venipuncture course version 1.0

A product developed and marketed by

THE APPRENTICE CORPORATION

Author: Dr. Anton Scheepers

Copyright© The Apprentice Corporation 2013

All rights reserved.

FOR FUTURE MEDICAL PROFESSIONALS

VenipunctureCourse &

Training KitA BASIC COURSE IN PHLEBOTOMY AND IV TECHNIQUES

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

4

Venipuncture Course and Kit |

A basic understanding of general human (or veterinary) anatomy and physiology, especially the cardiovascular system, is required in order to understand and safely apply the techniques that the student will learn. Every “simple” venipuncture procedure is in essence a minor surgical procedure governed by the basic principles of surgery:• Have a comprehensive understanding of basic

medical sciences, especially anatomy and physiology of the relevant areas and systems.

• Follow the basic principles of sterility and asepsis, including the use of barrier techniques.

• Take a medical history and interpret this information to modify your treatment plan.

• Use good lighting.• Respect life and bodily tissues.• Perform the procedure in a humane and professional

manner.• Anticipate the possibility of complications and deal

them promptly and effectively.

The Apprentice Doctor® Venipuncture Skills Course and Kit are not intended to be used as a substitute for clinical training. Instead, The Apprentice Doctor® offers a firm foundation so students can successfully master the initial learning curve in a non-clinical setting before confidently entering the clinical situation. The Apprentice Doctor® Venipuncture Course and Kit consist of:1. The Apprentice Doctor® Venipuncture Course on

DVD-ROM 2. The Apprentice Doctor® Venipuncture Kit with a

Venipuncture Trainer, as well as a variety of medical items to complete all the practical projects.

IMPORTANT NOTES: The information offered in The Apprentice Doctor® Venipuncture Course material is based on recent guidelines set by the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC). The References section gives more information with links to help you keep track of the latest information. Keep in mind that specifics may differ from the information or protocol of your local hospital or training institution. In a clinical field, there are often a number of acceptable protocols, knowledge of more than one offers students a fuller picture. Protocols and standards may vary in different regions and countries, as well as in different

hospitals and training institutions. The basic principles and essential steps, however, should remain very similar. Workable protocols and standards in a mission hospital in rural Tanzania in Africa will be quite different from what is acceptable in a top level training hospital in New York. Medical professionals should always use the highest standards and never compromise patient or personal safety.Despite thorough research, the author and contributing professionals aren’t necessarily perfect. Should you notice any mistakes in either the theory or the practical demonstrations on DVD-ROM, kindly report this to the author in writing or email. Your suggestions will be appreciated for future versions.The www.TheApprenticeDoctor.com website and community complement our products by offering future medical professionals a chance to join like-minded students and by providing a platform for learning from practicing healthcare professionals. You will find a suitable community in your area, and you’ll receive lots of free advice and support.Dr. Anton Scheepers, The Apprentice Corporation staff, and The Apprentice Doctor® community leaders would like to wish you a successful future and look forward to being of assistance towards fulfilling your dreams!

The Apprentice Doctor® Venipuncture Course and Kit is recommended training material for all healthcare professionals whether prospective, in training, or qualified:• Medical students• Pre-medical students• Paramedics and EMT students • Nursing students• Phlebotomy students• Dental students• Veterinary students• Surgery interns/registrars • Advanced first aid practitioners• Military medics• High school students interested in a career in medicine

(guidance required)• Practicing healthcare professionals who would like to

improve their venipuncture skills

The Apprentice Doctor® Venipuncture Course is intended as supportive training material for formally registered and accredited medical, dental and veterinary courses. In itself, this course does not qualify one as a phlebotomist or any other type of medical professional.

PREFACE

www.TheApprenticeDoctor.com

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In any practical endeavor—from writing a book, to painting a picture, to performing a surgical operation—a solid foundation in the basic skills of the discipline is an essential prerequisite.The days when clinical skills were simply taught from senior to junior, from one year to the next are long gone. Clinical skills require an in-depth knowledge of the procedure as well as the opportunity to practice in a simulation environment, with definite guidelines to follow, and parameters to evaluate the student’s progress. Students need to train in a non-clinical setting until they have the

proficiency, knowledge, and confidence to be successful in the clinical situation. Simulation training is not an optional extra, but an essential step in training clinicians who are able to practice medicine safely while avoiding or at least minimize clinical errors. An affordable venipuncture course and kit has been long overdue. The authors, developers, and the various contributors should be commended on a task well done!

Dr John Lemmer – Emeritus professor Oral Medicine and Periodontics, University of the Witwatersrand

Before starting the course, please read these warnings carefully:• The Apprentice Doctor® Venipuncture Course and

Kit is an Educational product. All items in this kit are intended exclusively for non-clinical purposes. Do not use any of these items on actual human or animal patients, even in an emergency.

• This kit and its components are intended exclusively for training/educational purposes. They are not intended for use in any clinical setting, or in the cure, mitigation, treatment, or prevention of disease in man or other animals.

• The Apprentice Doctor® Venipuncture Course and Kit contains sharp instruments. Please be cautious!

• Keep out of reach of children of 14 years and younger, especially toddlers and babies.

• Adult supervision is required for students 15-17 years of age. It is essential that students 18 years and older take extreme care while doing the practical projects.

• Some items may contain latex rubber, not suitable for persons with latex allergies.

• Always use clean items. Wash used items with liquid soap and water after each session then leave in an antiseptic solution (e.g., Savlon) for 60 minutes. Rinse thoroughly with clean water and dry before replacing in the kit.

• Re-use items only in a non-clinical practice situation. In a clinical setting, the re-use of items is not recommended (such as tourniquets) or strictly prohibited (used items such as needles, IV fluids, etc.). Refer to your local hospital’s policies and protocols.

• For any cut or needle prick injuries—squeeze the wound for 15-30 seconds to bleed out impurities, wash profusely with soap and water, apply pressure to stop the bleeding, and then apply an adhesive bandage strip. Seek professional medical assistance.

• Discard all sharp instruments in the “Used Sharps Biohazard Container” provided. On completion of The Apprentice Doctor® Venipuncture Course (including all the practical projects), close the sharps waste container and take the container to a hospital, a healthcare facility or any medical professional for proper sharps biohazard waste disposal. NEVER dispose any sharps (used or unused) into a regular waste bag or bin! Alternatively contact us per email and we will mail a self-addressed box. Return with your sharps container for safe disposal.

• Keep sharp instruments away from the eyes. Protective glasses or visors are recommended.

Important! Familiarize yourself with the warnings on the package and the disclaimer on the leaflets inside the package and on the DVD-ROM before proceeding.

FOREWORD

WARNINGS

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KEYS TO SYMBOLS USED IN THE PRACTICAL PROJECTS

VIDEO

• 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.

• 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.).

• 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.

Sharps will be used!

Blood hazard

SIMULATION PROCEDURE

video/KTS.mp4

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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.

These procedures can be practiced on a suitable fellow student or other adult volunteer.

CLINICAL PROCEDURE: RESTRICTED

CLINICAL PROCEDURE: VOLUNTEERS ALLOWED

DISCLAIMER

The producer or supplier of this application does not:• Offer any warranty regarding the accuracy or

correctness of any information contained in this application.

• Assume any responsibility for any damage or consequential damage related in any way to the information, instrumentation, or items contained in this product/application or as a result of their use.

The user takes full and exclusive responsibility for the safe application of any information contained in this application. The user also takes full and exclusive responsibility for all safety aspects related in any way to the use of any instrument, or item supplied with this application. This exclusive responsibility applies equally to the user or to any person being supervised by the user.

No warranties are offered on the functional status or fitness for the specific application of any information, instrument or item supplied in this application.

The supplier accepts no responsibility for the malfunction of any instrument or item. (The buyer will be entitled to the replacement of such defective items within the time limits of the Basic Terms and Conditions).

The supplier disclaims all liability for any direct or indirect damages—specific or consequential—related in any way to the information and instrumentation or to any items contained in this application.

All practical exercises are performed exclusively at the user’s risk. The producer or supplier of this application disclaims any responsibility for any medical emergencies, medical problems, or any other problems whatsoever that may arise while using any instrument or item or applying any information supplied with this application.

Regarding correctness of information and potential problems arising from any misinformation:Keep in mind that there are differing points of view in medicine and medical knowledge changes quickly. If you think that any information is incorrect, contact us at [email protected].

It is solely and exclusively the responsibility of the users of this application to ensure that the information offered in this course is correct, current and in line with their hospital or institution’s guidelines and protocols.

http://www.theapprenticedoctor.com/terms-conditions/

[email protected]

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The Apprentice Corporation is confident that you will be satisfied with this product in each and every way, as supported by our extremely low return statistics.

If for any reason, you are dissatisfied with your choice, The Apprentice Corporation will be happy to reimburse you (less postage and shipping charges) should you wish to return the complete medical kit, as well as the DVD-ROM in an undamaged state within 8 weeks of purchase.

Please be ethical. It is simply unfair to order and open the kit, as well as some of the items then copy the course material on your computer or other electronic device and then expect a refund on returning the product. Before returning, delete ALL copies of the course

material in your possession then repackage the kit with ALL the items and devices in their original condition, before returning. Shipping is your responsibility and expense. Reimbursement will follow automatically once the kit has been received in our warehouse and has been inspected for completeness and damage.

KINDLY INFORM US REGARDING YOUR INTENTION TO RETURN THE KIT VIA EMAIL. THE ORDER NUMBER AND THE DATE OF THE TRANSACTION SHOULD ACCOMPANY YOUR REQUEST FOR REIMBURSEMENT.

Email: [email protected] For more information see the Basic Terms and Conditions available on our website: www.TheApprenticeDoctor.com

REIMBURSEMENT POLICY

The Apprentice Corporation, its employees, any associates, as well as the distributors of the product completely absolve themselves of any liability or potential liability for any misadventure or complications that may result from using this kit or the information contained in the course material. We take no responsibility whatsoever for any adverse outcome, problems, or complications of any nature that might occur as a direct or indirect consequence

of using the kit or applying the information from the course material. Using this Kit—the instruments, items, and information supplied on the CD-ROM—is conditional upon your acceptance of this disclaimer and commitment to honor copyrights.

For further information on copyright see Copyright Information.

[email protected]





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RECOMMENDATIONS ONHOW TO USE THE APPRENTICE DOCTOR® VENIPUNCTURE KIT

VIDEO

To gain maximum benefit from The Apprentice Doctor® Venipuncture Course and Kit, the following guidelines should be followed:• Read the WARNINGS and DISCLAIMER sections

attentively. They are available on The Apprentice Doctor® Venipuncture DVD.

• Work systematically through course material. Be sure that you understand each section and can perform the practical projects skillfully before proceeding to the next section. Do not skip a section because you think it is unimportant or too simple. Although basic principles often appear to be simple, you must understand and practice these simple building blocks in order to succeed later with more complicated applications. Perform the practical skills projects only when you understand the theory involved in that specific section.

• Start with the Introduction section. You will learn about the items contained in The Apprentice Doctor® Venipuncture Kit. Section 2 contains vital information about taking a medical history, sterility and asepsis and offers the opportunity to practice relevant basic skills.

• Systematically study The Apprentice Doctor® Venipuncture Course Sections 3, 4 and 5 in order and perform all of the practical projects using your Venipuncture Trainer where applicable. Do not omit Section 5 on complications – it is of utmost importance that one has a thorough

knowledge of related complications and how to avoid, minimize and manage them.

• Study all of the medical terms in the Venipuncture Glossary. Play the various Venipuncture games – and have fun while learning!

• Check out the hyperlinks, particularly the latest information on the WHO and CDC websites. Visit The Apprentice Doctor® Web site (www.TheApprenticeDoctor.com) for information on other educational medical kits – like The Apprentice Doctor Suturing Course and Kit and the Examine Patients Course and Kit as well as information about events like The Apprentice Doctor Camps and Clubs.

• Please direct all technical enquiries regarding orders and products via the Contact us facility on the website. Use the Ask Dr. Anton link on the website for enquiries related to The Apprentice Doctor regarding course material or careers in medicine.

• Start with the Introduction section. You will learn about the items contained in The Apprentice Doctor® Venipuncture Kit. Section 2 contains vital information about taking a medical history, sterility and asepsis and offers the opportunity to practice relevant basic skills.

For business and reseller information email us at [email protected].

video/0INT.mp4

http://www.theapprenticedoctor.com/contact-us/

[email protected]

[email protected].

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This course helps you master venipuncture and intravenous (IV) techniques used by medical professionals.

The course explains the art and science of phlebotomy, setting up an IV-line, and related skills. Most importantly, the Venipuncture Trainer and Kit give students the opportunity to practice these skills before entering a clinical setting.• An illustrated hands-on course is available online

and on DVD-ROM. Download an APP for your mobile device.

• The kit includes real medical items you will need to practice more than 30 step-by-step practical projects.

• A simple but effective Venipuncture Trainer is 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

On completion of this course, students should have gained the following skills:

• Collecting capillary blood• Drawing venous blood (various techniques)• Drawing arterial blood• Giving a subcutaneous injection• Giving an intra-muscular injection• The student will receive basic information regarding

other specimens (excluding blood) received by the medical technology lab (e.g., urine, sputum and pus)

• The student will understand how to recognize and how to deal with common and less common complications of venipuncture

OBJECTIVES OF THE COURSE

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INDEXPREFACE 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

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*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

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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

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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

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Venipuncture Course and Kit | INTRODUCTION

CASE STUDY 1:AN AVOIDABLE ACCIDENT—AN UNNECESSARY DEATH

http://youtu.be/9-7jGulIUjI

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A 32-year-old nurse with an infectious smile cheerfully reported for duty, but she had no idea that this would be her final, ill-fated day.Helosini Pillay was a vibrant young woman who had just completed her degree and started a new job at Lancet Laboratories in Morningside Clinic. Helosini sat down to perform a routine blood draw on a patient. She accidentally bumped the trolley where she had placed the needle and syringe. The needle and syringe fell and pierce her right calf. She reported it to her senior who ordered an HIV test on this patient. Results showed that the patient was HIV-negative. However, a previous blood test indicated that he had malaria.Helosini asked if she might contract malaria from her needle stick injury but was assured that she could only contract malaria from a mosquito or if she lived in an area that was at risk for malaria. She went home thinking that everything would be fine.

That evening, Helosini complained to her sister that her leg was turning blue and that she had flu-like symptoms. Nine days later, she was worse. She decided to go to her doctor, but changed her mind and went to a pharmacy instead and purchased flu medication.On Christmas Eve, Helosini was so sick that she went to her doctor who diagnosed her with bronchitis. A few days later, Helosini’s sister, Yogeshini, found her unconscious on the bathroom floor. Yogeshini rushed her sister to the hospital where it was confirmed that she had contracted malaria. In addition, she had developed a complication called Adult Respiratory Distress Syndrome (ARDS). Family members were called as she was in a critical condition and gasping for breath. She never regained consciousness and two weeks later she died.

And so an expensive lesson is learnt. Routine use of safety needles would have prevented this tragedy.

PHLEBOTOMY Phlebotomy is the procedure of removing (drawing) blood from the vascular system by puncturing a vein or sometimes an artery with a needle or by making an incision (rarely) to obtain a blood sample for:• Diagnostic purposes• To be analyzed by a medical laboratory• Therapeutic purposes

- To treat polycythemia vera, a condition that causes an elevated red blood cell volume (hematocrit). Phlebotomy is also prescribed for hepatitis B and C and for patients with disorders that increase the amount of iron in their blood to dangerous levels, such as hemochromatosis. Phlebotomy may be 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.

Venipuncture is the act of puncturing a vein with a needle or cannula (needle carrying a flexible plastic catheter) for drawing blood, for administering a therapeutic substance for intravenous feeding, or for therapeutic purposes. Although venipuncture is often performed for medical purposes or to administer a general anesthetic, it is in essence a minor surgical procedure – and thus the basic principles of surgery apply.

Intravenous therapy (IV infusion) is the method by which therapeutic fluid/solution or medication is administered intravenously through an infusion set. The IV set includes: a plastic or glass bottle containing a solution, and tubing to connect the bottle to a catheter or a needle in the patient’s vein.

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.

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TYPESOLUTION

(EXAMPLE)USES

SPECIAL

CONSIDERATIONS

Isotonic Dextrose 5% in water

(D5W)

• Fluid loss

• Dehydration

• Hypernatremia

• Use cautiously in renal and cardiac

patients

• Can cause fluid overload

Isotonic 0.9% Sodium Chloride • Shock

• Hyponatremia

• Blood transfusions

• Resuscitation

• Fluid challenges

• DKA (diabetic ketoacidosis)

• Can lead to overload

• Use with caution in patients with

heart failure or edema

Isotonic Ringer’s Lactate/Lactated

Ringers (LR)

• Dehydration

• Burns

• Lower GI fluid loss

• Acute blood loss

• Hypovolemia due to third spacing

• Contains potassium, don’t use with

renal failure patients

• Don’t use with liver disease (can’t

metabolize lactate)

Hypotonic 0.45% Sodium Chloride (1/2

normal saline)

• Water replacement

• DKA

• Gastric fluid loss from NG or vomiting

• Use with caution

• May cause cardiovascular collapse

or increased intracranial pressure

• Don’t use with liver disease, trauma,

or burns

Hypertonic Dextrose 5% in ½

normal saline

• Later in DKA treatment • Use only when blood sugar falls

below 14 mmol/l (250 mg/dL)

Hypertonic Dextrose 5% in normal saline • Temporary treatment

for shock if plasma expanders aren’t

available

• Addison’s crisis

• Don’t use in cardiac or renal patients

Hypertonic Dextrose 10% in water • Hypertonic water replacement

• Conditions where some nutrition

with glucose is required

• Monitor blood sugar levels

Table 1: Intravenous Fluid Comparison by Type

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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.

PROJECT 1AFAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT

This kit contains sharp items that can be potentially hazardous if they are not used correctly and safely. Keep the kit and contents away from babies and children under the age of 15. Adult supervision is required for students 15-17. It is essential that all students take extreme care while doing the practical projects. Prepare yourself for the clinical situation and imagine

working on an HIV+ patient while practicing on the trainer.Some items in the kit may contain LATEX and are not suitable for persons with latex allergies.Before proceeding, familiarize yourself with the warnings on the package and DVD-ROM and with the disclaimer on the leaflets inside the package.

WARNING

VIDEO

video/1A.mp4

video/1A.mp4

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CHECK LIST OF MEDICAL ITEMS INCLUDED IN THE KIT

Connectors / Lumen stoppers 4

The Apprentice Doctor®Venipuncture CourseDVD-ROM

1

Syringe for SQ Injections 1

Regular Needles 9

IV Catheter 2

Regular Syringes 6

Venipuncture Trainer 1

Safety Needles 3

IV Fluid Bag 1

IV Lines 2

Glass Vial 1

Butterfly Needles 2

Lancets – Safety and Regular 3

Disposable Tourniquet 2

REQUIREMENTSVenipuncture 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.

https://www.dropbox.com/s/xbl15dw3qujc03d/list.pdf

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Blood Vacuum Tubes 5

Plastic Vial 1

Safety VacuumContainer Device 1

Vacuum Container Hub and Needles 1

Gauze Squares 10

1Tournistrip

Ruler and Pen 1

Alcohol Prep Swabs 10

Reusable Tourniquet 1

Cotton Wool 5

Roll of Strapping 1

Work Surface Cover 3

pairs

Gloves 5pairs

pairs

Sharps Waste Container 1

1Transparent Dressing

* PLEASE NOTE: • Contents may vary slightly from the list depending on

availability. • Kits are double checked for quality and completeness

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 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 working on the Venipuncture Trainer. However, in the clinical environment, safety needles should be used exclusively.

