hgb, Hct, CRP, uric acid

• AND Decreased: urine creatinine, renin

• stress WBC, Fe, ACTH, catecholamines, cortisol

• ____ effects Causes hemoconcentration

• AND Incr RBCs, enzymes, Fe, Ca, Na+, K+, coag factors

• ____ effects glucose, lipids, electrolytes

• diurnal/circadian variation effect TSH, cortisol, Fe

• drug therapy effects enzymes and hormones

• ____ effects pH, PCO2, CK, LDH, glucose

• fever effects Hormones, cortisol, insulin

• __ effects RBC, Hgb, Hct

• intramuscular injection effects CK, LDH

• jaundice causes Abnormal yellow color can interfere in testing

• position effects Aldosterone, bilirubin, blood cells, ca, K+

• ____ effects Chol., cortisol, glucose, GH, triglycerides, RBC, WBC

• age

• altitude

• dehydration

• diet

• exercise

• sex

• smoking

____ indicates liver inflammation caused by hep B or C

• incr bilirubin in bl

jaundice

Problem sites like burns, scars, ____

• Veins are difficult to palpate here

• May have impaired c___

• New burns are painful

• ___ may be more susceptible to infection; dyes may interfere

Tattoos

• circulation

• Tattoos

Damaged veins

• _____: hardened

• _____: clotted

• Difficult to puncture and yield erroneous results

• Sclerosed

• Thrombosed

• Swelling caused by abnormal accumulation of fluid in tissues

• Results when fluid from IV infiltrates surrounding tissues

• Contaminates blood w/ tissue fluid

• veins are harder to locate, and tissue is fragile

edema

• A swelling or mass of bl → forms bruises

• Caused by bl leaking from ___ during venipuncture

• Can be painful, contaminate blood sample, obstruct blood flow

hematoma

• vessel

• Surgical breast removal

• Lymph flow is obstructed w/ removal of lymph nodes

• Swelling & infection may be present

• Applying tourniquet here can cause injury

• Can change bl composition

mastectomy

with diabetic patinets, use bariatric tourniquet & try __ __ or cephalic vein

• median cubital

___ Access Devices (_ADs) are tubing that specifically designed to allow entry to veins or arteries

• IV line

• IV catheter lock

Vascular (VADs)

Type of VAD

• Catheter inserted in ____ vein

• Avoid drawing bl from arm containing IV, if possible

• delivers fluids, meds

Intravenous (IV) Line

• peripheral

Type of VAD

• Needless connection device in the form of a stopcock or cap

• Saline lock

• Heparin lock (heplock)

• wait 24-48 hr after IV inserted

IV Catheter Lock

Type of VAD

• A catheter placed in an artery (usually radial)

• Provides accurate & continuous measurement of bl ___

• No tourniquet or venipuncture on an arm w/ an arterial line

Arterial Line (A-line or art-line)

• pressure

Type of VAD

• Permanent, surgical ___ of an artery & a vein

• Created for dialysis access (fistula)

• Located on the back of arm above wrist

Arteriovenous (AV) Shunt/Fistula/Graph

• fusion

Type of VAD

• called CVC (central venous catheter)

• Connected to arterial or central venous catheter to collect bl

• Reduces chance of infection

• Prevents needlesticks

• Minimizes waste from line draws

Blood Sampling Device

Type of VAD

• Known as indwelling lines

• Consist of tubing inserted into a main vein or artery

• Used for:

  • Administering fluids and medications

  • Monitoring pressures

  • Drawing blood

Central Vascular Access Devices (CVADs)

Type of CVADs

• Inserted into large vein (subclavian)

• Advanced into ______ __ ___

• Exit end tunneled under the skin several inches away

• One or more lengths of capped tubing protrude from exit site

Central venous catheter (CVC) or line

• superior vena cava

Types of CVADs

• A small chamber attached to indwelling line

• Surgically implanted under skin (upper chest or arm)

• Self-sealing chamber located by palpating the skin and accessing with a special needle

Implanted port

Types of CVADs

• Inserted into peripheral venous syst and threaded into a main vein leading to the __

• Does not require surgical insertion

Peripherally inserted central catheter (PICC)

• heart

Allergies to Equipment and Supplies

• Adhesive allergy

  • Place gauze square over site; have patient remove in _ minutes

  • Or, have patient apply pressure for 5 minutes instead of bandage

• Antiseptic allergy

  • Use alternate antiseptic

• Latex allergy

  • Look for sign indicating latex allergy on patient’s door or ask outpatient

  • Use nonlatex equipment (e.g., gloves, tourniquet, and bandages)

