Sequence Study Guide

Patient Preparation, Positioning, and Lifespan Assessments

•  Colonoscopy Preparation and Care Protocols:

•  Dietary Requirements: Strict clear liquid diet for  pre-procedure. Prohibit red, blue, or purple dyes to prevent obscuring mucosal pathology or mimicking blood.

•  Bowel Evacuation Solution: Complete ingestion exactly  prior to procedure time to clear residual secretions and comply with  guidelines.

•  Procedural Positioning: Left lateral (Sims') position with knees drawn toward abdomen to facilitate endoscope insertion into the rectum and sigmoid colon.

•  Preventive Self-Examination Education:

•  Breast Self-Exam (): Monthly; perform  post-menses (or a consistent monthly date post-menopause). Systematically palpate three areas: breast tissue proper (all four quadrants), nipple-areolar complex, and the axillary region/tail of Spence.

•  Testicular Self-Exam (): Monthly during or after a warm shower (relaxes scrotal smooth muscle). Roll each testicle between the thumb on the anterior surface and index/middle fingers on the posterior surface to detect nodules. The epididymis is normally palpable on the posterior-superior aspect.

•  Lifespan-Specific Patient Measurements:

•  Geriatric Orthostatic Blood Pressure: Evaluates for postural hypotension (drop of  systolic or  diastolic within ). Measure blood pressure and pulse sequentially: supine (after resting ), sitting (after ), and standing (after ).

•  Pediatric Recumbent Length: Measured supine on a rigid infant measuring board for all pediatric patients under  () of age (crown against fixed headboard, soles perpendicular to footboard).

Routine Phlebotomy: Site Selection, Safety Mechanics, and Equipment

•  Venipuncture Site Selection:

•  Primary Vein: Median cubital vein in the antecubital fossa (largest caliber, superficial, well-anchored, lowest risk of nerve/arterial injury).

•  Sites to Avoid: Hematomas, scarred or fibrotic veins, tattoos, edematous tissue, active skin lesions/infections, arm ipsilateral to mastectomy/lymph node dissection, and extremities with active  fistulas/grafts or proximal  lines.

•  Tourniquet Application:

•  Apply  () proximal to the puncture site.

•  Maximum application time is  () to prevent hemoconcentration, venous stasis, and hemolysis.

•  Needle Mechanics and Safety:

•  Insertion Angle:  with the bevel facing upward.

•  Disposal Standard: Engage safety shielding immediately upon removal and dispose uncapped directly into a puncture-resistant biohazard sharps container. Never recap, bend, or shear needles.

•  Equipment and Aspiration Technique:

•  Syringe Blood Draws: Use a standard  syringe (or  calibrated syringe). Retract plunger slowly and steadily to prevent vein collapse and hemolysis.

•  Butterfly Needles: Indicated for geriatric patients with fragile or sclerosed veins and pediatric patients with small vascular caliber.

Venipuncture Order of Draw and Additive Specifications

1.  Light Blue Top

•  Additive: Sodium Citrate ( or ).

•  Mechanism: Reversibly binds ionized calcium () to inhibit coagulation.

•  Primary Uses: Coagulation tests ( / , , fibrinogen).

•  Rationale: Drawn before serum tubes to prevent contamination from clot-activating additives.

2.  Red Top / Gold SST

•  Additive: Clot activator (silica particles) with or without thixotropic polymer gel.

•  Mechanism: Initiates clotting to isolate serum following centrifugation.

•  Primary Uses: Chemistry panels (, ), serology, and immunology.

•  Rationale: Drawn after citrate and prior to heparin/EDTA to prevent anticoagulant contamination.

3.  Green Top

•  Additive: Lithium Heparin or Sodium Heparin.

•  Mechanism: Inhibits thrombin and thromboplastin to prevent clot formation.

•  Primary Uses: Plasma chemistry, electrolytes, and cardiac biomarkers.

•  Rationale: Drawn after serum tubes and prior to EDTA to avoid spuriously elevated potassium.

4.  Lavender Top

•  Additive: Potassium Ethylenediaminetetraacetic Acid ( or ).

•  Mechanism: Irreversibly chelates ionized calcium to preserve cellular morphology.

•  Primary Uses: Hematology testing (, differential, reticulocyte count, and Hemoglobin ).

•  Rationale: Drawn last among routine tubes to avoid binding divalent cations or falsely elevating potassium in other tubes.

Capillary Puncture Protocols and Specimen Processing Integrity

•  Capillary Puncture Execution:

•  Adult Site: Palmar surface of the distal phalanx of the 3rd or 4th finger, perpendicular to fingerprint ridges and slightly off-center.

•  Infant Site: Medial or lateral plantar surfaces of the heel. Avoid the posterior heel curvature and central plantar arch.

•  First Drop: Wipe away the initial blood drop with sterile gauze to prevent contamination by interstitial fluid and tissue debris.

•  Lancet Depth: Maximum  for infant heel sticks ( in premature/low-birth-weight infants) to prevent calcaneus osteomyelitis.

•  Specimen Processing and Integrity:

•  Evacuated Tube Volume: Fill to the nominal line to preserve exact blood-to-additive ratios (e.g.,  for sodium citrate).

•  Hemolysis Prevention: Invert collection tubes gently (), avoid needles smaller than , pull syringe plungers slowly, allow cleansing alcohol to dry completely, and release tourniquets within .

•  Centrifuge Operation: Ensure tubes are capped and balanced by weight and volume across the rotor axis with the lid locked shut.

•  Biopsy Preservation: Store tissue specimens in  neutral buffered formalin () to halt autolysis and fix cellular architecture.

Specialized Diagnostic Testing, Neurological Exams, and Surgical Guidelines

•  Neurological and Sensory Testing:

•  Deep Tendon Reflexes (): Elicited using a reflex hammer on target tendons.

•  Light Touch Sensation: Evaluated using a fine cotton ball or wisp brushed along dermatomes with patient eyes closed.

•  Point-of-Care Capillary Blood Glucose:

•  Site Cleansing: Swab with  isopropyl alcohol and air dry completely to avoid hemolysis and enzymatic strip interference.

•  Quality Control (): Perform daily with liquid controls, as well as when opening new strip lots or after meter drops.

•  Procedural Positions and Surgical Standards:

•  Gynecological Examination: Lithotomy position (supine, hips/knees flexed, thighs abducted, feet supported in stirrups).

•  Upper Endoscopy (): Left lateral position to facilitate scope passage and permit passive oral drainage to reduce aspiration risk.

•  Punch Biopsy Protocol: Obtain and verify informed consent before any clinical preparation or local anesthetic injection.

•  Minor Surgical Procedures: Maintain an uncompromising sterile field throughout the entire procedure duration.