More information [CLICK HERE]

[email protected]

http://www.venipuncture-training.com/

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STEP 2Open the Venipuncture Trainer and compare it with the illustration below.

The trainer is simple, effective, and functional.

The Apprentice Doctor® offers realistic trainer simulation arms for group training. [ORDER ONLINE].

STEP 3Buy red food colorant – available from grocery stores – and add to the kit.

STEP 4Replace all the items in your Kit and proceed with the 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.• Warm IV fluids are often used in restoring the body

temperature of hypothermic patients. IV fluids should be warmed to approximately 43°C or (109.4° F) prior to administration. As most hypothermic patients are also dehydrated, warm intravenous fluids serve a dual purpose.

• Contaminated IV fluids have at times resulted in the death of a patient or even multiple deaths. Ensure that 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.

ASPECTS OF SAFETY What is the most serious complication that may follow a

simple venipuncture procedure? Is it a large hematoma? Is

it permanent nerve damage that causes the loss of normal

sensation over the forearm and hand? Or is it a motor nerve

injury with partial paralysis of muscles in the arm or hand?

The truth is much graver – the ultimate complication is

death (see case studies in the various sections.)

A great number of serious or even fatal accidents and

complications are avoidable, so do not skip this section or

rush through it. This information is vitally important! Study

this section thoroughly before proceeding – you and your

patients’ lives depend on your carefully application of this

information.

Sharps injuries are ‘through the skin’ wounds caused by

sharp medical items like needles, scalpels, or other sharp

objects such as glass medicine vials. Sharps injuries are

occupational hazards frequently encountered by medical

professionals who handle needles. These injuries pose the

risk of transmitting bloodborne pathogens such as the

hepatitis B virus (HBV), the hepatitis C virus (HCV), as well

as the human immunodeficiency virus (HIV). Needlestick

injuries are common events in the healthcare environment;

Mario Saia et al¹ in 2010 reported an estimated 384,000

cases in the USA alone.¹

Hollow needle injuries are especially dangerous and carry

a very high risk of transmitting bloodborne diseases.

Infected material coming into contact with a mucus

membrane (e.g. blood splashing into the eye) also carries a

risk of transmitting disease.

BEFORE STARTING, YOU MUST FIRST READ THE FOLLOWING:

http://www.theapprenticedoctor.com/venipuncture/

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Centers for Disease Control and Prevention (CDC) guidelines and recommendations regarding the use of needles, cannulas, and intravenous delivery systems:

• Use aseptic techniques to avoid contamination of sterile injection equipment.

• Do not administer medications from the same syringe to more than one patient, even if the needle or cannula on the syringe has been changed. Needles, cannulas, and syringes are sterile, single-use items; they should neither be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.

• Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) for one patient only and then dispose of them appropriately. Once a syringe or needle/cannula has been used to enter or connect a patient’s intravenous infusion bag or administration set, consider it contaminated.Use single-dose vials for parenteral medications whenever possible.

• Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents.

• If multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile.

• Do not keep multi-dose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable.

• Do not use bags or bottles of intravenous solution as a common supply source for several patients.

Download CDC Posters on preventing injuries with sharps:

[POSTER 1 HYPERLINK][POSTER 2 HYPERLINK][POSTER 3 HYPERLINK][STUDY CDC GUIDELINES FOR HANDLING SHARPS²]

Look at the WHO Publication on sharps injuries:Assessing the burden of disease from sharps injuries to health care workers at national and local levels.³

All students, especially those in USA, should acquaint themselves with the relevant legalities in the OSHA Occupational Safety & Health Administration’s documents:

• Read OSHA’s Workers page,

• Bloodborne Pathogens and Needlestick Preventions and http://www.osha.gov/needlesticks/needlefaq.html

In the USA, the Needlestick Safety and Prevention Act of 2000 makes the use of ‘engineered sharps injury protection’ mandatory in the workplace. In practice, it means that safety needles and safety devices are compulsory in the USA and in a number of other countries.

In order to reduce or eliminate the hazards of occupational exposure to bloodborne pathogens, an employer must implement an exposure control plan for the worksite with details on employee protection measures. The plan must describe how the employer will use a combination of engineering and work practice controls. Among other provisions, the employer must ensure the use of personal protective clothing and equipment and provide training, medical surveillance, hepatitis B vaccinations, as well as signs and labels. Engineering controls are the primary means of eliminating or minimizing employee exposure and include the use of safer medical devices, such as needleless devices, shielded needle devices, and plastic capillary tubes.

[SEE ACT HERE: USA NEEDLESTICK SAFETY AND PREVENTION ACT OF 2000]

IMPORTANT!If you are injured or pricked by a needle or other sharp object or get blood or other potentially infectious materials in your eyes, nose, mouth or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Immediately report this to your employer and seek immediate medical attention. Credit: U.S. Department of Labor

http://www.cdc.gov/sharpssafety/pdf/sharpssafety_poster1.pdf



http://www.cdc.gov/sharpssafety/


http://www.who.int/quantifying_ehimpacts/publications/en/sharps.pdf

http://www.who.int/quantifying_ehimpacts/publications/en/sharps.pdf

http://www.osha.gov/workers.html

http://www.osha.gov/SLTC/bloodbornepathogens/

http://www.osha.gov/needlesticks/needlefaq.html

http://www.cdc.gov/sharpssafety/pdf/Neelestick%20Saftety%20and%20Prevention%20Act.pdf

http://www.cdc.gov/sharpssafety/pdf/Neelestick%20Saftety%20and%20Prevention%20Act.pdf

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PROPER SHARPS DISPOSAL AND ILLEGAL INJECTION DRUG USERS Globally, around 16 million people inject drugs and 3 million of them are living with HIV according to 2012 WHO statistics.

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

into a regular waste bin or bag. Hand a full sharps waste container to a medical professional at a hospital, a medical clinic, or to your family doctor for proper sharps waste disposal.

Alternatively contact us per email and we will mail a self-addressed box. Return with your sharps container for safe disposal. Email to [email protected]

http://www.who.int/hiv/topics/idu/en/index.html

http://www.who.int/hiv/topics/idu/en/index.html

[email protected]

25


PROJECT 1BHOW TO USE A SAFETY NEEDLE/DEVICE

VIDEO

It is all about safety—for your patients AND YOU!

WARNINGS: • In this project you will work with sharp items. Take

great care to avoid injury to yourself and others.• You will use safety needles in this project. The

Autosafe®-Reflex® needle’s safety features will make a needle injury unlikely – but in the final analysis there is no substitute for caution.

• Follow the instructions accurately!

INFORMATIONThe Apprentice Doctor® has done a fair amount of research to identify the best safety needle system for our Venipuncture Kits. Based on research of The Health Care Product Evaluation Center at the University of Virginia, the Autosafe®-Reflex® safety needles showed excellent results and came out on top. Therefore we include 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 needleThese needles are VERY easy to use – however, in order for them to be effective, one needs to use them correctly.

video/1B.mp4

http://www.youtube.com/watch?v=-z3KqWd2c4U

http://autosafereflex.ipcoweb.com/user_images/university_of_viriginia/autosafe_reflex_safety_needle_university_of_virginia_evaluation.PDF



26


FOLLOW THESE INSTRUCTIONS EXACTLY: STEP 1Look at the diagram of the needle with its various parts

Figure 2: Cross section of the Autosafe®-Reflex® safety needle

STEP 2Open a clean work surface cover. On it, place the unassembled Venipuncture Trainer, an opened 5ml syringe, and an unopened safety needle.

STEP 3Wash your hands. Start now to develop this simple but effective habit. If you like, don clean gloves (gloves optional).

STEP 4Orientation is important when opening the Autosafe®-Reflex® safety needle. Hold the needle with the paper cover facing up. The needle is packed with its bevel facing up, towards the paper cover. Kept in this orientation, the needle will be positioned correctly for performing clinical procedures like venipuncture.

STEP 5Lift the edge of the paper cover and peel it backwards. Pinch the package at the fold (at the base of the package) and fold the base down.

STEP 6Fit the needle to the syringe, and withdraw the safety needle from the package while maintaining the needle’s orientation.

STEP 7Withdraw the plunger of the syringe to fill the syringe with 3-5 ml of air, just for practicing purposes.

STEP 8Pull the safety mechanism back and hold gently, just on the one side, in the activated position with your middle or index finger.

STEP 9Remove the protective sleeve of the needle.

STEP 10Perform 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 Injection for more information.

STEP 11Inject the air into the Venipuncture Trainer.Warning note: Normally one would carefully eliminate all air bubbles from the syringe and needle before injecting. NEVER inject air into a patient — neither by SCI, IMI, nor IVI.

STEP 12Remove your index finger from the safety mechanism.

STEP 13Withdraw the needle; you will notice the reflex mechanism activates spontaneously and passively. The sharp needle tip will be covered by the safety cap, in a somewhat off-center position.

STEP 14Remove the needle by disconnecting it from the hub of the syringe. Discard the used needle into the sharps waste container. Never try to recap a regular needle or reassemble a safety needle. In a clinical setting, you will discard the complete unit (syringe and needle).

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NOTE:• In rare instances, after activating the Autosafe®-

Reflex® needle’s safety device, you may need to expose the needle again — for example when withdrawing medication from a vial using the safety needle. See this demonstration on how to safely expose the needle again: [VIDEO-CLIP]

• Look at the Autosafe®-Reflex® Vacutainer Phlebotomy Device – it is equipped with an Autosafe®-Reflex® needle. Do not open the device at this stage – this device will be used in PROJECT 11 A – DRAW VENOUS BLOOD USING A VACUUM TUBE.

POINTS OF INTEREST• According to the Centers for Disease Control and

Prevention (CDC), about 385,000 sharps injuries occur annually to hospital employees and WHO resources estimate the frequency of needlestick injuries at about 3.5 million cases worldwide. [CLICK HERE] for more information.

• As a consequence of sharps injuries, there are an estimated 66,000 infections with HBV, 16,000 with HCV, and more than 1,000 with HIV worldwide.

• CDC guidelines for PEP (post-exposure 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]!

video/1B.mp4

https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html

http://www.who.int/eht/ps/en/index.html

http://www.autosafe-reflex.com

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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]

https://www.dropbox.com/s/0fte3ie1qbzcah9/the_main_arteries.pdf

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VEINS AND ARTERIES OF THE HEAD AND NECK

[DOWNLOAD PDF]

https://www.dropbox.com/s/tsqcmd2q96u6vwl/head_arteries_and_veins.pdf

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ARTERIES OF THE ARM

[DOWNLOAD PDF]

https://www.dropbox.com/s/jz5fkhircfcxcbc/arm_arteries.pdf

31


VEINS OF THE ARM

[DOWNLOAD PDF]

https://www.dropbox.com/s/sm669hegww7fh4x/arm_veins.pdf

32


VEINS OF THE ARM (CLOSE-UP)

[DOWNLOAD PDF]

https://www.dropbox.com/s/rzzp13dinev60x2/arm_veins_close_up.pdf

33


VEINS OF THE HAND

[DOWNLOAD PDF]

https://www.dropbox.com/s/0g5pv8hz9pbgg10/dorsal_hand_veins.pdf

34


ARTERIES OF THE LEG

[DOWNLOAD PDF]

https://www.dropbox.com/s/9ufr9nvcpygvwl0/leg_arteries.pdf

35


VEINS OF THE LEG

[DOWNLOAD PDF]

https://www.dropbox.com/s/qd6nlovt2t9kczc/leg_veins.pdf

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BLOOD

ANOMALOUS SUPERFICIAL ARTERIES IN THE ARMThe 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 is classified as a specialized connective tissue from an embryological point of view. Blood is the fluid that circulates through the heart, arteries, capillaries, and veins and is the chief means of transport within the body. It transports oxygen from the lungs to the body tissues, and carbon dioxide from the tissues to the lungs. It transports nutritive substances and metabolites to the tissues and removes waste products to the kidneys and other organs of excretion. It has an essential role in maintaining fluid

balance. The total blood volume of an adult varies between 5-6 liters for males and 4-5 liters for females. Whole blood is blood drawn from the body from which no constituent, such as plasma or platelets, has been removed.Blood fractionation is the process of fractionating whole blood, or separating it into its component parts. This is typically done with a centrifuge.

BLOOD PLASMAThe liquid phase of the blood, obtained by sedimentation or centrifugation of blood treated with an anticoagulant (anti-clotting agent).Plasma is mostly fluid, consisting mainly of water, as well as three specific types of proteins (albumin, globulins,

and fibrinogen), dissolved salts (ions), food nutrients, waste products, hormones, vitamins, and dissolved gasses (oxygen and carbon dioxide).Albumin’s main function is to prevent water from leaving the capillaries – thus albumin holds water inside the intravascular space.

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.

Figure 3a: A typical hematology lab centrifuge apparatus Figure 3b: Centrifuged blood in tube

http://bja.oxfordjournals.org/content/94/5/692.full

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Globulins are mainly the immune system’s antibodies.Fibrinogen plays a major role in blood clotting. Blood serum is blood plasma without fibrinogen or the other clotting factors.

BLOOD CELLSIf a drop of human blood is thinly smeared across a 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

Blood cells include red blood cells, a variety of white blood cells (lymphocytes, neutrophils, basophils, eosinophils, and monocytes), and blood platelets. Leukocytes include the following white blood cells: lymphocytes, neutrophils, eosinophils, and monocytes. Blood platelets are small cell fragments that play an essential role in the blood clotting process. The buffy layer between the plasma and red blood cells contains all the white blood cells, as well as the blood platelets.

Packed red blood cells are red blood cells that have been separated from whole blood for transfusions. Packed red blood cells (RBCs) essentially contain the same amount of hemoglobin as whole blood, but most of the plasma has been removed.

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

of hemoglobin molecules. This maximizes the cell’s oxygen-carrying ability. The biconcave shape increases its surface area to ensure optimal gas exchange.

HEMOGLOBINHemoglobin has four protein chains, and each protein chain is called a globin. Hemoglobin consists of four contorted protein globin chains, two Apha and two Beta.

Figure 4: A graphic illustration of hemoglobin

A heme is ring shaped molecule with an iron ion (Fe+2). Oxygen has a high affinity to the heme ion. Each hemoglobin molecule has four hemes; each heme provides a place to carry an oxygen molecule. So each hemoglobin molecule can carry four oxygen molecules. Every single red blood cell is packed with 280 million hemoglobin molecules. It follows that one red blood cell could carry about one billion oxygen molecules!

Hematology: Hematology is the study concerned with the diagnosis, treatment, and prevention of diseases of the blood and bone marrow, as well as of the immunologic, hemostatic (blood clotting) and vascular systems. Because of the nature of blood, the science of hematology profoundly affects the understanding of many diseases.

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Venipuncture Course and Kit | PREPARATION

CASE STUDY 2:CONTRACTING ONE OF THE MOST FEARED DISEASES IN THE WORLD TODAY

http://youtu.be/vQSCv7UIGe8

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Imagine being extremely ill with a high fever, a splitting headache, diarrhea, and vomiting. You are also bleeding from the nose, the mouth, and all bodily orifices! The healthcare workers treating you are wearing clothes that look like space suits. In one week, your chance of survival is a slim 20%.Sounds exaggerated? This is real–the hemorrhagic fever of the highly contagious Ebola virus! In the past 20 years, more than 1000 confirmed cases of Ebola had a mortality rate of 80% to 90%. There is no known drug or cure for Ebola.Marilyn Lahana of Parkmore, South Africa is believed to have been the first diagnosed victim to contract the deadly Ebola virus. For three weeks, she bravely fought for her life in isolation at Johannesburg Hospital, while medical officials desperately scrambled to find the source of the virus. Marilyn Lahana was a nurse working at a private clinic in Johannesburg. Officials believe that she contracted the virus from a man from Zaire who died at

this clinic undiagnosed three weeks earlier. People who had been in contact with Marilyn were checked twice daily for symptoms, but fortunately none of her family members or friends contracted this vicious disease.

Ebola is spread through tainted blood and the only sure cure is by prevention. Patients with Ebola are kept under strict quarantine.

• All healthcare workers need to have a thorough knowledge of sterility, asepsis, barrier techniques, as well as well as, the various skills associated with aseptic technique.

• Saving lives are not necessarily intricate cardio – or neurosurgical procedures – in most cases medical professionals save lives by performing simple routines – like washing hands and donning clean gloves.

Your and your patients’ lives depend on you to strictly follow procedures for sterility and asepsis – do not slip up!

SHORT NOTES ON MEDICAL HISTORYThe taking of a comprehensive medical history by a qualified medical professional is essential for diagnosing, managing, and treating any patient. A full comprehensive 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.

WARNING!Some syringes and medication vials contain a tiny amount of latex. Ensure that all items are factory marked: latex-free if you treat a patient who is allergic to latex. A patient’s severe latex allergy may become life threatening in a matter of minutes!

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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]

SAMPLE REQUISITION FORMAn 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.)

• Phlebotomist’s name• Indicate the test(s) requested• An example of a simple requisition form with the

essential elements is shown below:

LABELING THE SAMPLEA 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 tubeAutomated systems may include labels with bar codes. Examples of labeled collection tubes are shown below:

PROJECT 2 TAKE A MEDICAL HISTORY

[PRINT A FORM] A number of forms are available in the kit.

Figure 5: Examples of labeled collection tubes

PATIENT INFORMATIONWhen 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.

http://www.theapprenticedoctor.com/store/products/the-apprentice-doctor-how-to-examine-patients-course-and-kit/

http://www.theapprenticedoctor.com/store/products/the-apprentice-doctor-how-to-examine-patients-course-and-kit/

hyperlinks/lab_requisition_form.pdf

https://www.dropbox.com/s/k3u98oxh2mmsdbl/lab_requisition_form.pdf

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Study this section carefully as it can make the difference between frequent and occasional complications and possibly the difference between life and death!

Figure 6: A surgeon scrubbing before surgery

SHORT NOTESON ASEPTIC TECHNIQUE

PROJECT 3A A TECHNIQUE FOR PROPER HANDWASHING

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 excretions (e.g., feces.)

• Don clean gloves

Learn to wash your hands – prepare them hygienically before examining a patient

VIDEO

PROJECTS 3A – 3I

video/3A.mp4

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INFORMATIONIt is recommended that students study the WHO Guidelines on Hand Hygiene⁴ before starting this section of the course.• The simple act of handwashing is probably the single

most important way to reduce the transfer of harmful microorganisms from one person to another.