• adhesive allergy

  • 15

• Excessive Bleeding

  • Patients on ___ or anticoagulant may bleed longer

  • Maintain pressure until bleeding stops

  • If bleeding continues >5 minutes, notify appropriate personnel

• aspirin

• A loss of consciousness and postural tone

• Caused by insufficient bl flow to ___

• Have patients with history of fainting lie down during venipuncture

• Lower patient’s head and apply cold compress to back of neck

Fainting (Syncope)

• brain

• Discontinue blood draw until feeling subsides

• Give patient emesis basin or wastebasket

• Apply __, damp washcloth to forehead

Nausea and Vomiting

• cold

• Tiny, nonraised red spots

• Appear on arm when tourniquet is applied

• or sign of low platelet count (thrombocytopenia)

Petechiae

• Discontinue draw immediately

• Hold pressure over site without restricting patient’s movement

• Do not put anything in patient’s mouth

• Protect patient from self-injury

• Notify first-aid personnel

Seizures/Convulsions

____ Formation and Bruising

• from bl leaking into tissues → swelling

• Discontinue draw immediately and hold pressure over site _ minutes

• Offer cold compress or ice pack if it is large and swollen

Hematoma

• 2

• _____ Anemia

  • Anemia brought about by bl loss from bl draws

  • Life is threatened if >__% of bl volume is removed at once

  • Collect only minimum required specimen volumes

• _____ Arterial Puncture

  • Signs: rapidly forming hematoma, blood filling tube quickly

  • from deep/blind probing

• Iatrogenic

  • 10

• Inadvertent

Infection

• Avoid by doing the following:

  • Don’t open tape or bandages ahead of time

  • Don’t preload needles onto tube holders ahead of time

  • Don’t touch needle insertion site after sterilizing it

  • Minimize time between needle cap removal and ____

  • Remind patient to keep bandage on at least __ minutes

• venipuncture

• 15

• Nerve Injury

  • Caused by:

    • Improper site or vein selection

    • Inserting needle too deeply or quickly

    • Excessive ___ redirection of needle

    • Blind probing

  • If initial vein entry is unsuccessful:

    • Use slight forward or backward redirection of needle

    • Remove needle and try an alternate site

• lateral

____ of additive

• Blood flows back into vein from collection tube

  • Tube additives may cause adverse reaction

  • Keep arm in downward position and tube below venipuncture site

___ Damage

• Avoid numerous venipunctures in the same area over time

• Avoid blind probing and improper technique

Reflux

Vein Damage

Hemoconcentration

• A ____ in fluid content of blood

• An ____ in nonfilterable large molecules (like RBCs)

• Caused by stagnation of normal venous flow due to tourniquet

• decrease

• increase

____

• Damage to or destruction of RBCs

• ____ escapes into fluid part of specimen

• can elevate electrolytes

Partially Filled Tubes (short draw)

• Blood-to-additive ratio may be incorrect

Hemolysis

• Hemoglobin

• _____ Contamination

  • Allowing alcohol residue, fingerprints, glove powder, baby powder, urine on newborn screening samples

  • Getting glove powder on bl films or capillary specimens

  • Dripping perspiration into capillary specimens

  • Following improper antiseptic procedure

  • Using wrong antiseptic

• Wrong or Expired Collection Tube

  • Routinely check expiration dates

  • Additives in expired tubes may not work properly

• Specimen contamination

Needle Position

• Needle not inserted far enough

• Bevel partially out of skin

• Bevel partially into vein

• Bevel partially through vein

• Bevel completely through vein

• Bevel against vein wall

• Bevel in valve

• Needle ___ vein

• Undetermined position

• beside

____ Vein

• Vein walls draw together temporarily, shutting off blood flow

• Caused by:

  • Vacuum of tube or plunger pressure is too ___ for vein

  • Tourniquet is too tight or too close to site

  • Tourniquet is removed during draw (especially with the elderly)

• Tube Vacuum

  • Loss of vacuum due to bevel partially out of skin

  • Loss of vacuum due to damage of tube

Collapsed vein

• strong

• Sterile, disposable, sharp-pointed or bladed instrument

• Punctures or cuts skin to obtain capillary bl specimen

• Designed for either finger or heel puncture

Lancet/Incision Devices

• Small plastic tubes used to collect tiny amounts of bl from capillary punctures