• For handwashing to be effective, you must adherence to proper technique.

• Handwashing is also important for reasons of personal hygiene, e.g., washing hands after using the bathroom and before meals.

• Staff working in the food and restaurant industries require a high level of hygiene including a protocol regarding handwashing in order to avoid contaminating food with dangerous microorganisms.

SETTING:The bathroom or any room with a suitable faucet and sink for washing hands.

REQUIREMENTS• A nail clipper or nail care set.• Soap (antiseptic or regular). Liquid soap is preferable,

but a bar of soap will do.• Clean single-use towels, e.g., disposable paper towels.

NOTE:1. Handwashing can be subdivided into the following seven important steps.

• Open faucet • Wet • Soap• Wash• Rinse• Dry• Close faucet

2. Hands should be washed for at least 40-60 seconds to be effective.

3. A healthcare worker’s nails should ALWAYS be kept neat, short, and hygienically clean!

PROCEDURE:STEP 1Turn on the faucet and adjust to a moderate stream of water. Wet both hands up to the wrists.

STEP 2Apply enough soap to the hands until you have a rich foamy lather. Completely lather the surface of both hands and up the wrist.

STEP 3Repeat the following actions at least five times:

3.1 Rub hands palm to palm.3.2 Right palm over the back of the left hand with fingers interlaced and vice versa.3.3 Palm to palm with fingers interlaced.3.4 Backs of fingers to opposing palms with fingers interlocked.3.5 Rotational rubbing of left thumb clasped in right palm and vice versa. 3.6 Rotational rubbing, backwards and forwards with clasped fingers of right hand and vice versa.3.7 Rotational rubbing of wrist by opposing palm and vice versa.

STEP 4Rinse the hands well. Allow running water to flow over the hands. If possible let the water run from the fingertips to the palms and then towards the wrists. Rinse soap off completely.

STEP 5Dry hands thoroughly with a single-use disposable paper towel. Start at the fingers, work to the palms and back of the hands, and lastly dry the wrist areas. Use the same towel to turn off the faucet. Alternatively use your elbow to close the faucet. Do not use your clean hands.

STEP 6Your hands are now hygienically prepared. If you intend to perform a clinical examination, don clean gloves. (See PROJECT 3C)

http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf


video/3C.mp4

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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.

video/3B.mp4

46


PROJECT 3CHOW TO DON (PUT ON) CLEAN GLOVES

Print out the World Health Organization’s (WHO) guideline diagram and follow the steps

PROJECT 3B CLEANING HANDS WITH AN ANTISEPTIC RUB


VIDEO

video/3C.mp4

video/3B.mp4

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• Touching only the cuff, take the first glove out of the original box.

• Try to touch only the wrist area of the glove, i.e., the top end of the cuff.

• Don the first glove by sliding it over the fingers, palm, and wrist.

• With the bare hand, take a second glove from the box – again, only touching the glove’s cuff or wrist.

• Don the second glove – touch only the external surface of the second glove with the already gloved hand.

• Your gloved hands should not touch anything else that is not indicated for glove use.

• 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

PROJECT 3F *HOW TO SCRUB FOR A STERILE PROCEDURE

PROJECT 3G *HOW TO GOWN FOR A STERILE PROCEDURE

PROJECT 3DHOW TO SAFELY REMOVE USED GLOVES


*See The Apprentice Doctor® Foundation Course for further information on how to perform these procedures. [CLICK HERE]



video/3D.mp4

http://www.theapprenticedoctor.com/pre-med-course-for-high-school-students-future-doctors/



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PROJECT 3HHOW TO DON STERILE GLOVES


PROJECT 3I*HOW TO REMOVE CONTAMINATED GLOVES


video/3H.mp4


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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.

PATIENTPOSITIONING

PERFORMING VENIPUNCTUREON A VEIN OF THE UPPER EXTREMITY

Figure 8b: Patient in supine positionFigure 7: Patient in sitting position

Figure 8a: Patient in Semi-Fowler’s position

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The supine position is best when performing venipuncture on a vein of the lower extremity or neck. To distend the veins, you may position the bed in a slight Trendelenburg position for the external jugular vein and in a slight reverse Trendelenburg position for the veins of the lower extremity

Figure 9a: Trendelenburg

Figure 9b: Reverse Trendelenburg position

PATIENT POSITIONING FOR ARTERIAL BLOOD SAMPLING FROM THE RADIAL ARTERYThe 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 FROM THE FEMORAL ARTERYThe 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.

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PROJECT 4AHOW TO APPLY A TOURNIQUET (DISPOSABLE)

TOURNIQUETS - PROJECTS 4A – 4D

INFORMATIONA tourniquet is a constricting or compressing device used

to control (stop or reduce) venous or arterial circulation to

an extremity for a period of time.

IMPORTANT NOTE REGARDING ARTERIAL TOURNIQUETS: A surgeon may use an arterial tourniquet under controlled

conditions within specific time limits to stop the arterial

blood flow to a limb. However, in the following discussion

we will exclusively focus on the use of tourniquets to reduce

or stop the venous return of blood to the heart for a period

of time.

A venous tourniquet is usually applied 7-10 cm (3-4 inches)

above the intended venipuncture point on either the upper

or lower extremity. The idea behind applying a tourniquet

is to minimize the flow of venous blood back to the heart

while allowing the arterial blood to flow undisturbed to

the extremity. Blood will thus fill and distend the veins due

to their fairly thin and collapsible walls. Then the veins are

easier to see and feel, thus making venipuncture easier

to perform without complications. Pressure exerted by

the tourniquet must be high enough to stop or impede

the venous return to the heart, but low enough to allow

free arterial blood-flow, about 45-65 mmHg (millimeters

Mercury).

From a hygienic point of view, a disposable tourniquet is

the best option, as each one is discarded after a single-use.

Disadvantages may include cost and secondly you must be

careful of latex allergies, as these tourniquets are often made

of latex. Affordable latex-free disposable tourniquets (like

the one in your kit) are available and recommended.

Reusable tourniquets should be properly laundered at

regular intervals and after any suspected contamination.

Enquire about this at your hospital’s infection control section.

A simple technique to facilitate easier venipuncture

video/4A-4D.mp4

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REQUIREMENTSYou will need:• A volunteer test patient• One disposable (latex-free) tourniquet• A re-usable tourniquet• A blood pressure cuff (if you have one available)

FOLLOW THESE STEPS FOR DRAWING BLOOD FROM THE CUBITAL FOSSA AREA:

STEP 1Take a short medical history, especially regarding allergies (latex, Iodine and IV drugs, etc.). The tourniquet and gloves in this kit are latex-free

STEP 2Remove clothing from the arm up to the middle of the upper arm. Place the tourniquet about 7-10 cm (3-4 inches) above the elbow.

STEP 3Place the tourniquet under the patient’s arm with an end in each hand. Ensure that it lies flat on the skin surface

STEP 4Swap the two tourniquet ends to opposite hands so that the end on the right is closer to you. Pull the ends upwards to form an ‘X’.

STEP 5Fold the end on the right side over on itself. Pull both ends upwards, with the end on the right side being somewhat tighter.

STEP 6Tuck the double-folded end halfway under the other left end, leaving the free end, approximately 5 cm (2 inches) long, pointing away from you. Ask your volunteer patient to clench a fist to help distend the veins. Inspect and palpate the veins.

STEP 7When you are finished with the venipuncture procedure, simply pull the free end to release the tourniquet.

POINTS OF INTERESTIf a tourniquet is used for preliminary vein selection, do not leave the tourniquet on for more than one minute. If you need more time, release it for two minutes then reapply.Recommended maximum tourniquet time for phlebotomy procedures is one minute. WHO guidelines give the maximum time as two minutes.

The following guidelines ONLY apply to practicing:When practicing you may leave the tourniquet on for longer – as long as one does not make it so tight as to stop the arterial flow as well – which is unlikely. For safety reasons when practicing do not leave the tourniquet on for longer than 5 minutes. Take a break for at least 5 minutes before reapplying.

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PROJECT 4BHOW TO APPLY A TOURNIQUET (TOURNISTRIP®)

INSTRUCTIONS

The Tournistrip® is an easy-to-use disposable tourniquet that complies with single-use tourniquet protocol.

STEP 1Remove Tournistrip® from box.

Pull a Tournistrip® from the roll and tear along the perforated line. You can use the tabs on the box to help further reduce cross infection.

STEP 2Expose the adhesive panel on Tournistrip® (see peel here)

Peel the removable section before wrapping the tourniquet around arm.

STEP 3Place Tournistrip® around arm with the printed side facing outward.

Slip the slim end through the slot in the wider tab end.

STEP 4Hold the tab end between thumb and forefinger and pull the slim end to tighten.

When tension is sufficient, stick the slim end down on the exposed adhesive stripIf necessary, lift Tournistrip® away from the adhesive and reapply.

STEP 5Release Tournistrip®.

To remove, pull slim end up and away from adhesive section.

Order Tournistrips® [Click Here]

video/4A-4D.mp4


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PROJECT 4CHOW TO APPLY A TOURNIQUET (REUSABLE)

PROJECT 4DHOW TO APPLY A TOURNIQUET (BLOOD PRESSURE CUFF)


The main concern with reusable tourniquets is the possibility of transferring harmful microbes to a patient, especially if the cleaning recommendations are not followed to maintain the highest levels of hygiene possible. Reusable tourniquets if you follow the hygienic handling recommendations – see TOURNIQUETS CLEANING GUIDE for more information.

A good reusable tourniquet should have an easy application lock, as well as a quick release mechanism.A simple design with VELCRO® (like the one supplied in this kit will do the job equally well).[SEE VIDEO CLIP ON HOW TO APPLY THESE TOURNIQUETS]

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).

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.

video/4A-4D.mp4

http://www.tourniquets.org/cleaning_guide.php

http://www.tourniquets.org/cleaning_guide.php

video/4A-4D.mp4

video/4A-4D.mp4

http://www.narescue.com/

video/4A-4D.mp4

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PROJECT 5AIDENTIFY THE VEINS OF THE UPPER EXTREMITY

PROJECTS 5A – 5D

INFORMATIONVeins, by definition, are blood vessels that carry blood towards the heart. The veins of the arms are anatomically divided into two groups: superficial and deep. The two groups communicate (anastomose) frequently with each other. The superficial veins are placed immediately beneath the integument between the two layers of superficial fascia. The deep veins often accompany the arteries. For the purpose of this project we will focus in on the superficial veins.

REQUIREMENTSYou will need:• Alcohol hand rub • A pair of clean gloves• A tourniquet• A skin marker pen• A volunteer (A person with a low BMI, male, athletic,

middle-aged, or older with fair skin will show the veins more clearly.)

• If no volunteer is available, use your own arm• Good lighting

video/5A-5D.mp4

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FOLLOW THESE STEPSSTEP 1Study the detailed illustration of the veins of the upper extremity (arm). [CLICK HERE]

STEP 2 Have a look at the simplified diagrams:

Figure 10a: The ventral arm veins

Figure 10b: The dorsal hand veins

Figure 10c: The cubital fossa veins

STEP 3Ask the volunteer to lie down and let the arm hang down below the rest of the body to allow passive gravitation to fill the veins with blood. Apply the tourniquet about 5-7 cm (2-3 inches) above the elbow joint

STEP 4Prepare your hands hygienically and don clean gloves. (Gloving is optional for this project.)

See PROJECTS 3A, 3B and 3C

STEP 5Use 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 6Use the skin marker pen to draw the veins on the arm.

STEP 7Identify the veins of the dorsum of the hand (upper side), as per the simplified diagram, by inspection and by palpation. Use the tips of your middle three fingers.

STEP 8Use 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 INTERESTThe 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 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!

http://www.apan.com.au/wp-content/uploads/Relationship-ff-nerves-and-veins.pdf

hyperlinks/ventral_ar_veins.pdf

hyperlinks/cubital_fossa_veins%202.pdf

hyperlinks/dorsal_hand_veins2.pdf

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INFORMATIONREQUIREMENTSYou will need:• Alcohol hand rub • A pair of clean gloves• A tourniquet• 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 1Study the detailed illustration of the veins of the lower extremity (leg).

STEP 2Have a look at the simplified diagram:

Figure 11: The anterior leg veins

STEP 3Ask the volunteer to expose the leg area up to some distance above the knee. The person should be standing, sitting, or lying down with the leg lower than the rest of the body to allow passive gravitation to fill the veins with blood. Apply the tourniquet somewhere at least 10-15 cm (4-6 inches) above the knee joint.

Figure 12: Examining the veins of the leg

STEP 4Prepare your hands hygienically and don clean gloves. (Gloving is optional but strongly recommended.)


PROJECT 5BIDENTIFY THE VEINS OF THE LOWER EXTREMITY

hyperlinks/leg_veins2.pdf

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STEP 5Identify the veins, using the simplified diagram, by inspection and by palpation. Use the tips of your middle three fingers.

Figure 13: Identifying the greater saphenous vein

STEP 6Use the skin marker pen to draw the veins on the leg. Feel free to take a photograph of the venous pattern of your volunteer’s leg (of course, with permission). You may also label the veins using the diagram in Step 2.

POINTS OF INTERESTThere 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

the superficial veins into the deep venous system through small perforator veins. Superficial, deep, and perforator veins have one-way valves that allow blood to flow only 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 WARNINGSAs 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.

• Legs or feet when injuries, areas of bruising, previous burns, or scar tissue are visible.

• Phlebotomists and nursing staff are required to get permission from the attending physician before using a vein of the lower extremity for venipuncture/phlebotomy.

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PROJECT 5COTHER IMPORTANT VEINS (FACE, NECK AND CHEST)

INFORMATIONThe 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].

REQUIREMENTSYou 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

http://commons.wikimedia.org/wiki/File:Venous_valve_00013.gif

video/5A-5D.mp4

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FOLLOW THESE STEPS STEP 1Study the detailed illustration of the veins of the neck [CLICK HERE].

STEP 2Have a look at the simplified diagram:

Figure 14: The head and neck veins

STEP 3Ask 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 4Prepare your hands hygienically and don clean gloves. (Gloving is optional but strongly recommended.) See PROJECTS 3A, 3B and 3C

STEP 5Identify 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 6Use 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.

POINTS OF INTEREST• External jugular vein cannulation is a skill that

every medical student should master. It is a useful alternative in certain situations for: - Repeated blood sampling. - Administering intravenous fluid, medication,

chemotherapy, radiological contrast, as well as 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.

hyperlinks/head_and_neck_veins.pdf

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REQUIREMENTYou will need:• Alcohol hand rub • A pair of clean gloves• A skin marker pen• A volunteer (Look for a person with a low BMI,male,

physically fit, middle-aged or older, or with fair skin to show the veins more clearly.)

• If no volunteer is available, use your own arm• Good lighting

METHOD 1FOLLOW THESE STEPS

STEP 1 Prepare your hands hygienically and don clean gloves (gloving optional but strongly recommended). See PROJECTS 3A, 3B and 3C

STEP 2Identify 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.

STEP 3Occlude the vein distally (on the finger’s side) by applying firm pressure with an index finger. Press your second index finger next to your first index finger. Move the second index finger towards the elbow while exerting mild pressure. This empties the blood from the lumen as you move your finger along the vein.

STEP 4Stop at the proximal side of the section identified and then release the second index finger. The vein will immediately refill up to the point where a venous valve is situated. Notice that the previously distended vein 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 5Mark the position of the valves with the skin marker pen and photograph the valve-mapped arm.

PROJECT 5DMAP THE VALVES IN VEINS

INFORMATIONThere 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

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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 15: Diagram of a normal and a varicose vein

Malfunction of the normal one-way valves in the veins

is the main underlying cause of varicose veins. This

causes venous blood to accumulate in superficial veins

and branches, causing the walls of the veins to distend

(enlarge) and stretch in a convoluted fashion.

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.

• Varicose veins affect about 20% of the population.

They are more common in women (20-25%), than

in men (10-15%). Pregnancy is often an initiating

event in women. Varicose veins tend to get worse

with age.

• Never attempt to use a varicose vein to perform

venipuncture!

STEP 1 Prepare your hands hygienically and don clean gloves.

(Gloving optional but strongly recommended.)


STEP 2Have a volunteer make a fist and extend the arm, with

the palm up and slightly below elbow level. Locate a

prominent vein on the inside of the forearm.

STEP 3Starting near the elbow, run your finger along the vein

going towards the wrist. Exert mild pressure to empty

the blood from the lumen of the vein.

STEP 4Blood will immediately refill the vein up to the point

where a venous valve is encountered and then you will

notice the distended vein remaining flat up to the point

of the valve inside the vein. Lift your finger and notice

how the flat section of vein fills up with venous blood.

STEP 5Mark the position of the valves with the skin marker

pen. Take a photograph of the valve-mapped arm.

METHOD 2FOLLOW THESE STEPS

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BLOOD SAFETY INSTRUCTIONSThe 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 6APREPARE 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.

video/6A.mp4

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CHOOSE THE CORRECT SIZE SYRINGE:0.5ML AND 1ML(DEDICATED DIABETIC SYRINGES)Note: Milliliter (ml) indicates the same volume as cubic centimeter (cc)The standard insulin syringe holds one ml (or one cc), divided into 100ths, which is equal to one UNIT of insulin. It is vital that you exclusively use a U100 insulin solution with a U100 syringe. There are some smaller insulin syringes that only hold 0.5ml but they are still marked properly for U100 insulin even though they are smaller in size.The syringe in the kit is a 0.5ml insulin syringe with a protective cap over the needle and plunger. Remove these orange colored caps to use. Orange is the color code for U100 insulin.

1ML SYRINGE (TB SYRINGE)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 SYRINGESCommonly used for IM injections or for mixing or drawing up other medications. Use the smallest syringe that will hold the dose properly.

10ML – 12ML SYRINGEUsed 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)

IMPORTANT NOTES: Always keep your and your patient’s safety as your first priority!• Use insulin syringes only for insulin. • Too high a dose of insulin may cause a hypoglycemic

coma, or irreversible brain damage. It can even be lethal!• Too low a dose given to a diabetic may lead to a

hyperglycemic coma.• Use safety needles whenever possible according

to the manufacturer’s instructions and discard in a dedicated sharps safety container after use.

• In all cases when preparing more than one syringe of different medications or if you are not administering the medication straight away, clearly label the syringe above the volume markings the type of medication and the concentration (e.g., ketamine 100 mg/ml).

• Always take great care to avoid needle stick injuries when working with sharps!

• If you need to recap a needle – use the one hand scoop technique (see below).

• Never recap a blood-contaminated needle.

Figure 18: The one hand scoop technique for recapping a needle

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YOU WILL NEED:• Syringe with attached needle (10ml or 12 ml and

18G-21G needle)• 10 ml glass vial of sterile water• Alcohol wipes• Sharps container• Sticker paper or a strip of strapping for labeling• A pen for labeling

HOW TO DRAW UP MEDICATIONIn each of the projects to draw up medication in various ways, follow begin each time with these steps:

GENERAL PREPARATION*• Clean the work surface with an antiseptic solution.• Open a clean work surface cover.• Gather all the items to be used with the outer package

intact.• Prepare your hands hygienically.• Don clean gloves (optional).• Open the syringe on the work surface cover.• Partially open the needle at the hub end.• Connect the needle to the syringe and place on the

cover• Tear open an alcohol wipe and drop it on the work

surface cover

HOW TO DRAW UP MEDICATION FROM A GLASS VIALFOLLOW THESE STEPS• General preparation – (*see above)• Hold the vial upright between your fingers and swivel

the vial two to three times in a circular motion to ensure that all medication is in the bottom of the vial and not in the top section. Do not flick your finger against the vial as you may break the vial and injure your finger.

• Identify the small dot on the vial and face it towards 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.

• Carefully remove the needle cap from the syringe (or

remove the protective cover from the safety syringe,

see PROJECT 1B).

Important: DO NOT touch the needle!

• Turn the vial horizontally and insert the needle into

the vial.

• Gently pull back the plunger and allow the medication

to fill the syringe. 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.

• To remove air bubbles, hold the syringe vertically with

needle pointing up. Tap the syringe gently to move

any air bubbles toward the needle.

• Gently push the plunger to remove the air and possibly

bubbles mixed with a couple of droplets of medicine.

Label the syringe by placing a sticker with the name

and concentration of the medication noted legibly.

Do not stick the label over the volume markings.

• 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

(preferably a safety needle) on the syringe.

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IMPORTANT NOTE REGARDING WITHDRAWING MEDICATION FOR AN IM INJECTION • Most training centers recommend a standard two-

needle protocol when performing an IMI—the first

needle for withdrawing the medication and the

second sterile needle for injecting the patient.

• Be careful when changing needles. You may use a

conventional needle to draw up the medication, but

use a safety needle when injecting the patient.

• A single needle protocol for IMI injections is not

recommended for the following reasons:

• The fine, sharp needle tip is easily damaged when

hit against the bottom of the glass vial. This is not

too uncommon and increases pain on subsequent

injection!

• The first needle may touch a non-sterile surface and

become contaminated with microbes.

HOW TO DRAW UP MEDICATION FROM A GLASS VIAL WITH A RUBBER MEMBRANEYOU WILL NEED:• Syringe with attached needle

• Vial of medication

• Alcohol wipes

• Sharps container

FOLLOW THESE STEPS:• General preparation – (*see above)

• Carefully remove the protective cap from the vial

and swab the top of the vial thoroughly with a fresh

alcohol wipe. Allow time to dry.

• Determine the volume of medication required in ml

(cc). Draw in an equal amount of air by pulling back

on the syringe plunger.

• Carefully remove the needle cap from the

syringe (or remove the protective cover

from the safety syringe—PROJECT 1B)

Important: Do not touch the needle!

• Insert the needle into the center of the rubber

membrane of the vial.

• Turn the vial upside down and slowly inject air from

the syringe into the vial of medication.

• Gently pull back on the plunger, 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.

• Hold the syringe with needle pointing upwards

and tap the syringe gently to move any air bubbles

towards the needle.

• Push the plunger gently to remove the air and air

bubbles, possibly mixed with a couple of droplets

of medicine.


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.

HOW TO DRAW UP MEDICATION FROM A PLASTIC CONTAINER• General preparation – (*see above)

• Open the plastic container (usually containing sterile

water or normal saline solution for injection) by using

a 180° twist-and-open action.

• Carefully remove the needle cap from the syringe (or

remove the protective cover from the safety syringe –

PROJECT 1B). Important: Do not touch the needle!• Turn the vial horizontally and insert the needle into

the vial.

• Gently pull back the plunger and allow the medication

to fill the syringe. 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.


appropriate route. If IMI injection – appropriately

discard the needle used to draw up the medication

and place a new needle on the syringe.

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SAFETYPlastic vials are safe from the point of view that it eliminates the possibility of a sharps injury to the clinician.On the down side, one can accidentally stick a needle in an unused vial and unintentionally contaminate it, or stick the needle right through the container and cause a needle stick injury.

HOW TO DRAW UP MEDICATION FROM A CONTAINER WITH THE MEDICATION IN POWDER FORM. (MANY ANTIBIOTICS COMES AS A POWDER IN A VIAL.)SINGLE UNIT• General preparation – (*see above)• 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 alcohol wipe. Allow time to dry.

• Let the syringe’s needle penetrate the rubber membrane of the powder vial.

• 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)

• Press down on the plastic activator to force diluent into the lower compartment.

• Gently agitate to effect solution.• Remove plastic tab covering center of stopper.• Sterilize top of stopper with a suitable germicide

(alcohol wipe).• Insert needle squarely through center of stopper until

tip is just visible. Invert vial and withdraw dose.

HOW TO DILUTE MEDICATION IN A 1:10 RATIO• Use a 10ml or 12ml syringe with 18G needle attached.• Open a 1ml medication vial (e.g., epinephrine).

Withdraw the full volume of the vial into the syringe.• Open 10 ml of solvent (e.g., sterile water or normal

saline for injection vial) and withdraw 9 ml into the 10 ml (or 12 ml) syringe.

• Discard the 1 ml of water remaining in the vial.• Prepare to administer the medication using the

appropriate route.

NOTE:It is safer to administer a medication that has potentially serious or even life threatening side effects by diluting it and injecting it slowly!

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POINTS OF INTERESTSTUDY THE CDC GUIDELINES FOR INJECTION SAFETY:What is injection safety?Injection safety, or safe injection practices, is a set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel, and others. A safe injection does not harm the recipient, does not expose the provider to any avoidable risks, and does not result in waste that is dangerous for the community (e.g., through inappropriate disposal of injection equipment). Injection safety includes practices intended to prevent transmission of infectious diseases between one patient and another, for example between a patient and healthcare provider, and also to prevent harm such as needlestick injuries.

What is aseptic technique?In this context, aseptic technique refers to the manner of handling, preparing, and storing of medications and injection equipment/supplies (e.g., syringes, needles and IV tubing) to prevent microbial contamination.

What are some of the unsafe injection practices that have resulted in transmission of pathogens?The most common practices that have resulted in transmission of hepatitis C virus (HCV), hepatitis B virus (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.

What are some procedures that have been associated with unsafe injection practices?Unsafe injection practices that put patients at risk for HBV, HCV, and other infections have been identified during various types of procedures. Examples include:• Administration of sedatives and anesthetics for surgical,

diagnostic, and pain management procedures; • Administration of IV medications for chemotherapy,

cosmetic procedures, and alternative medicine therapies;

• Use of saline solutions to flush IV lines and catheters;• Administration of intramuscular (IM) vaccines.

The medications used in these procedures were in single-dose or single-use vials, multi-dose vials, and bags. What they had in common was the vials or bags were used for more than one patient and were entered with a syringe that had already been used for a patient; or the syringe itself was used for more than one patient.

The above is an excerpt from the CDC website on injection safety.

For more information and answers on frequently asked questions go to the DCD website: http://www.cdc.gov/injectionsafety/providers/provider_faqs_general.html

http://www.cdc.gov/injectionsafety/providers/provider_faqs_general.html





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INFORMATIONThe skin harbors, in large numbers, a variety of bacterial

species, as well as other microorganisms. These microbes

(also called flora) can be divided into two groups:

resident flora (lives in and on the skin) and transient flora

(temporary visitor microorganisms). Resident and transient

flora do not normally cause diseases on the skin but if they

enter the body they may cause diseases. For example,

Staphylococcus epidermidis lives quite innocently on the

skin in great numbers but may cause sub-acute bacterial

endocarditis (SBE) under certain conditions if they enter

the blood stream.

It is impossible to sterilize (kill all known microorganisms

and spores) on a patient’s skin but one can reduce and

weaken these skin bacteria to the extent that it would be

unlikely for them to cause problems. Isopropyl alcohol is

the most common substance used for this purpose when

performing venipuncture/phlebotomy procedures.

Isopropyl alcohol is a colorless, flammable chemical

compound with a strong odor with the molecular formula

C3H8O. It is used in medical disinfecting pads (alcohol

preps), which typically contain a 60–70% solution of

isopropyl alcohol in water. It kills bacteria by causing each

bacterium cell membrane to lose its structural integrity.

Then the isopropyl alcohol enters the bacterium cell

and denatures the proteins within, causing intracellular

dehydration. This is why allowing the alcohol to completely

evaporate spontaneously is so important in killing bacteria

before performing venipuncture.

PROJECT 6BHOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY(ROUTINE VENIPUNCTURE)

A simple but essential step to prevent infections

REQUIREMENTSYou will need:• Antiseptic soap for handwashing or alcohol hand rub• A clean work surface cover• A tourniquet (re-usable)• Clean gloves• Alcohol prep swabs

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FOLLOW THESE STEPS: STEP 1Unfold the clean work surface cover and open it on your working area. Place the following items on this cover: Clean gloves Alcohol prep swabs

STEP 2Prepare your hands hygienically (wash or alcohol hand rub—PROJECT 3A/B). Choose a venipuncture site, apply a tourniquet, and select a suitable vein.

STEP 3 Tear open an alcohol prep sachet and place on the work surface. Put on clean gloves and remove the alcohol-saturated square.

STEP 4Cleanse in a circular fashion for 30 seconds beginning at the intended puncture site then make circular motions 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.

POINTS OF INTERESTThe total number of microorganisms on a person’s skin is estimated at 1012 (1,000,000,000,000).Common species include: Staphylococcus epidermidis Staphylococcus aureus Micrococcus species Neisseria species Streptococci Diphtheroids Small numbers of other organisms

IMPORTANT: Adhering to a meticulous sterility and aseptic protocol will dramatically reduce the number of infective complications that your patients could experience. Insignificant deviations from the recommended protocol make a big difference!Ensure that the alcohol prep square is saturated with clear alcohol. If the square is dry or semi-dry, cloudy or colored, then discard it and use a new one.

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STEP 1Prepare your hands hygienically (wash or alcohol hand rub—PROJECT 3A/B). Choose a venipuncture site, apply a tourniquet, and select a suitable vein.

STEP 2 Use a 2% chlorhexidine gluconate in 70% alcohol solution, as well as 3-6 sterile swabs opened onto the sterile field. Alternatively a 2% iodine tincture or 10% povidone iodine may be used in place of the chlorhexidine gluconate and alcohol solution.

STEP 3 Remove the cap of each blood culture bottle and use a non-touch technique to scrub the vial stoppers well with a fresh chlorhexidine and 70% alcohol swab. Allow these to dry for 30 seconds.

STEP 4Ensure that all the items and equipment for drawing blood are ready and prepared.

STEP 5Position patient appropriately, apply tourniquet to palpate and identify appropriate vein.

STEP 6Perform hand hygiene for the second time.

STEP 7Put on CLEAN gloves (do not touch the venipuncture site after skin preparation. If palpation is absolutely necessary then STERILE GLOVES must be used prior to palpation).

STEP 8Using swabs saturated with 2% chlorhexidine in 70% alcohol, disinfect the venipuncture site in a scrubbing motion. Perform 2-3 scrubs using a fresh swab for each scrub, with the last scrub starting at the intended puncture site and spiraling out in a circular motion towards the periphery. Clean for a total of 1-2 minutes, and then allow the site to dry for approximately 30 seconds. (If tincture of iodine is used, remove with 70% ethanol after the procedure.)

PROJECT 6CHOW 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.

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STEP 9In a real patient scenario, you will now perform the venipuncture for blood culture/s using a vacutainer.

POINTS OF INTEREST:• Using a sound skin preparation technique and

protocol the specimen contamination rate should be in the low single figures range (definitely < 9%)

• Iodine is usually used in an alcoholic solution, called tincture of iodine, as a pre- and post-operative antiseptic. It is not recommended to disinfect minor wounds, because it induces scar tissue formation and increases healing time. Povidone-iodine is much

better tolerated, doesn’t negatively affect wound

healing, and leaves a deposit of active iodine thereby

creating the so-called “remnant” or persistent effect.

The great advantage of iodine antiseptics is their wide

scope of antimicrobial activity, killing all principal

pathogens and, given enough time, even spores.

• See conclusion made by researchers is this interesting

article: [CLICK HERE FOR FULL ARTICLE]

Chlorhexidine is a better alternative to iodine tincture

because it has a comparable effectiveness and is safer,

cheaper, and preferred by staff. (Of course it should

not be used on patients who are sensitive or allergic to

Chlorhexidine.)⁶

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC404630/

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PROJECT 6DHOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY(COLLECTING BLOOD FROM BLOOD DONOR)

ONE-STEP PROCEDURE (recommended – takes about one minute):• use a product combining 2% chlorhexidine gluconate

in 70% isopropyl alcohol;• 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, or for a minimum of

30 seconds by the clock.

TWO-STEP PROCEDURE(if chlorhexidine gluconate in 70% isopropyl alcohol is not available, use the following procedure – takes about two minutes):

STEP 1 – use 70% isopropyl alcohol;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);

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.

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.

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Venipuncture Course and Kit | COLLECTING BLOOD

Dr. Louise Weimar wore a cream wedding gown and her groom, Scottish engineer Mark Mynhardt, wore a kilt. From an outsider’s perspective they looked perfect on the happiest day of their lives. But behind the wedding music, cake and champagne lay a devastating story of how an accidental needle stick changed a life.Dr. Louise Weimar performed her medical duties at a remote public hospital. On a day like any other, she was drawing blood from a 3-month-old baby. After an unsuccessful first attempt she reached for a second needle to re-attempt the procedure but just as she turned around, the baby pulled loose from the nurse’s arms and bumped Dr. Louise’s hand right into the first needle. It penetrated the little finger of her right hand to the bone. Dr. Louise followed protocol and reported the incident. A sample of the baby’s blood was immediately sent to the lab to be tested for HIV. It was positive.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

prick injury. The pathologist simply remarked: “Good luck!” She told her fiancé about her disease, fearing that this might be the end of their relationship, but to him it was a simple decision. She was the woman of his dreams and they married two weeks later. Sadly, Dr. Weimar had to approach a human rights lawyer for some form of compensation.

Let’s survey some lessons learned: • Always use safety needles in all clinical and laboratory

settings when working with blood or any other bodily fluids/secretions/excretions.

• Discard used needles in an appropriate sharps waste container immediately after use.

• Start the recommended PEP (Post Exposure Prophylaxis) protocol as soon as possible after exposure to an infective agent requiring PEP.

CASE STUDY 3:MY LIFE CHANGED DRASTICALLY IN A SPLIT SECOND

http://youtu.be/_eCETCXxhAw

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CAPILLARY BLOOD COLLECTION USING A LANCET:WARNINGS: • During the following projects you will be working

with sharp items. Take great care to avoid self-injury or injury to others.

• Observe age recommendations (18 years and older/15-17 adult guidance and supervision).

• Choose a place to practice where the fake-blood used in this project won’t stain any valuable items of clothing, carpets, etc.

• Do not use any of the items in the kit for real patients – not even in an emergency!

A useful method of sampling a couple of drops of blood

PROJECT 7A DRAW CAPILLARY BLOOD – ADULT

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.

INFORMATIONBlood from a finger stick differs from blood collected from a vein in the fact that it is a mixture between venous, (mainly) capillary and arterial blood, as well as minute amounts of tissue fluid.If properly executed, blood collected from a finger (or heel stick) will offer surprisingly accurate bio-chemical information. Keep in mind that the following readings may be slightly different: • Lower concentrations of potassium, total protein, and

calcium. • Higher glucose.

Relative contraindications for finger prick blood collection:• General contraindications: Patients with general edema

and patients with severe dehydration may not be good candidates.

• Local contraindications: Injury of the finger or hand, infection of the finger/nail area, scar tissue, previous burns, mastectomy with axillary lymph gland resection (on the side of the intended finger puncture site), Raynaud’s disease.

• Patients with cold fingertips: Warm to increase the blood-flow before puncturing.

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REQUIREMENTSYou will need:• A sterile lancet• Alcohol prep swabs• Clean gauze squares• Gloves• Clean work surface cover• Alcohol hand rub• A mini-blood receiver/container (not supplied in the

kit)• A suitable volunteer

FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION: STEP 1Open the above items on the clean work surface cover.

STEP 2Greet the patient, introduce yourself and positively identify the patient. Do short medical history (allergies, bleeding tendencies, and anticoagulant medication). Verify the patient’s status regarding fasting, dietary restrictions, medications taken (and time), and other relevant information. Properly fill out and make appropriate notes on the lab requisition form including the specific tests requested.

STEP 3Prepare your hands hygienically.

STEP 4The patient should be comfortably positioned sitting or lying down. Extend the patient’s arm, keeping the hand relatively open. Choose a suitable puncture site. Use the pads of the middle or fourth fingers of the non-dominant hand and somewhat to the side of the finger pad.Avoid: • The thumb, index finger, as well as the fifth fingers if

possible• The tip-area and central pad area of the finger• Puncturing a finger that is cold or cyanotic, swollen,

scarred, or covered with a rash

STEP 5Ensure that the fingertip is clean with no visible dirt. Wipe the fingertip with an alcohol prep swab. Wait 30 seconds to air dry.

STEP 6The puncture should be made perpendicular to the fingerprint ridges to prevent the drop of blood running in the grooves. Stab the finger with the sterile lancet in a single brisk stab movement. Puncture the flesh right up to the shoulder of the lancet at 90° to the skin’s surface.

STEP 7Wipe away the first drop of blood which may contain excess tissue fluid.

STEP 8Collect drops of blood into the collection device by gently massaging the finger. Avoid excessive pressure that may squeeze tissue fluid into the drop of blood.

STEP 9Cap then rotate and invert the collection container to mix the blood collected.

STEP 10Have the patient hold a small gauze pad over the puncture site for a couple of minutes to stop the bleeding.

STEP 11Dispose of contaminated materials in their designated containers. Important note: All lancets are single-use only and must be disposed of in an approved sharps container immediately after use.

STEP 12Label all appropriate tubes at the patient bedside and deliver specimens promptly to the laboratory.

POINTS OF INTERESTA number of disposable spring-loaded skin puncture devices are available that will ensure a safer procedure. The spring-load mechanism should be pre-activated. The lancet will automatically puncture the skin when the auto-stab mechanism is released, and will then immediately retract back into the housing of the device. This virtually eliminates the possibility of accidental needlestick injury to the medical professional performing the procedure.Regular venipuncture tubes generally hold 5-10 ml (adult) and 2-4 ml (pediatric) of blood. Tubes for finger sticks or heel sticks generally hold one-half ml or less.

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A useful method of sampling a couple of drops of blood


PROJECT 7BDRAW CAPILLARY BLOOD – BABY

It is commonly used for the following purposes in babies:• Metabolic and genetic screening tests• Bilirubin levels (to monitor jaundice of the newborn) • Blood glucose and Lactate analysis

• Newborn bloodspot screening tests• Full blood counts• Levels of certain drugs • Blood gases• Urea and electrolytes

REQUIREMENTSYou will need:• A sterile lancet (an appropriately sized automated

lancet devised for use on infants is recommended) • Alcohol prep swabs• Cotton wool

• Receiving mini-blood container, capillary tube, and/or blood bottle

• Clean gauze squares• Clean gloves• Clean work surface cover• Alcohol hand rub

INFORMATIONWarning: 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.