• Some come with narrow capillary tubes attached

• Have color-coded bodies or stoppers and markings for min/max fill levels

Microcollection Containers/Microtubes

• Disposable, narrow-bore plastic or plastic-clad glass tubes

• Fill by capillary action and hold 50 to 75 microL

• Used primarily for Hct determinations

• 1 end of tube is sealed with plastic or clay sealant

Microhematocrit Tubes and Sealants

_____ Blood Gas (_BG) Equipment

• _BG collection tubes: narrow-bore plastic capillary tubes

• Stirrers: metal filings or bars inserted into tube to mix

• ___: used for mixing, in conjunction w. stirrer

• Plastic caps: used to seal tubes

Microscope Slides

• Used for blood films for hematology determinations

Warming Devices

• Warming the site increases bl flow up to seven times

• capillary (CBG)

• Magnet

Capillary Puncture Risks

• Bruising, hematoma, infection

• Puncture site c____, scarring

Composition of Capillary Specimens

• Mixture of arterial, venous, and capillary bl

• Interstitial and _____ fluid

• More closely resembles arterial bl than venous

Reference Values

• Capillary reference values may differ from venous values

• ____ concentrat are higher in capillary bl

• Bilirubin, calcium (Ca2+), Cl, (Na+), & total protein (TP) concentrations are ___ in capillary blood

• calcification

• intracellular

• Glucose

• lower

Indications for Capillary Puncture

• ___ ___ and ____

  • Available veins are fragile, difficult to access, or must be saved for other procedures

  • Venipunctures have been unsuccessful

  • Venipuncture sites have burns or scars

  • Patient has clot-forming tendencies

  • Patient is apprehensive or is needle phobic

  • Patient is overweight, and veins are difficult to find

  • No accessible veins (IVs in both arms, scars, burns)

  • POCT procedures such as ___ monitoring

• Older children and adults

Indications for Capillary Puncture (cont.)

• ___ and ___ ___ (the preferred method)

  • Small bl volume presents risk of anemia. (For every 10 mL blood removed, up to 5 mg iron also removed)

  • Rapid removal of large quantities risks cardiac arrest

  • venipuncture is difficult and may damage veins and surrounding tissues

  • Puncturing deep veins can cause hemorrhage, venous thrombosis, infection, and gangrene

  • Risk of injury due to restraint needed for venipuncture

  • Capillary bl is preferred specimen for some tests for newborns

screening

• infants and young children

Tests That Cannot Be Collected by Capillary Puncture

• Most erythrocyte _____ rate methods

• Coagulation studies that require plasma specimens

• Blood cultures

• Tests that require large volumes of ___ or __

• sedimentation

• serum or plasma

Order of Draw (put in order)

• EDTA specimens, Serum specimens, Other additive specimens, Blood gas specimens (CBGs)

• Blood gas specimens (CBGs)

  • To minimize exposure to air

  • Usually collected separately

• EDTA specimens

  • Affected by the clotting process and any clotting is unacceptable

• Other additive specimens

  • Also affected by clotting

• Serum specimens

  • They are supposed to clot

Step 6: Position the Patient

• Finger puncture: arm supported on firm surface, hand extended & palm up

• Young child: held in lap of parent or guardian

• Infant heel puncture: supine with foot lower than the ___

• Hold _ or _ of a toddler’s fingers together

• torso

• 3 or 4

Step 7: Select the Puncture Site

• General criteria

  • Skin is __, normal color; no scars, cuts, bruises, rashes, edema, or infection; not cyanotic

• Adults and older children

  • Palmar surface of distal or end segment of middle or ring finger of _____ hand

  • Central, fleshy portion of the finger

• Infants

  • Finger puncture: infants 6 to 12 months >10 kg, lancets specifically developed to penetrate ≤_ mm

  • Heel puncture: plantar surface, on medial or lateral edge to avoid bone damage (<_ mm deep)

• warm

• nondominant

• 1

• 2

Step 8: Warm the Site if Applicable

• Warming incr bl flow up to ___fold

• Essential: pH or bl gas specimens & recommended for heelsticks

• Wrap site for 3 to _ min w/ a warm, moist washcloth, towel, or diaper

Step 9: Gather Supplies and Equipment

• Helps ensure correct equipment is ready

• Select lancet according to patient ___ & amount of bl to be collected

• sevenfold

• 5

• age

Step 10: Clean and Air-Dry the Site

• Cleanse site w/ antiseptic

• Allow to air-dry to ensure maximum antiseptic action, and prevent stinging, and ____ from residual alcohol