VIDEO

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FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION:STEP 1Open the above items on the clean work surface cover.

STEP 2Check 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 3Ensure 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 restraining the baby.Wash your hands. See handwashing guidelines and put on clean gloves (PROJECT 3A, 3B and PROJECT 3C). Clean the site with warm water/saline and gauze or cotton wool. Do not use alcohol wipes to clean the skin of a baby.

STEP 4Hold the baby’s heel with the non-dominant hand. It 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 lancet or with a disposable lancet, to a depth of 1-2mm in the plantar surface of the heel (see Fig. 15). The puncture should be made perpendicular to the heel-print ridges. If you must use a regular lancet, then use a sterile single-use lancet to stab the heel at 90° to the skin’s surface in a single, brisk stabbing movement.

Figure 20: How to hold the heel when performing a heel prick procedure

Figure 21: Permissable areas to perform a heel prick procedure

STEP 5Gently but firmly compress the baby’s heel (avoid excessive pressure). Release the tension, wipe away the first drop of blood, and then re-apply the tension to allow the blood to collect in globules, which can then be collected into the blood bottle.

STEP 6Cap then rotate and invert the collection container to mix the blood collected.

STEP 7Apply pressure to the site with gauze and maintain the pressure until bleeding has stopped. Tape a small piece of gauze or cotton wool over the puncture site using hypoallergenic tape.

STEP 8Dispose 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 9Take a consecutive blood sample from the alternate heel. Vary the puncture site positions.

STEP 10The person performing the skin puncture should wash their hands.

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STEP 11Label all appropriate tubes at the patient bedside and deliver specimens promptly to the laboratory.

POINTS OF INTERESTTo avoid irritating, and even possible mutilating complications the operator should adhere to a very strict procedural protocol (as above).Complications that can arise in capillary sampling include:

• Damage to nerves, blood vessels, and bones • Osteomyelitis of the heel bone • Excessive scarring • Skin breakdown from repeated use of adhesive strips• Skin necrosis• Excessive blood loss • Cellulitis and abscess formation • Hemolysis of the sample (will require a re-sampling)• Increased pain (compared to venipuncture) • Sore heels

Deposit medication in the subcutaneous layer of the skin

PROJECT 8HOW TO GIVE A SUBCUTANEOUS INJECTION

*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!

VIDEO

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.

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Some medicines work best when they are injected under the skin into the fatty layer. These medicines require slower absorption compared to medication taken by mouth or injected into a vein. Examples of medicines given subcutaneously include growth hormone, insulin and epinephrine (adrenalin).Medication for injection comes in various containers (bottle, vial, etc.), each with its own specifications on opening the container, maintaining sterility, withdrawing medication, etc. See PROJECT 6A.Three basic types of devices for giving subcutaneous injections are available: a syringe (for small volumes with a narrow gauge needle), an auto-injector and a pen device. In this project we will use a syringe.

REQUIREMENTSYou will need:• Alcohol wipe• Clean work surface cover• Clean gloves• Ampule of medication• Small syringe (0.5 ml)• 30 gauge needle (preassembled on syringe)• Cotton wool or gauze• The Venipuncture Trainer

To simulate a subcutaneous injection using the Venipuncture Trainer, see Step 12.

FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION: STEP 1Greet the patient and positively check the identity of the patient. Check the following on the medication ampule or vial before proceeding:• The correct medication name, amount (or volume,

e.g., 10 ml) and concentration, (e.g., 5 mg/ml).• The expiration date. Never use expired medication. • Abnormalities regarding consistency and color of the

medication in the container. If in doubt, send it back to the pharmacy.

STEP 2Follow the steps described in Project 6A to draw up the medication for SQ injection.

STEP 3Choose the injection site for this dose and expose the area (if working on a real patient). There are several areas

CROSS SECTION OF THE SKIN

hyperlinks/cross_section_of_the_skin.jpg

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of the body suitable for giving subcutaneous injections, as shown in figure 17. Enquire about the patient’s previous injection site.

STEP 4Prepare your hands hygienically and don clean gloves (sterile gloves are not required).

STEP 5Open an alcohol prep swab and wipe the intended area for SQ injection in a circular motion and allow to air dry.

STEP 6Spread 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 of the skin is required, presuming reasonable personal hygiene. When a medical professional gives the SQ injection, skin prepping is advisable—especially in a clinic or hospital where medical professionals need to maintain a sterile chain, unlike the home-care situation.

STEP 7Continue to hold the skin and insert the needle into the skin in the center of the skin fold so that the needle is at an angle of 45°-90°. *Aspirate if your hospital/unit recommends aspiration when giving a subcutaneous injection.

STEP 8Push the syringe plunger to inject the medicine. It is recommended that you count slowly from 1 to 10 while injecting the medication.Remove the needle from the skin and release the skin. *Comments: • As a general rule, aspirating before injecting is a good

habit and is thus recommended. • How to aspirate:

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!

• Some experts say that if you keep to the suggested injection sites, aspiration is unnecessary, specifically for subcutaneous injections as there are no major blood vessels in these specific subcutaneous injection site areas. (See safe subcutaneous injection sites diagram below).

Figure 23: Permissible areas for giving a subcutaneous injection

STEP 9Press a piece of cotton wool or gauze lightly over the injection site for a couple of seconds (optional). Do not massage the injection site.

STEP 10Discard the used syringe and needle in the sharps waste container. Do not recap or remove the needle! Remove gloves and discard in suitable medical waste bin.

STEP 11Mark the puncture site, date, and time of the injection on a suitable chart or diagram.

STEP 12Simulate the project by following Steps 1-10 using the unassembled Venipuncture Trainer. Do not inject in the blood vessel areas.Use 2ml of air or withdraw 2ml of fluid from the ‘In’ of one of the IV fluid bags to use as “medication” when doing the simulation exercise.

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POINTS OF INTERESTSafe areas for giving subcutaneous injections:Abdomen: Uncover the abdomen from about 5 cm

(2 inches) below the umbilicus up to the waist area. You

may give a shot below the waist, to just above the hipbone,

and from where the body curves at the side to about

5 cm (2 inches) from the middle of the abdomen. Avoid

the umbilicus.

Thigh: Uncover the leg from the knee to the hip. The mid-

section of the thigh, from mid-front to mid-side on the

outside area of the thigh, is a safe site. Gently, grasp the

area with index finger and thumb to ensure that you can

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

behind the patient. Find the area halfway between the

elbow and shoulder. Gently grasp the skin at the back of

the arm between your thumb and first two fingers. You

should have 1-2 inches of skin.

Various other areas – see Figure 23.When a patient receives multiple injections over a period

of time, ensure that you vary the injection sites to reduce

pain and irritation. In other words, don’t give the injection

at the same spot every time. Instead, use a new spot each

time in an organized rotational way. A site rotation chart

for marking injection sites is recommended for patients

who need subcutaneous injections on a regular basis (e.g.,

diabetics). It may be helpful to mark the injection site with

a small plaster as a reminder for next time.

Injecting the medicine into the same area all of the time

will cause scarring or a fatty lump (lipohypertrophy) to

form, causing medication to be absorbed more slowly.

Intradermal injections are often used for conducting

skin allergy tests. With the intradermal injection, a small

thin needle of 25 or 27 gauge and 3/8 to 3/4 inch (1-2 cm)

is inserted at a 10° to 15° angle to the skin of the forearm,

with the bevel facing upward.

Intradermal injections are also used by Plastic Surgeons to

deposit fillers and Botox into the skin for cosmetic reasons.

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Deposit medication in a suitable muscle


PROJECT 9 HOW TO GIVE AN INTRAMUSCULAR INJECTION

VIDEO

INFORMATIONMedication is injected well into the muscle layer below the various layers of skin.

Figure 24: An intramuscular injection

This route for injection is recommended for:• Medication requiring a relatively fast absorption

speed for fast onset of action with a duration of action of anything from hours up to several weeks (variation dependent on the type and specifics of the medication)

• A fairly small volume of medication (2-5 ml) depending on the muscle (deltoid – maximum 2ml and gluteus – up to 5 ml).

• Medication causing little to moderate chemical irritation. It is not intended for medication that will cause a severe tissue reaction.

• 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.

REQUIREMENTSYou will need:• Alcohol wipe• Clean work surface cover• Clean gloves• Container with medication• Syringe (5ml) • Two needles – preferably safety needles (Gauge 18 or 20)• Cotton wool or gauze• Adhesive bandage strip• IV bag• The Venipuncture Trainer

video/9.mp4

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SIMULATE A SUBCUTANEOUS INJECTION USING THE VENIPUNCTURE TRAINER. SEE STEP 12.FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION:STEP 1Greet and positively check the patient’s identity. Check the following on the medication ampule or vial before proceeding:• The correct medication, name, amount (or volume,

e.g., 10 ml), and concentration (e.g., 5 mg/ml).• The expiration date. Never use expired medication.• Abnormalities regarding consistency and color of the

medication in the container. If in doubt, send back to the pharmacy.

STEP 2Follow the step-by-step instructions on withdrawing medication for an IM injection—see PROJECT 6A.

STEP 3Prepare your hands hygienically and don clean gloves (sterile gloves not required).

STEP 4Choose the injection site for the dose and expose the area (if working on a real patient). There are several areas of the body suitable for giving intramuscular injections (IMI), shown on the diagrams.

STEP 5Swab the injection site with an alcohol pad for 30 seconds in a circular outward motion, up to 5 cm around. Allow the alcohol to air dry (30 seconds). 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. 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!

STEP 6It is essential to aspirate before depositing the medication into the muscle. To do this, gently withdraw the plunger before injecting the medication into the muscle, in order to avoid an inadvertent intra-vascular injection and thus a possible medical emergency.If you aspirate blood, withdraw the needle and prepare a new syringe.

STEP 7If no blood is aspirated, continue to hold the skin and push the syringe plunger to inject the medicine. It is recommended that you count slowly from 1 to 10 for every milliliter (ml) being injected.

STEP 8When all of the medication has been injected, promptly withdraw the needle and apply pressure to the injection site using a gauze square to prevent bruising or a hematoma; this will also minimize medication seeping into the subcutaneous space. Certain medications may require massaging of the injection area for a minute or two, but for others this may be contraindicated. Apply an adhesive bandage strip if necessary.

STEP 9Discard the used syringe and needle in a designated sharps waste container. Do not recap or remove the needle! Remove gloves and discard in a suitable medical waste bin.

STEP 10Document the time, medication, dose, route, site, and patient’s response to injection.

STEP 11Perform the project by following Steps 1-10 using the unassembled Venipuncture Trainer. Do not inject in the blood vessel areas.Withdraw 2ml of air or withdraw 2ml of fluid from the ‘In’ of one of the IV fluid bags as “medication” when doing the simulation exercise.

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Deltoid Muscle: The deltoid muscle is located in the upper arm, just below the shoulder. To mark this site, place the palm of your hand on the shoulder and spread your thumb away from the four fingers in an upside down V shape. Ensure that the middle of the patient’s arm is centered in your V. You will want to give the injection into the middle of this V.

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 thigh into thirds from the top to the bottom of the thigh. The needle should go into the middle third.

Figure 26a and b: Giving an intramuscular injection in the vastus later-alis muscle

Ventrogluteal Muscle: This muscle is located in the hip area. To mark this site, have the person lie on their back. You should stand facing their hips. Place the palm of your hand on the side of the hip, with your wrist lining up with the thigh, the thumb is pointed towards the groin and the fingers pointed towards the patient’s head. You should feel 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 27a and b: Giving an intramuscular injection in the ventral gluteus muscle

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 28a and b: Giving a intramuscular injection in the dorsal gluteus muscle

POINTS OF INTERESTRelatively safe sites for IM injection are the deltoid, dorsal gluteal, ventrogluteal, and vastus lateralis (especially for children under two years of age).

hyperlinks/deltoid_intramuscular.pdf

hyperlinks/ventrogluteal_intramuscular.pdf

hyperlinks/gluteus_maximus_intramuscul.pdf

hyperlinks/vastus_lateralus_intramuscu.pdf

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How to prepare the trainer for performing various practical projects

PROJECT 10 ASET UP THE VENIPUNCTURE TRAINER FOR PHLEBOTOMY

VIDEO

INFORMATIONIn the final analysis, phlebotomy is a clinical skill. The Apprentice Doctor® Venipuncture Kit is designed so you can get acquainted and feel at ease with phlebotomy skills before being confronted with real human or animal patients in a clinical setting. The Venipuncture Trainer might not look like a real arm or like the much more expensive plastic arm simulators (available from the Online Store), but it is a fantastic affordable tool to practice phlebotomy and IV skills repeatedly. It resembles the real clinical feel of “in/out/missed the vein” or “right through the vein” situations superbly well. Practice makes perfect. You will notice your “in 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.

REQUIREMENTSYou will need:• Venipuncture Trainer• Lumen stoppers/connectors• IV line – adult• Small IV fluid package• Syringe 5 ml• Syringe needle 22 gauge• Red colorant• A shallow container, (e.g., a kidney dish, not

supplied in kit)

Choose a suitable, easily cleanable work surface.

video/10.mp4

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FOLLOW THESE STEPS (SEE THE ACCOMPANYING DIAGRAM): STEP 1Inspect the Venipuncture Trainer. It represents a fake 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]

STEP 2Inspect the IV fluid bag. Note the two ports marked as ‘In’ and ‘Out’.

STEP 3Connect the syringe and needle. Draw up ½ to 1 cc of red colorant and inject the contents into the IV fluid bag, using the ‘In’ port. Mix the colorant within the IV bag.

STEP 4Connect the adult IV line to the bag using the ‘Out’ port. Connect the other end to one of the tubes (Venipuncture Trainer veins) using a connector. Ensure that the connection is secure and doesn’t leak.

STEP 5Place or suspend the IV-fluid bag about ½ a meter (½ a yard) above the work surface. Suspend it from a hook or nail in the wall or place it on a shelf above the work surface.

STEP 6Keep 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

about halfway. When fake blood starts to flow from the tube, close the flow control, and then block the outflow opening with a lumen stopper.

STEP 7You are ready to start with the phlebotomy projects. (PROJECTS 11-14)

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.

stand

IV bag

“in” port

“out” port

drip chamber

IV line

flow-control clamp

connector

IV Trainer

simulation veins

lumen stoppers


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PROJECT 10 CSET 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 VENIPUNCTURE TRAINERPut your Venipuncture Trainer away when you are finished with projects:• Close the flow-speed mechanism.• Empty the fake blood inside the tubes into the plastic

container and discard. • Pack all of the components and place them into your

kit.• Keep the kit in a secure location and out of reach of

young children. Important note: Keep in mind that the red colorant may leak and stain clothes, tablecloths, carpets, etc.

REFILLING THE IV FLUID BAGIf the IV fluid runs dry, refill the bag using a 10 ml syringe and an 18 gauge needle and homemade saline (one teaspoon of salt in a glass of lukewarm water). Stir it well, draw 10 ml into the syringe and inject it into the ‘In’ port of the IV bag. Repeat 10 times to add 100 ml. Add 5 ml of red food colorant to create fake blood.

THERAPEUTIC PHLEBOTOMY (BLOODLETTING)Therapeutic phlebotomy (therapeutic bleeding) is a controlled removal of a relatively large volume of blood (usually 500 ml to one pint or more). The procedure is performed to reduce blood volume and consequently, red blood cells and iron stores. Therapeutic phlebotomy may be indicated as part of the treatment for:• Hemochromatosis (including hereditary

hemochromatosis)• Polycythemia vera• Porphyria cutanea tarda• Sickle cell crisis• A number of other conditions, but rarelySpecific indications and parameters are in place for the conditions listed above. In the Middle Ages, bloodletting was a common procedure for a variety of diseases. Today it is well established that bloodletting is not effective in treating most diseases and frankly, may be detrimental (the above list excluded).

MAXIMUM ALLOWABLE TOTAL BLOOD DRAW VOLUMESThe 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.

http://www.feinsteininstitute.org/wp-content/uploads/2013/02/Maximum-Blood-Draw-Limits.pdf

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One of a number of methods to draw venous blood

PROJECT 11ADRAW VENOUS BLOOD USING A VACUUM TUBE

VIDEO

INFORMATIONIt is strongly recommended that the student read the WHO guidelines on drawing blood: Best Practices in Phlebotomy before proceeding with this project. Notes on choosing a venipuncture site:• The most commonly used veins are the larger and

easily accessible median cubital or cephalic veins of the arm, followed by the basilic vein on the dorsum of the arm or dorsal hand veins.

• The veins of the foot are a last resort because of the higher probability of complications.

• Other veins, like the external jugular vein, are rarely used.

• A good vein will be both visible and palpable. However, occasionally you may have to depend only on your sense of palpation.

• To make it easier to see the veins, warm the arm for 10 minutes with a hot pack or let the hand hang down.

• If you feel a pulse when palpating the blood vessel, you may be looking at a superficial artery. Inspect the area further to identify a definite vein.

• Avoid inserting the catheter into a bifurcation (where the vein splits) or near large valves.

Certain areas are to be avoided when choosing a site:• Areas with extensive scars from burns or previous

surgery. It is difficult to penetrate skin through scar tissue.

• The arm on the side of a previous mastectomy. Test results may be affected because of lymphedema.

• A hematoma may cause inaccurate results. • The arm on the side that is being used for intravenous

therapy (IV) / blood transfusions, as the fluid may dilute the specimen. Collect from the opposite arm if possible.

• Cannula/fistula/heparin lock. In general, blood should not be drawn from an arm with a fistula or cannula.

• Edematous extremities. Tissue fluid may cause inaccurate test results.

• Extremities with extensive injuries (external wounds or fractured bones).

• Extremities with a joint replacement. Use an alternative site/extremity.

video/11A.mp4

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REQUIREMENTSYou will need:• Laboratory specimen labels (only in clinical setting)• Pen for writing• Laboratory forms• The sharps waste container• Alcohol wipe• Clean gloves• Clean work surface cover• A Vacutainer® holder (hub)• A Vacutainer® needle • Vacutainer® tubes• An Autosafe® Safety Phlebotomy Device (safety

needle preassembled on hub/holder)• Cotton wool or gauze• Strapping (adhesive bandage strip)• A fully set up Venipuncture Trainer See PROJECT 10A A phlebotomist will also need leak-proof transportation bags and containers (not supplied in kit).

IMPORTANT NOTE:• Use either the Autosafe® Safety Phlebotomy Device

or the standard Vacutainer® hub and needle.• If you choose the Autosafe® Safety Vacutainer

Phlebotomy Device, familiarize yourself with PROJECT 1B – HOW TO USE AUTOSAFE®-REFLEX® SAFETY DEVICES

• The BD Vacutainer® system is used in the Video clip demonstration – for more information visit the BD website: [CLICK HERE]

FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER:

STEP 1Greet the patient; introduce yourself and then pause to confirm the following:• Correct patient—positively identify the patient.

• Correct procedures—check the requisition order form against the labels.

Then:• Conduct a short medical history (allergies, bleeding

disorders, etc.). See PROJECT 2.• Position and prepare the patient.• Verify the following regarding the patient: fasting,

dietary restrictions, medications, timing, medical treatment, and any other relevant information.

• Make notes on the lab requisition form.

STEP 2Open a clean work surface cover. From the REQUIREMENTS list above, gather the relevant items and equipment (open outer plastic wrapping) and place on this cover. Set out all of the tubes you will need by the order of the draw* and have any necessary tools (tourniquet, alcohol swabs, sharps waste container, and biohazard waste bag) nearby. Tear open the alcohol prep sachet.

Assemble the Vacutainer® by attaching the Vacutainer® needle to the Vacutainer® hub or use the Autosafe® Safety Vacutainer Phlebotomy Device (with needle preassembled to the hub).

STEP 3Perform hand hygiene. See PROJECT 3A – A TECHNIQUE FOR PROPER HANDWASHING and PROJECT 3B – CLEANING HANDS WITH AN ANTISEPTIC RUB.

STEP 4Select the site, preferably at the cubital (antecubital) area (i.e., the inner bend of the elbow). 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 above the intended venipuncture site in order to facilitate the inspection and palpation. Remove the tourniquet until ready to proceed. Note: To make it easier to see the veins, warm the arm for 10 minutes with a hot pack or let the hand hang down.

STEP 5When ready for drawing the blood, apply the tourniquet about 4-5 finger widths above the selected venipuncture site.

STEP 6Ask the patient to form a fist to make the veins more prominent.

http://www.bd.com/vacutainer/

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Important note: Don’t ask the patient to pump (repeatedly open and close) the fist.

STEP7Put on clean (non-sterile) gloves.

STEP 8Disinfect the site using 70% isopropyl alcohol for 30 seconds and allow it to dry completely (30 seconds). DO NOT touch the site again once the alcohol (or other antiseptic) has been applied! If you must touch it again to feel the vein, touch a clean alcohol pad first to aseptically treat your glove.

STEP 9Anchor the vein by holding the patient’s arm and placing the thumb of the opposite hand below the venipuncture site.DO NOT insert the needle where veins are branching as this will increase the chance of a hematoma.

STEP 10Enter the vein swiftly at a 15°-30° angle. Ensure that the bevel of the needle is pointing up. DO NOT bend the needle. Note: Angling the needle less than 15° increases the chance of the needle staying above the vein and an angle of more than 30° increases the chance of penetrating the deep wall of the vein.

STEP 11Support the Vacutainer® tube holder, then push the Vacutainer tube into the hub and check for blood flow. Allow the tube to fill and then remove it from the tube 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 12If 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).

• The tourniquet must be released after a maximum of 2 minutes** irrespective of whether or not you have completed the venipuncture task.

**WHO guidelines. Some experts recommend a maximum tourniquet time of 1 minute.

STEP 13Withdraw the needle gently and then give the patient a clean gauze or dry cotton-wool ball to apply to the site with firm pressure for 2-3 minutes to achieve hemostasis and avoid a hematoma. Ensure that the patient has stopped bleeding and then apply tape and gauze to the venipuncture site.

STEP 14Discard sharps (e.g., the used needle/s and broken glass and syringe or blood-sampling device) into a puncture-resistant sharps container. Place other items like used gloves and all items contaminated with blood or body fluids into the infectious waste.

STEP 15Check the labels and forms for accuracy.

STEP 16Perform hand hygiene.

STEP 17Simulate the project by following Steps 1-16 using the fully setup Venipuncture Trainer—see PROJECT 10A.Ensure that the tubes are filled with fake blood, that the IV fluid’s tubing flow-speed regulation device is set on ‘open’, and that the ends of the tubes have lumen stoppers in position.

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PEP (post-exposure) prophylaxis - for more information [CLICK HERE]

Credit: WHO, World Health OrganizationAlways use the one-hand scoop technique for recapping a needle – see Figure 18

Tubes Additives Tests

Yellow SPS Blood Culture Tube

Blue Sodium Citrate PT,PTT, APTT – All Coagulation Studies

Red No Additive (Serum tube)Electrolyte, Lipid Panel, Hepatic Function, Digoxin, Bilirubin, HCG (pregnancy)

Red-gray or gold topContains a gel at the bottom to separate blood from serum on centrifugation

Chemistries, immunology and serol-ogy

Green Sodium Heparin or Lithium Heparin Ammonia Level

Light greenLithium heparin anticoagulant and a gel separator

Various chemical studies

Lavender EDTACBC, Hemoglobin, Hematocrit, ESR (Erythrocyte Sedimentation Rate)

Pale yellow Acid citrate dextroseHLA tissue typing, paternity testing, DNA studies

Gray Potassium Oxalate, Sodium Fluoride All Glucose Studies – Anticoagulant

DO DO NOT

DO carry out hand hygiene (use soap and water or alcohol rub), and wash carefully, including wrists and spaces be-tween the fingers for at least 30 seconds

DO NOT forget to clean your hands

DO use one pair of non-sterile gloves per procedure or patient

DO NOT use the same pair of gloves for more than one patientDO NOT wash gloves for reuse

DO use a single-use device for blood sampling and drawing

DO NOT use a syringe, needle or lancet 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-gle unit) immediately into a robust sharps container

DO NOT leave an unprotected needle lying outside the sharps container

Where recapping of a needle is unavoidable, DO use the one-hand scoop technique (see figure xx)

DO NOT recap a needle using both hands

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 injecting into the rubber stopper

DO NOT inject into a laboratory tube while holding it with the other hand

DO immediately report any incident or accident linked to a needle or sharp injury, and seek assistance; start PEP (see below) as soon as possible, following protocols

DO NOT delay PEP after exposure to potentially contaminated material; beyond 72 hours, PEP is NOT effective

POINTS OF INTEREST

Table 4: The rules of safety when performing phlebotomy

Table 3: *Recommended order of draw for plastic vacuum tubes (may differ slightly from your hospital’s protocol).

http://www.who.int/hiv/pub/prophylaxis/pep_guidelines/en/index.html

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ADDITIONAL SAFETY RECOMMENDATIONS:• If at all possible, use specially designed safety devices

to minimize the risk of accidental needle injuries

Don’t re-use the tube holder (Vacutainer® hub) – it is intended for single-use only

Safety syringes have a safety mechanism built into the syringe. The needle on a safety syringe can be detachable or permanently attached. On some models, a sheath is placed over the needle or the needle retracts into the barrel following injection in order to protect healthcare workers

and others from accidental needle stick injuries. The importance of the safety syringe has increased; legislation requiring it or an equivalent has been introduced in many countries since needlestick injuries and re-use prevention became the focus of governments and safety bodies.

Important note: In the final analysis there are simply no substitutes for taking CARE. Be careful at all times. You and your patient’s health and life depend on it!

Also see:W.H.O. Injection Safety Toolbox [1]W.H.O. Injection Safety [2]Centers for Disease Control – Injection Safety [3]

VIDEO

http://www.who.int/injection_safety/toolbox/Bundling.pdf

http://www.who.int/injection_safety/en

http://www.cdc.gov/injectionsafety/

video/OHS.mp4

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PROJECT 11 BDRAW VENOUS BLOOD USING A SYRINGE AND NEEDLE

VIDEO

INFORMATIONIt is strongly recommended that the student read the WHO guidelines on drawing blood: Best practices in phlebotomy before proceeding with this project. As a matter of preference, or for specific reasons, a phlebotomist may prefer using a syringe and needle to perform a venipuncture. Using a syringe and needle will necessitate that the blood specimen be transferred from the syringe to the lab’s blood sample tube/s using specific methods with the emphasis on avoiding accidental needle prick injuries and minimizing the risk of cross infection.

REQUIREMENTSYou will need:• Laboratory specimen labels• Pen for writing• Laboratory forms• The sharps container• Alcohol wipe• Clean gloves• Clean work surface cover• Syringe (20ml) • 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.

video/11B.mp4



http://www.theapprenticedoctor.com/venipuncture_training/PROJECT11B/index.html

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MEMORIZE THESE STEPS TO BE FOLLOWED IN A REAL-LIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER: STEP 1Greet the patient, introduce yourself, and then pause to confirm the following:• Correct patient – positively identify the patient • Correct procedure/s – check requisition order form

against labels

Then:• Do short medical history (allergies, bleeding disorders,

etc.) See PROJECT 2• Position and prepare the patient• Verify the following regarding the patient: fasting,

dietary restrictions, medications, timing, medical treatment and any other relevant information

• Make notes on the lab requisition form

STEP 2Open a clean work surface cover then gather and open the relevant items and equipment. Assemble equipment (see REQUIREMENTS above). Set out all of the tubes you will need and have all the necessary tools (e.g., tourniquet and alcohol swabs) nearby. Tear open the alcohol prep sachet.

The needle should be 21g or wider in order to minimize hemolysis. ALL needles and syringes are single-use only. Briefly inspect the needle, especially the tip, to ensure it is sharp and undamaged.

Remove the syringe from the packaging and insert the nozzle of the syringe firmly into the exposed hub of the capped hypodermic needle. Move the plunger within the barrel to ensure free movement.

Note: Use safety needles in all clinical settings. When simulating the procedure you may use a regular needle – but take great care not to injure yourself.

STEP 3Perform hand hygiene. See PROJECT 3A – A TECHNIQUE FOR PROPER HANDWASHING and PROJECT 3B – Cleaning hands with an antiseptic rub.

STEP 4Select the site, preferably at the cubital area. Locate the anatomic landmarks. Inspect and palpate the veins in the intended venipuncture site. One may apply a tourniquet temporarily, if necessary, 4-5 fingers above the intended venipuncture site to facilitate the inspection and palpation. Remove the tourniquet until ready to proceed. Note: Warming the arm with a hot pack or hanging the hand down may make it easier to see the veins.

STEP 5When you are ready to draw blood, apply the tourniquet about 4–5 finger widths above the selected venipuncture site.

STEP 6Put on clean (non-sterile) gloves.

STEP 7Ask the patient to form a fist so that the veins are more prominent. Important note: Don’t ask the patient to pump his/her fist.

STEP 8Disinfect the site using 70% isopropyl alcohol for 30 seconds and allow it to dry completely (another 30 seconds). DO NOT touch the site again once the alcohol (or other antiseptic) has been applied! If you must touch it again to feel the vein, touch a clean alcohol pad first to aseptically treat your glove.

STEP 9Anchor the vein by holding the patient’s arm and placing the thumb of the opposite hand below the venipuncture site.Do not insert the needle where veins are branching, as this will increase the chance of a hematoma.

STEP 10Enter the vein swiftly at a 15°-30° angle. Ensure that the bevel of the needle is pointing up. D NOT bend the needle. Hold/stabilize the barrel of the syringe and gently withdraw the plunger until the required amount of blood has filled the syringe.

Note: Angling the needle less than 15° increases the chance of the needle staying above the vein and an angle of more than 30° increases the chance of penetrating the deep wall of the vein.

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STEP 11 Once you collect sufficient blood, ask the patient to relax the fist, and then release the tourniquet.Note: The tourniquet must be released after a maximum of two minutes according to *WHO guidelines, irrespective of whether or not you have completed the venipuncture task or not. Some experts recommend a maximum tourniquet time of one minute.

STEP 12Withdraw the needle gently and place clean gauze or a dry cotton-wool ball with strapping to the site. Apply firm pressure to achieve hemostasis and avoid a hematoma. Inspect the site after 2-3 minutes to ensure that the patient has stopped bleeding.

STEP 13**Always use a safety transfer device for transferring blood from a syringe to the vacuum tubes or the blood culture bottles. [Click here] for more information on 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 vacuum tube in your hand!• Do not exert pressure on the plunger of the syringe.

This ensures that you avoid hemolysis or causing the needle or stopper to pop off thus creating a spray of blood droplets with the danger of exposing you and others to bloodborne pathogens.

STEP 14If the 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.

STEP 15Discard sharps (e.g., the used needles, syringes, as well as any glass items) into a puncture-resistant sharps container. Place other items like used gloves and all items contaminated with blood or body fluids into the infectious waste.

STEP 16Recheck the labels and forms for accuracy.

STEP 17Perform hand hygiene.

STEP 18Simulate the project by following Steps 1-17 using the fully setup Venipuncture Trainer—see PROJECT 10 A. Ensure that the tubes are filled with fake blood, that the IV fluid’s tubing flow-speed regulation device is set on ‘open’, and that the ends of the tubes have lumen stoppers in position.

POINTS OF INTEREST:Comments on safety and avoiding injury to you and your patientStudents of phlebotomy should be aware of the most recent information regarding the safety aspects related to safety needles and other devices by visiting the following websites:

*WHO (World Health Organization) http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf **OHASA (Occupational Safety and Health Administration) http://www.osha.gov

USA: Safety holders (preferably disposable), safety needles, safety blood transfer devices, and shields are mandatory, regardless of the blood collecting system used. See Occupational Safety and Health Agency (OSHA) guidelines.

Other countries: visit your country’s governmental Occupational Health and Safety Department.

http://www.bd.com/ca/pdfs/safety/products/collection/needles_devices/blood_transfer_device_highlight_sheet_VS7037.pdf



http://www.osha.gov/

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PROJECT 11CDRAW BLOOD USING A BUTTERFLY NEEDLE

VIDEO

INFORMATIONWinged infusion sets, commonly known as butterfly infusion sets or butterfly needles, are frequently used to perform venipuncture procedures. They are especially useful when doing venipuncture on patients with spastic, thin, or ‘rolling’ veins. Winged needles are most commonly used when the available veins are very small, fragile, and difficult to access or when veins are in a location that 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 much shallower angle (10-15°) compared to a standard evacuated tube system. Winged needles are nearly always used when drawing blood from the hand, wrist, or other places where veins are very close to the skin. Due to the fact that the winged needle is attached to a flexible tube, there is less chance of the needle slipping out or perforating the deep end of the vein. This can happen if either the patient or the phlebotomist moves during the procedure, especially when drawing blood for multiple tubes. Winged needles are usually 21g (green label) or 23g (blue label). Rarely, a 25g (orange label) is used, mostly in pediatrics or in very difficult cases; a needle of such small diameter may cause hemolysis, thus invalidating test results.

The needle is held by the ‘wings’ and placed into the vein, generally at a fairly shallow angle. The wings allow the phlebotomist to grasp the needle very close to the end to ensure accurate insertion into a vein. When the needle enters the lumen of a vein a ‘flash of blood’ can be seen. The flash is a small amount of blood that flows back into the tubing when the needle enters a vein. The phlebotomist can then push vacuum tubes into the hub or use a syringe to draw blood.

REQUIREMENTSYou will need:• Laboratory specimen labels• Pen for writing• Laboratory forms• The sharps container• Alcohol wipe• Clean gloves• Clean work surface cover• Winged infusion set–21 gauge • Syringe (10ml or 20ml) • Cotton wool or gauze square• Strapping (adhesive bandage strip)• Fully setup Venipuncture Trainer—see PROJECT 10A

Phlebotomist, in addition to the above items, will also need leak-proof transportation bags and containers.

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FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER: STEP 1Greet, identify, position and prepare the patient, and then ask relevant medical questions. Check the requisition order against labels. Verify the following patient information: fasting, dietary restrictions, medications, timing, medical treatment, etc.Make notes on the lab requisition form.

STEP 2Assemble equipment (see REQUIREMENTS above). Set out all of the tubes needed and have all the necessary tools (tourniquet and alcohol swabs, etc.) nearby. The butterfly needle should be a 21 gauge or wider in order to minimize hemolysis. ALL needles and syringes are single-use only. Open the outer packaging of all items to be used, including the butterfly needle and syringe.Insert the nozzle of the Vacutainer® or the syringe firmly into the hub end of the butterfly needle tubing.

Note: Use safety butterfly needles in all clinical settings. When simulating the procedure you may use a regular needle but take great care not to prick yourself.

STEP 3Perform hand hygiene. See PROJECT 3A – A technique for proper handwashing and PROJECT 3B – Cleaning hands with an antiseptic rub

STEP 4Select the site, preferably at the cubital (antecubital) area. Locate the anatomic landmarks. Inspect and palpate the veins in the intended venipuncture site. One may apply a tourniquet temporarily, if necessary, 4-5 fingers above the intended venipuncture site to facilitate inspection and palpation. Remove the tourniquet until ready to proceed. Note: Warm the arm with a hot pack or hang the hand down to make it easier to see the veins.

STEP 5When ready to draw the blood sample, apply the tourniquet about 4-5 finger widths above the selected venipuncture site.

STEP 6Put on clean (non-sterile) gloves.

STEP 7Ask the patient to form a fist to make the veins more prominent. Important note: Don’t ask the patient to pump the fist.

STEP 8Disinfect the site using 70% isopropyl alcohol and allow to dry completely (clean for 30 seconds and allow to dry for another 30 seconds). Do not touch the site again once the alcohol (or other antiseptic) has been applied! If you must touch it again to feel the vein, first touch a clean alcohol pad to aseptically treat your glove.

STEP 9Anchor the vein by holding the patient’s arm and placing the thumb of the opposite hand below the venipuncture site.DO NOT insert the Butterfly needle where veins are branching as this will increase the chance of a hematoma.

STEP 10Use the butterfly needle to enter the vein with a swift movement at a 15° to 30° angle. Ensure that the bevel of the needle is pointing up. DO NOT bend the needle. Keep your eyes open for the flash-back of blood appearing in the tube lumen indicating a successful venipuncture.

STEP 11Draw blood by using either a Vacutainer ™ or a syringe connected to the butterfly tubing (some winged needles have the Vacutainer ™ hub pre-attached). See PROJECT 11A or PROJECT 11B.Note: If you have to draw a tube for a coagulation specimen (citrate/light blue top) as the first specimen, then draw blood using a clear top* (no additive) vacuum tube before the citrate tube in order to fill the empty tube space with blood, thereby ensuring the proper blood-to-additive ratio (discard this tube after use). *Preferably a clear top but any other color top tube will be good.

STEP 12 Once you collect sufficient blood, ask patient to relax the fist, and then remove the tourniquet.Note: The tourniquet must be released after a maximum of two minutes* regardless of whether or not you have completed the venipuncture task.

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*WHO guidelines. Some experts recommend a maximum tourniquet time of one minute.

STEP 13Gently withdraw the butterfly needle and give the patient a clean gauze or dry cotton-wool ball to apply firm pressure to the site to achieve hemostasis and avoid a hematoma. Ensure that the patient has stopped bleeding, and then apply tape and gauze to the venipuncture site.

STEP 14Always use a safety transfer device for transferring blood 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!• DO NOT exert pressure on the plunger of the syringe

to avoid hemolysis or causing the needle or stopper to pop off, thus creating a spray of blood droplets with the danger of exposing you and other people to bloodborne pathogens.

STEP 15If 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 been filled.

STEP 16Discard sharps (e.g., the used needles and broken glass) and syringe or blood-sampling device into a puncture-resistant sharps container. Place other items like used gloves and all items contaminated with blood or body fluids into the infectious waste.