Step 11: Prepare Equipment

• Don gloves if not already on

• Prepare collection devices aseptically

• Verify lancet sterility by checking to see if package is intact

• Prepare equipment in view of adult patient

Step 12: Grasp the Finger or Heel Firmly

• Hold lancet between thumb and ___ finger, dominant hand

• Fingersticks: grasp patient’s middle or ring finger between your nondominant thumb and index finger

• Heelsticks: Grasp foot gently with ____ hand

• Hemolysis

• index

• nondominant

Step 13: Position Lancet, Puncture Site, and Discard Lancet

• Place lancet flat against skin in appropriate area

• Warn the patient or parent/guardian

• Activate release mechanism to trigger puncture

• Remove device from skin and immediately discard it in a sharps container

Step 14: Lower Finger or Heel; Apply Gentle Pressure Until a Blood Drop Forms

• _____ position helps encourage blood flow

• Downward

Step 15: wipe Away First bl Drop

• 1st drop is typically contaminated with ___ fluid & may contain alcohol residue

• Alcohol residue can __ specimen or keep it from forming a round drop & possibly interfere in glucose tests

Step 16: Fill and Mix Tubes/Containers in Order of Draw

• Collect slides, platelet counts, and other hematology specimens first to avoid clumping and clotting

• Collect other anticoagulant containers next and serum specimens last

• Touch collection tube or device to drop of blood

• DONT SQUEEZE SITE

• tissue

• hemolyze

Neonatal Bilirubin Collection (cont.)

• newborns tested for incr levels due to accelerated RBC hemolysis

• ___: brain dysfunction from toxic levels

• May need transfusion if levels incr at rate equal to or greater than _ mg/dL/hr or bl level exceeds 18mg/dL

• Infant placed under light: phototherapy

• Collect specimen by heel puncture using amber microtainer or protect it from light with __

• New way: transcutaneous bilirubin (TcB) test device

  • Directs light into the skin on the infant’s __ or sternum and measures intensity specific wavelength reflected back

• Kernicterus

• 5

• foil

• head

____ screening (NBS)

• State-mandated testing

• Detects rare, serious, inherited, metabolic, hormonal, and functional conditions that can cause severe mental handicaps

• _____ Uniform Screening Panel (_USP)

  • 36 disorders for which there are effective treatments

  • Most states screen this panel. Some screen up to 60 disorders

• Timing: infant is between 24 and __ hours old

• Common tests

  • Phenylketonuria

  • Hypothyroidism

  • Galactosemia

  • Cystic fibrosis

• 6 gps of disorders that can be detected

  • ___ acid metabolism disorders

  • fatty acid oxidation disorders

  • amino acid metabolism disorders

  • e___ disorders

  • hemoglobin disorders

  • other disorders from hearing to heart to immunodef

Newborn

• Recommended (RUSP)

• 72

• organic

• endocrine

_______ (PKU)

• Defect in enzyme that breaks down phenylalanine

• No cure, but can be treated with special diet

Phenylketonuria

___thyroidism

• Insufficient levels of thyroid hormone

• Also detects noninherited form

• Positive results confirmed by thyroid stimulating hormone (TSH) test

• Treat by supplying ___ hormone

Hypothyroidism

• missing

____

• ___ enzyme that metabolizes galactose (milk sugar)

• Treat by removing all __ products

Galactosemia

• Missing

• milk

Cystic Fibrosis (CF)

• 1 or more ___ in the gene that directs a protein responsible for regulating ___ transport across cl membr

• Affects multiple organs, but primarily lungs and ____

• Thick, sticky mucus secretions build up in lungs and other organs

• Patient’s sweat tastes very ___

• mutations, chloride

• pancreas

• salty

Blood film/slide/smear

• required to perform a manual ____

  • where number, type, & characteristics of bl cls are determined under microscope

• differential

Thick blood smear preparation

• Used to test for ____

• Diagnosed by presence of orgsm in peripheral bl smear

• A very large drop of bl is placed in center of glass slide

• Drop is spread with corner of another slide or cover slip until it is the size of a dime

• Allow to dry for a minimum of 2 hours before staining

• malaria