STEP 17Recheck the labels and forms for accuracy.

STEP 18Thank the patient and perform hand hygiene.

STEP 19Simulate 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.Ensure that the tubes are filled with fake blood, the IV fluid’s

tubing flow-speed regulation device is open, and that the ends of the tubes have lumen stoppers in position.

POINTS OF INTEREST:Notes on safety:Two examples of butterfly needles with built-in safety features are:• The Punctur-Guard™ uses an internal blunt needle.

The mechanism is activated after blood is drawn. • The Angel Wing ™ is activated by sliding a safety shield

over the needle after venipuncture.

Figure 29: The Angel Wing ™ Safety butterfly needle [For more informa-tion]

Important note: • Always use a needle with safety features in a clinical

setting! • Safety needles minimize the risk of needle prick

injuries but do not eliminate these risks completely. There is no substitute for being careful.

CUTTING DOWN A VEIN Venous cutdown is an emergency procedure in which the vein is exposed surgically and then a cannula is inserted directly into the vein. Common veins used for this purpose are the saphenous vein at the ankle and the basilic vein in the cubital area. Venous cut down is indicated when peripheral veins are very difficult or impossible to access due to obesity, vascular collapse, or thrombosis.

Figure 30: How to cut down a vein

Read more on how to perform the procedure at: [CLICK HERE]

http://www.bd.com/safety/products/b_collect/index.asp#b3

http://www.medindia.net/education/familymedicine/Common-Bed-Side-Procedures-Venous-Cut-Down.htm#ixzz28e2HGjwQ

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How to place a venous cannula into a vein

PROJECT 11 DHOW TO START AN IV LINE

VIDEO

INFORMATIONMastering the skill of setting up an IV line requires, time, patience, and a lot of practice.

Figure 31a: The components of an IV line [Photo with labels to be added]

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 the skin into a peripheral vein. This is usually in the form of a flexible plastic “cannula over a needle” device. Once

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the tip of the needle and cannula are located in the vein the needle is withdrawn and discarded and the cannula is then advanced inside the vein and secured into position with tape.

REQUIREMENTSYou will need:• The sharps container• Alcohol wipe• Clean gloves• Clean work surface cover

• Cotton wool or gauze square• Strapping• Transparent dressing • 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)• IV fluid bag• IV tubing • The Venipuncture Trainer (modified setup required).

See PROJECT 10B • A linen saver (not supplied in the kit)

MEMORIZE THESE STEPS TO BE FOLLOWED IN A REAL-LIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER: STEP 1Greet the patient, introduce yourself, and then pause to confirm the following:• Correct patient—positively identify the patient • Correct procedures—check and follow the physicians

orders, including specifics regarding IV fluid and medications (if applicable) to be used.

Then:• Place the patient in the Semi-Fowler’s or supine

position. • Do a short medical history (allergies, bleeding

disorders, etc.) See PROJECT 2• Make notes on patient’s clinical chart

STEP 2Assemble equipment and all the relevant items using REQUIREMENTS above. Open the outer packaging of all the items on the clean work surface cover. Note: Use safety catheters and safety needles in all clinical settings. When simulating the procedure, you may use a regular catheter/needle but take great care not to prick yourself with the sharp needle.


STEP 4Connect the IV tubing to the ‘Out’ port of the IV fluid bag. Prime the line by pressing the chamber once or twice, allowing it to fill about halfway. Open the control-flow mechanism and allow fluid to fill the tube until all air bubbles are out of the tube.

STEP 5Select a suitable site for setting up an IV line. Start by looking for a suitable vein on the dorsal part of the hand. If no suitable vein is identified (or if you fail with the venipuncture attempt) move proximally to the side of the wrist, possibly the forearm, and then the cubital area.

Inspect and palpate the veins in the intended venipuncture site. If necessary, you may temporarily apply a tourniquet 4-5 fingers above the intended venipuncture site to facilitate inspection and palpation. Remove the tourniquet until ready to proceed.

Place a linen saver under the patient’s arm to protect the bed linens as it is difficult to avoid a couple of drops of blood from occasionally flowing out of the vein.

Warning: When setting up an IV line, it is of utmost importance to ensure that one is placing the cannula in a 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!

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STEP 6Choose your IV catheter needle size with care. The size will depend primarily on the size of the vein; however the patient’s age and gender may also influence your gauge selection. • Adults—an 18 or 20 gauge catheter will work well for

most cases.• Elderly and pediatric patients—use a smaller catheter

(larger number, e.g., 22 or 24 gauge). • Emergency fluid replacement—use a larger catheter

(smaller number, e.g., 14 or 16 gauge).

STEP 7When ready to perform the venipuncture, apply the tourniquet about 4–5 fingers above the selected venipuncture site.

STEP 8Don preferably sterile gloves, otherwise use clean examination gloves. See PROJECT 3C or 3H.

STEP 9Ask the patient to form a fist to make the veins more prominent. (Some clinicians will first ask the patient to form a fist first, and then don gloves while the veins are distending).

Important note: If you do not intend performing phlebotomy before attaching the IV line, you may ask the patient to clench and open the fist a couple of times to facilitate vein distention.

STEP 10Disinfect the site using 70% isopropyl alcohol for 30 seconds and allow it to dry completely (another 30 seconds). DO NOT touch the site again once the alcohol (or other antiseptic) has been applied! If you must touch it again to feel the vein, touch a clean alcohol pad first to aseptically treat your glove.

STEP 11Remove the protective cap from the needle section of the catheter. Anchor the vein by holding the patient’s arm and placing the thumb of the opposite hand below the venipuncture site. Insert the needle, bevel up, at an angle of 15°-20°. Some instructors advise students to imagine an airplane landing on a runway as they insert the needle.

DO NOT insert the needle where veins are branching as this will increase the chance of a hematoma.

STEP 12Look for the flashback of blood in the catheter’s plastic applicator. Once you see this flash of blood, advance the catheter slightly, taking care not to go right through the vein. Remove the needle while advancing the catheter in one simultaneous movement. Take great care once the needle is removed to avoid needle prick injury.

STEP 13Remove the tourniquet.If required, take the opportunity to draw blood before attaching the IV line.

STEP 14 Remove the plastic connector cap/plug from the catheter’s connector (if applicable). Apply finger pressure on the vein above the catheter to prevent the retrograde flow of blood. Apply a small gauze square under the catheter to catch any escaping blood.

STEP 15Attach the IV tubing to the catheter. Secure the catheter with tape and a transparent dressing.

STEP 16Open up the IV line. If you were successful, you will see fluid dripping in the drip-chamber of the tubing.Observe the area for a couple of minutes. If the surrounding tissue swells, the drip is infiltrating the tissue. Stop the drip, apologize, and move to another site.

Important note: If you see a drop of IV fluid in the drip chamber moving in and out in a pulsatile fashion then you are probably in an artery. Stop the drip immediately, remove the needle and apply pressure on this site for five minutes. To avoid grave complications, never inject medication into an artery!

STEP 17Adjust the drip rate to whatever is appropriate for your patient. To keep the line open, turn the drip rate down to just a few drops a minute.

STEP 18Discard sharps (e.g., the used needles) into a puncture-resistant sharps container. Place other items like used gloves and all items contaminated with blood or body fluids into the infectious waste container.

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STEP 19Thank your patient. Compliment pediatric patients for being brave. Perform hand hygiene.

STEP 20Simulate the project by following Steps 1-19 using the Venipuncture Trainer. You will have to modify the Venipuncture Trainer setup: Do not attach the tubing to the tubes on the trainer. Place a lumen stopper on one end of the tube/imitation vein and a shallow container below the open end. When you are convinced that you have successfully entered a vein on the Venipuncture Trainer, attach the free end of the IV tube to the catheter, and then open the flow-control mechanism. If you were successful, fluid will flow out of the open end of the fake vein. If no flow is observed, close the flow-control mechanism and try again. Keep practicing!

POINTS OF INTEREST:If you fail, a bit of blame shifting is quite permissible. Blame it on the vein, on the weather or anything else, as you 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 professional—unless that person is you!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.

How to calculate IV flow rates:Intravenous fluid must be given at a specific rate. The specific rate is measured as milliliter per hour (ml/h) or drops/minute. To control or adjust the flow rate only drops per minute are used.

Common drop factors are:10 drops/ml (blood set), 15 drops/ml (regular set), 60 drops/ml (micro-drop).

To measure the rate we must know:1. The number of drops2. Time in minutes.

The formula for working out flow rates is:

Example:3000 ml IV Saline is ordered over 24 hours. Using a drop factor of 15 drops/ml, how many drops per minute need to be delivered?

Volume (ml) x drop factor (drops/ml) = drops/min (flow rate)

3000 (ml) x 15 (drops/ml)

Time (minutes)

= 31.25 drops/minute24 hrs. x 60 (gives us total minutes)

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How to remove a venous cannula from a vein

PROJECT 11 EHOW TO REMOVE THE IV LINE

VIDEO

• Shut off the IV by closing the roller clamp of the flow control mechanism.

• Remove the tape and OpSite or Tegaderm™ from the tubing and catheter.

• Place non-sterile 2x2 gauze over the IV site, remove the catheter from the arm, and secure the gauze in place with a piece of tape.

• Maintain pressure over the site for 2-3 minutes to secure hemostasis.

• Discard all sharps into the sharps waste container and all other items in a biohazard waste bag.

• Perform hand hygiene.

ALTERNATIVES TO IV INFUSION FOR ACCESSING THE BLOODSTREAM:Intraosseous infusion (commonly used in pediatric patients)

Figure 32: Performing an Intraosseous infusion

• Intraosseous infusion is a temporary emergency measure indicated in life-threatening situations when intravenous access fails (3 attempts or >90 seconds).

• Use the anteromedial aspect of the tibia.• Insert, pointing slightly inferior in order to avoid the

epiphyseal growth plate.• 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].

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http://en.wikipedia.org/wiki/Intraosseous_infusion

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THE NEONATE PATIENT A neonate is a newborn infant, especially one less than four weeks old. The neonate patient has specific challenges due to anatomical and physiological variables that differ substantially from an adult patient. This is why neonatologists need specialized knowledge and proficiency with difficult skills. Below is an excellent article about venous access in neonates with the abstract below:Vascular access in neonates and infants—indications, routes, techniques and devices, complications.⁸ By Möller JC, Reiss I, Schaible T.

Abstract:Venous cannulation has been in regular use in neonates since the 1940s. This was at first through the umbilical 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]

THE PEDIATRIC PATIENTThe basic principles of phlebotomy and venipuncture in the pediatric patient are similar to the adult patient yet differ quite a bit.The key to successful venipuncture lies with the restrainer (parent or fellow medical professional).Look at the recommended technique as suggested by WHO: WHO guidelines on drawing blood: Best practices in phlebotomy⁷Especially read the section on “Practical guidance on pediatric and neonatal blood Sampling” pages 35-40.This is a must read for any medical professional working with pediatric patients:Difficult Venous Access in Children: Taking Control by Laura L. et al.⁹Download this excellent article: [Click Here]

SPECIAL GROUPS OF PATIENTS

http://www.ncbi.nlm.nih.gov/pubmed/10150755



http://www.tmh.org/workfiles/journalclub/journalClubArticle.pdf

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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:

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.

VETERINARYVENIPUNCTURE

The animal patientThe basic principles of performing venipuncture procedures on the animal patient are the same as for the human patient.

VIDEO

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VeinViewer®VeinViewer® is a medical imaging device that uses near-infrared light to produce a digital image of a patient’s veins and project it directly on their skin.See this YouTube video: [CLICK HERE]

AccuVein® is a similar medical imaging device that uses a specific frequency of light to produce a digital image of a patient’s veins projected directly on their skin.See: [CLICK HERE]

Breastlight™Breastlight™ was originally designed as a breast cancer screening modality for examining the female breast for nodules. However, it is also quite useful to show blood vessels or venipuncture purposes! The frequency of light waves penetrates soft tissue readily, but shows blood vessels as dark lines.For more information [CLICK HERE]It is also more affordable than the previous two products.

Ultrasound Ultrasound is useful in detecting problems with most of the larger blood vessels in the body (e.g., the abdominal aorta and the carotid arteries). Using Doppler ultrasound technology, the flow of blood through vessels can be observed and measured. This makes it possible to detect arterial stenosis and aneurysms.Ultrasound is also useful in demonstrating superficial or deep veins and to differentiate between veins and arteries. [CLICK HERE]Anesthetists use ultrasound to guide them to correctly place the needle when performing regional anesthesia.

RadiographyCentral lines are commonly placed in critically ill patients. Chest radiographs are used to ensure proper positioning and to rule out complications during placement. The ideal location for the tip of a central line is at the cavoatrial junction, which is where the superior vena cava meets the right atrium. This allows for the infusion of large volumes of fluids or medications.Also see section on interventional radiology.

AIDS TO ASSIST THE CLINICIAN

1. Vascular access: theory and techniques in the small animal emergency patient¹⁰

AbstractAcquisition 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

AbstractThe 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]

http://www.youtube.com/watch?v=PWnl_Kuetag

http://www.accuvein.com/

http://www.youtube.com/user/breastlight1?feature=watch

http://www.youtube.com/watch?v=Pga4SAD-J9U

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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

INFORMATIONEach time the heart contracts (systole), a pressure wave is perpetuated throughout the arterial system of the body. A throb or pulse can be palpated anywhere in the human body where an artery crosses a bony prominence or firm structure (e.g., a tendon). The pulsation occurs due to a slight increase in the diameter of the artery coinciding with an increase in arterial pressure during systole. Arteries have strong, muscular, elastic walls.

REQUIREMENTSA suitable volunteer for checking the pulse pointsA watch with a minute indicator (if you want to determine the heart rate)

HINTS• Use the middle three fingers to feel for a pulse. Do not

feel with the thumb as you may in fact be sensing the small artery pulsating in your own thumb.

• Firmly (but not with too much pressure) press down with the middle three fingers in the area where you want to feel for a pulse.

• You may have to move the position of these fingers slightly over the specific area before feeling the pulse.

• Do not press too hard as this may block the artery and stop the pulsations.

• Some practice may be necessary before you can identify a clear pulse.

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 1Look at this diagram showing a number of the more common pulse points of the body:

STEP 2Identify the wrist pulse points. Two arteries supply each hand with oxygenated blood: the radial and the ulnar arteries. See if you can identify these two pulse points.

NOTE:The radial pulse point is situated on the thumb’s side of the wrist and the ulnar pulse on the little finger’s side, as indicated in the illustration.

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Note: A thorough knowledge of the regional anatomy will be helpful to locate these pulse points.

Figure 35a – h: Various pulse points of the body

STEP 3Identify the bony angel of the mandible. Place two fingers on this point. Move these fingers 3-5 cm (1-1½ inches) forward and feel for the facial artery pulsating as it crosses the lower border of the mandible.Place your fingers on the angle of the mandible again. Now go down 3-5 cm (1-1½ inches) towards the neck. Press towards the midline in a direction slightly towards the back. You should feel a strong pulse here; it is the internal carotid artery pulsating as it carries oxygenated blood to the brain.

WARNINGDo not press too hard to find the carotid pulse in the neck. Do not press on both carotid arteries at the same time. This may cause fainting!

STEP 4Identify the brachial pulse – an important pulse point used for the purpose of taking routine blood pressure readings.

STEP 5Identify the pulse points as shown in the diagram above. The femoral pulse is reserved for self-examination.

STEP 6To determine the pulse rate, count the number of beats or pulsations in one minute. This number is the pulse rate and equals the heart rate for the specific person – it is measured in BPM (beats per minute).

STEP7Practice by identifying a variety of these pulse points and checking the pulse rate of other people.

POINTS OF INTEREST:• An arterial line is a thin catheter inserted into an artery.

It’s commonly used in intensive care medicine and anesthesiology to monitor real time blood pressure and to obtain samples for arterial blood gas measurements.

• An arterial line is usually inserted in the wrist (radial artery) but can also be inserted into the upper arm (brachial artery), the groin (femoral artery), the foot (dorsalis pedis artery), or the inside of the wrist (ulnar artery).

• The femoral artery is commonly used by diagnostic and interventional radiologists, as well as cardiologists to access the arterial system.

• For a more detailed discussion on the pulse rate—see Project 24 in The Apprentice Doctor® Foundation course.

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Check the collateral circulation of the hand

PROJECT 12 BPERFORM A MODIFIED ALLEN’S TEST

VIDEO

INFORMATIONIn 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.

video/12B.mp4

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FOLLOW THESE STEPS TO PERFORM THE MODIFIED ALLEN TEST:STEP 1With the middle two or three fingers (not the thumb), locate the pulsating radial and the ulnar arteries on the palm side of the wrist (see illustration). Keep in mind that the ulnar artery is smaller and more difficult to locate.

Figure 36: The radial and ulnar arteries

STEP 2Elevate the hand and ask the patient to make a tight clenching fist for about 30 seconds.

STEP 3Apply firm pressure over the ulnar and the radial arteries, occluding both of them.

STEP 4Still elevated, the hand is then opened. It should appear blanched. (Pallor can be observed over the palm, as well as the fingernails).

STEP 5Release the ulnar pressure and the color should return within ±7 seconds (between 5 and 15 seconds).

INTERPRETATION: When you release the occlusive pressure on the ulnar artery, you should notice a return of normal color to the palm and nails within ±7 seconds. This indicates that the ulnar artery is patent and has good blood flow.

Negative Allen’s test: The normal color (flushing) returns within ±7 seconds.

Positive Allen’s test: The normal color of the hand does not return (flushing) within the specified time. A negative modified Allen’s test indicates that ulnar circulation is inadequate or nonexistent.

SIGNIFICANCEDespite 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, or harvesting as a graft in order to avoid serious ischemic (insufficient blood supply) complications to the hand.

Instead, use the radial artery of the opposite hand (remember to do an Allen’s Test first) or use another artery of the body for the specific clinical task or surgical procedure.

hyperlinks/radialandulnararteries.pdf

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Sample arterial blood from an artery

PROJECT 12 CDRAW ARTERIAL BLOOD

VIDEO

INFORMATIONThis project will describe sampling blood for ABG (arterial blood gasses) using the radial artery.Other arteries that may be used for this purpose include the ulnar artery, the brachial artery, and the femoral artery. Some medical/surgical emergencies like acute pulmonary edema, an acute exacerbation of COPD, and surgical shock reduces the body’s ability to take in oxygen and eliminate carbon dioxide. Often the patient’s life depends on the appropriate action based on the ABG results. ABG may also be needed when weaning a patient from a ventilator or administering a general anesthetic to a very sick patient.The ABG test results include the following: the blood’s pH, the partial pressure of Oxygen (PaO2), the partial pressure Carbon Dioxide (PaCO2), Oxygen saturation (SaO2), and bicarbonate (HCO3) levels.Drawing an arterial blood gas sample is not as difficult as you may think. Arteries pulsate, making them easier to locate and unlike some veins they don’t ‘roll’.

REQUIREMENTSYou will need:• Laboratory specimen labels• Pen for writing• Laboratory forms• A sharps waste container• Alcohol wipe• Clean gloves* • Clean work surface cover• Tourniquet• Syringe (3ml or 5ml)** • Needle (23g Use a safety needle if available.) • Cotton ball or gauze square• Strapping (adhesive bandage strip)• Fully set up Venipuncture Trainer—see PROJECT 10C

For ABG sampling use: Sterile gloves* (in most centers) Eye protection glasses* (recommended)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.

video/12C.mp4

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FOLLOW THESE STEPS IN A REAL-LIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER: STEP 1Assemble equipment (see REQUIREMENTS above). Open the outer packaging of all the items to be used.

Note: Use safety needles in all clinical settings. When simulating the procedure you may use a regular needle but take great care not to prick yourself with the sharp needle.

STEP 2Greet, identify, and inform the patient. Explain the procedure shortly (unless comatose) and that they will experience a ‘small needle prick’, a ‘mosquito bite’, or whatever works for you. You can ask them to ‘please, keep your arm still’.


STEP 4Site selection: as a first choice, select the radial artery of the non-dominant wrist. See PROJECT 12A – IDENTIFY THE BODY’S PULSE POINTS.

Warning: Radial arteries are contraindicated in patients who have a fistula or shunt in place for dialysis or have had the radial artery used as a coronary artery bypass graft on the side of the intended sampling.

STEP 5Perform a modified Allen’s test. See PROJECT 12B – PERFORM A MODIFIED ALLEN’S TEST. If you have a positive Allen’s test (normal pink color doesn’t return): don’t use the radial artery for blood sampling or cannulation so as to avoid serious ischemic (insufficient blood supply) complications to the hand.

Rather use the radial artery of the opposite hand (remember to do an Allen’s Test first) or choose another artery.

STEP 6Position is important! The patient should be seated comfortably (patients in bed should be in the semi-recumbent position) and the arm must be comfortably extended towards you, wrist up, and the skin over the radial artery taut. Let the forearm rest on a small pillow; use a rolled towel or linen under the back of the hand to facilitate the extended wrist position. Cover the rolled support with a ‘linen saver’.

STEP 7 (OPTIONAL)Give local anesthetic. Don non-sterile gloves and prepare the skin aseptically. Infiltrate (e.g., 2% plain Lidocaine 0.2 – 0.3 ml) intradermally with a 25G needle to reduce the anticipated pain associated with the procedure. Remove your gloves.

STEP 8Perform hand hygiene, don sterile gloves, and disinfect the site with an alcohol wipe for 30 seconds and allow to dry completely (allow another 30 seconds).

STEP 9With the fingertips of your gloved left hand, find the area of maximal pulsation of the radial artery. In addition to the pulsation, you should be able to feel the radial artery as a cord-like structure beneath your fingers.

With the fingers of your left hand over the radial artery, visualize the course of the radial artery underneath your fingers in three dimensions.

STEP 10Hold the syringe with the attached exposed needle in your right hand like a pencil. Approach the skin at 30°-45°, in line with the radial artery, pointing in the direction towards the elbow. The needle should enter the radial artery immediately below the gloved fingers of the left hand (careful not to slip and injure yourself ). Keep the skin taut and enter the skin with a brisk movement is the skin penetration that causes the most pain.

STEP 11Once in the soft tissue, slowly advance the needle to where you think the radial artery is. Do not rush; it is easy to go straight through the radial artery. You may feel a slight ‘give’ as the needle penetrates the wall of the radial artery. Once the needle has entered the artery you should see a flashback of blood pulsating into the syringe. If you don’t see blood you may have missed the artery or may have gone right through it. If so, withdraw the needle until blood starts filling the syringe or you may have to try again by re-aiming the syringe towards the pulsating artery.

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STEP 12Instruct the patient not to move the arm or wrist. If they do, the needle may become dislodged. Blood gas syringes fill automatically, stopping at ± 2 ml. If you are using a regular syringe you will have to stabilize the syringe with 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 prevent air aspiration and then withdraw the needle.

STEP 13Immediately place a gauze pad or cotton ball over the site and firmly apply pressure for 5-10 minutes. Use the tourniquet over the cotton ball to apply pressure.

STEP 14Inspect the syringe for air bubbles and slowly eject using a gauze square. Mix the blood with the heparin by gently rolling the syringe a couple of times between your fingers.

STEP 15Seal the needle or tip of the syringe with a rubber stopper to prevent the influx of air.

STEP 16Place the syringe onto the ice (pack some ice cubes over the syringe) and send it off to the lab immediately. ABG samples should be analyzed within 10 minutes of collection for accurate results.

STEP 17Discard all sharps (e.g., the used needles, syringes) and potential sharps such as glass items into a puncture-resistant sharps container. Place other items like used gloves and all items contaminated with blood or body fluids into the infectious waste.

STEP 18Recheck the labels and requisition forms for correctness of the patient’s name, the date, time, puncture site, etc.

STEP 19Monitor the site and extremity for a while for any sign of circulatory problems, nerve damage, or other complications.

STEP 20Thank the patient and perform hand hygiene.

STEP 21Simulate the project by following Steps 1-20 using the fully setup Venipuncture Trainer. See PROJECT 10C.

Unfortunately you won’t be able to feel a pulse on the simulator.

POINTS OF INTEREST:Although arterial puncture is a fairly complication-free procedure, you may encounter the following complications:

Hematoma Blood under pressure is initially more prone to leak from an arterial puncture than from a venipuncture site. It is important to exert sufficient pressure over the puncture site for 5-10 minutes.

HemorrhageHemorrhage is especially a problem with patients receiving anticoagulant therapy or patients with blood coagulation disorders. A longer compression time will be necessary.

Nerve damageCompression neuropathy secondary to hematoma may cause temporary numbness of the hand. Direct needle injury to a nerve may cause permanent numbness of part of the hand. Know your anatomy and avoid continuous blind and deep poking of the wrist area.

Aneurysm and AV (Arterio-Venous) FistulaThese rare complications usually occur with repeated punctures. An aneurism will cause the artery to ‘balloon-out’ due to a weakened muscular wall. An AV fistula is a communication between an artery and a vein before the capillary bed.

ArteriospasmArterial spasm may decrease the pulse volume and cause pain but fortunately is temporary.

Thrombus formationInjury to the artery can lead to clot (thrombus) formation. A large thrombus can obstruct the flow of blood and impair circulation to the hand.

Infection of the puncture siteUse sterile/aseptic protocol as recommended by your institution/hospital.

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The following factors will negatively influence the integrity of the ABG:• Air bubbles remaining in the specimen• Delay in cooling the specimen• Venous blood mixed in ABG sample

Note: The best way to be certain that a specimen is arterial is by observing the blood pulsating into the syringe.• Improper anticoagulant Note: Heparin is the only accepted anticoagulant for ABGs.

A person’s blood type is determined by certain proteins markers (antigens) on the surface of red blood cells (RBCs). A total number of 30 human blood group systems are now recognized by the International Society of Blood Transfusion (ISBT). There are many types of blood; however, the most important ones are ABO and the Rhesus factor.

The ABO blood group systemIn the ABO blood group system, there are four possibilities A-antigen (A blood), B-antigen (B blood), both A and B antigen (“AB blood”), and lastly neither A nor B antigens called “O blood”. A person with Type A blood produces 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).

BLOOD TRANSFUSIONS,BLOOD TYPE (BLOOD GROUPS) AND AGGLUTINATION

Figure 37: The ABO antigens and antibodies

Table 7: Prevalence of Blood groups in the general population (approximate global averages)

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%

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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 SYSTEMThe Rh system (another type of protein that is exposed on RBC is called “Rh-factor”) is the second most significant blood-group system in human blood. The most significant Rh antigen is the D antigen. You either have it or you don’t. The person who has the D antigen is positive and one who doesn’t is negative. So, someone could be Type A, B, AB, or O, and then Rh positive or negative (e.g., A Rh+ or B Rh-). An Rh+ person can donate blood ONLY to another Rh+ person while an Rh- person can donate blood to both an Rh+, as well as an Rh- person. Rh factor is especially important in pregnant women. Let’s say a woman is Rh- and the Rh+ father gave the baby the genes to be Rh+ as well. This will be fine, as the baby’s blood isn’t mixing with the mothers or vice-versa. When it becomes important is when she gives birth to the baby because there’s a break in the blood systems and small tears cause some of the blood cells from the baby to cross over into the mother’s bloodstream during birth, which causes the mother’s immune system to 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.

AGGLUTINATION REACTION (CLUMPING TEST)Should a medical professional infuse the wrong blood type to somebody by accident, the result will be that blood will agglutinate (create clumps of red blood cells followed by serious life threatening complications). It is important to test the blood from the donor and the recipient by mixing a small amount in a test tube or on a glass slide to test for compatibility. Agglutination will be noted if the bloods are incompatible. Type O Rh- blood can be given to anybody because there’s nothing on the blood cells for the person to attack. A person with type O Rh- blood is considered a “Universal donor” and any person in any other blood group may receive type O Rh- blood. A person with type AB Rh+ blood carries both A, B, and D (Rh) antigens but neither A nor B nor D antibodies and can therefore receive anyone’s blood (types A or B or AB or O blood – Rh+ or Rh-) because they don’t have antibodies to fight antigens. Type AB is known as a “universal recipient“.

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Table 9: Red blood cell compatibility

Recipi-ent

0- 0+ A- A+ B- B+ AB- AB+

0- 0+ A- A+ B- B+ AB- AB+

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Become a blood donor (if you aren’t a donor already)!

PROJECT 13DONATING BLOOD FOR THE BLOOD BANK

INFORMATIONStudy pages 25 – 30 (Practical guidance on venipuncture for blood donation) of the WHO document: WHO guidelines on drawing blood: Best practices in phlebotomy. WHO Publication 2010⁷

Your mission is as follows:• Identify your closest blood bank.• Arrange a date and time to donate blood.• Observe the steps and method used by the

phlebotomist to collect blood from you as a blood donor and compare it with the information below.

• Ask questions and have a hands-on learning experience!

REQUIREMENTSYou will need:• The contact details of your local blood bank.• Transport to and from your local blood bank.

COLLECTING BLOODFor collection of blood for donation use the procedure detailed in Section 2 for blood sampling (e.g., for hand hygiene and glove use) as far as it is relevant and follow the six steps given below:

STEP 1 • Identify donor and label blood collection bag and test

tubes• Ask the donor to state their full name. • Ensure that:

• The blood collection bag is of the correct type.• The labels on the blood collection bag and all its

satellite bags, sample tubes, and donor match.• Records have the correct patient name and

number.• The information on the labels matches with the

donor’s information.

STEP 2Select the vein• Select a large, firm vein, preferably in the cubital fossa,

from an area free from skin lesions or scars. • Apply a tourniquet or blood pressure cuff inflated to

40–60 mm Hg to make the vein more prominent. • Ask the donor to open and close their hand a few

times. • Once the vein is selected, release the pressure device

or tourniquet before the skin site is prepared.

STEP 3Disinfect the skin • 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 (recommended—takes about one minute):

• Use a product combining 2% chlorhexidine gluconate in 70% isopropyl alcohol.

• 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 or for a minimum of 30 seconds by the clock.

• Two-step procedure (if chlorhexidine gluconate in 70% isopropyl alcohol is not available, use the following procedure—takes about two minutes):

• Step 1: Use 70% isopropyl alcohol• 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).

• 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.

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STEP 4 Perform the venipuncture • Perform venipuncture using a smooth, clean entry

with the needle. Take into account the points given below which are specific to blood donation.

• In general, use a 16 gauge needle, which is usually attached to the blood collection bag. A retractable needle or safety needle with a needle cover is preferred, if available, but all should be cut off at the end of the procedure (as described in step 6 below) rather than recapped.

• Ask the donor to open and close their fist slowly every 10-12 seconds during collection.

• Remove the tourniquet when the blood flow is established or after 2 minutes, whichever comes first.

STEP 5Monitor the donor and the donated unit • Closely monitor the donor and the injection site

throughout the donation process. Look for:• Sweating, pallor, or complaints of feeling faint

that may precede fainting• Development of a hematoma at the injection

site• Changes in blood flow that may indicate the

needle has moved in the vein and needs to be repositioned

• About every 30 seconds during the donation, mix the collected blood gently with the anticoagulant, either manually or by continuous mechanical mixing.

STEP 6Remove the needle and collect samples• Cut off the needle using a sterile pair of scissors. • Collect blood samples for laboratory testing.

AFTER A BLOOD DONATIONDonor care after the blood has been collected:• Ask the donor to remain in the chair and relax for a

few minutes.• Inspect the venipuncture site. If it is not bleeding,

apply a bandage to the site. If it is bleeding, apply further pressure.

• Ask the donor to sit up slowly and ask how they are feeling.

• Before the donor leaves the donation room, ensure that they can stand up without dizziness and without a drop in blood pressure.

• Offer the donor some refreshments.

IMPORTANT NOTE!If you are not already one – consider becoming a regular blood donor.

POINTS OF INTERESTCurrent FDA guidelines allow a maximum of 10.5 ml/kilogram body weight of whole blood to be collected every eight weeks. The majority of blood collection facilities use 500 ml whole blood bags, with an additional 50 ml (10%) allowed to be drawn for mandated screening tests.

Great advances have been made with minimizing the need for blood during surgery. See “Bloodless surgery” for more information: [Click Here]

http://www.surgeryencyclopedia.com/A-Ce/Bloodless-Surgery.html

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Venipuncture Course and Kit | RELATED TOPICS OF INTEREST

Michelle, an experienced phlebotomist, has been working in a kidney transplant unit for years. On this specific occasion, she receives a requisition order for drawing venous blood for kidney function tests. The necessary items for drawing blood are collected but the safety needle container is empty. “I will just use a regular needle for now and get new supplies in a moment,” Michelle whispers to herself. The blood draw proceeds quite smoothly until, for some unknown reason, the patient suddenly and unexpectedly jerks away. In an instant the needle slips out of the patients arm and penetrates Michelle’s index finger. The

required protocol is followed and the patient is asked for permission to draw more blood samples—with the necessary explanations and relevant forms to be filled out. Eventually, later in the day, the patient’s blood results arrive.Michelle is summoned to the Infection Control Officer’s office. They discuss the results of the blood tests after which the Infection Control Officer asks Michelle, “When was your previous Hepatitis B inoculation?” An ice-cold shiver goes down the phlebotomist’s spine as she realizes that it is long, long overdue. Three months later, after a slow decline in health and

CASE STUDY 4:DESPITE ALL THE TRAINING AND THE NECESSARY CARE, ACCIDENTS DO HAPPEN

http://youtu.be/Mqce0gXQ9AM

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CENTRAL VENOUS LINEA 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 38: Central Venous Line Insertion

Depending on its use, the catheter is monoluminal, biluminal, or triluminal, dependent on the actual number of lumens (1, 2 and 3 respectively).

Figure 39a: Examples of a central venous catheters

Figure 39b: An introducer and a central venous catheter

Figure 39c: Placing a central venous catheter under sterile conditions

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• Need for intravenous therapy when peripheral venous

access is impossible

despite the best of medical attention by specialists in their fields and the best treatment medical science had to offer, the able phlebotomist succumbs to complications of sub-massive viral liver necrosis and all ends in tragedy.

Warnings: • In all clinical settings use safety needles and don’t

allow for any exceptions.Ensure that your Hepatitis B inoculations are up to date.

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An arterial line is a thin, hollow tube that is inserted into an artery — the most common being the radial or femoral arteries. It is often used in intensive care medicine and anesthesia to monitor the blood pressure real time and/or to obtain multiple samples for arterial blood gas measurements. The arterial line must be clearly marked to avoid accidental intra-arterial injection of intravenous drugs.

Figure 40: Inserting a catheter into the radial artery

COMMON REASONS FOR ITS USE ARE:• Severe hypotension or hypotensive shock • Life-threatening hypertension• Severe pulmonary problems

RISKS INCLUDE• Pain: Discomfort can result from the needle stick and

placement of the catheter at the time it is inserted. Consider infiltrating the skin over the intended insertion site before catheterization.

• Infection: As is the case with all catheters inserted into the body, bacteria can travel up the catheter from 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 followed by the application of pressure to the site.

ARTERIALCATHETERIZATION

Central venous catheters usually remain in place for a longer period of time than other venous access devices. Possible complications include:• Pneumothorax• Central-line associated bloodstream infections

• Thrombosis• Other complications• Air embolism (rare)• Hemorrhage and formation of a hematoma

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CORONARYARTERIOGRAPHY

INTERVENTIONALRADIOLOGY

A cardiologist may catheterize the coronary arteries, usually via a femoral artery access to evaluate the coronary arteries or to perform an interventional procedure, such as placing a stent.

A coronary angiogram is an X-ray of the coronary arteries showing the coronary arteries. Radiologists inject a contrast medium into the artery to assess the patency of the blood vessel.

Interventional radiologists utilize minimally invasive, image-guided procedures to diagnose and treat diseases in nearly every organ system. The concept behind interventional radiology is to diagnose and treat patients using the least invasive techniques available in order to 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.

Many conditions that once required surgery can now be treated non-surgically by interventional radiologists, thus minimizing the physical and psychological trauma to the patient, with reduced risk of infection and often drastically reduced recovery time.

VIDEO

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Conventional chronic hemodialysis is usually done three times per week for about 3-4 hours per dialysis treatment, during which the patient’s blood is drawn out through a tube at a rate of 200-400 ml/min. The tube is connected to a 15, 16 or 17 gauge needle inserted into the dialysis fistula or graft, or is connected to one port of a dialysis catheter. The blood is pumped through the dialyzer and then the processed blood is pumped back into the patient’s bloodstream through another tube connected to a second needle or port. During the treatment, the patient’s entire blood volume (about 5000 cc) circulates through the machine every 15 minutes.

AV (arteriovenous) fistulas are recognized as the preferred access method for gaining access to the bloodstream. Fistulas are usually created in the non-dominant arm and may be situated on the hand, the forearm or the elbow by a vascular surgeon who surgically joins an artery and a vein together. Since this bypasses the capillaries, blood flows rapidly through the fistula and this rapid flow of blood is necessary for withdrawing and replacing relatively large volumes of blood during dialysis.

KIDNEYDIALYSIS

Figure 41a: Placement of ‘In’ and ‘Out’ lines for renal dialysis Figure 41b: An AV fistula for renal dialysis

hyperlinks/figure41a.pdf

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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.

A PORT MAY SERVE THE FOLLOWING PURPOSES:• For the delivery of TPN (Total Parenteral Nutrition)• To deliver coagulation factors in patients with

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)

When no longer needed, the port can be removed in the operating room.

KIDNEYDIALYSIS

Figure 42a: A diagram of a venous access port Figure 42b: A clinical example of a venous access port

hyperlinks/figure42a.pdf

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Parenteral nutrition is given intravenously. Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing oral intake. Many hospitalized patients are given dextrose or amino acid solutions by this method.

TPN supplies all daily nutritional requirements. TPN can be used in the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required.For more information: [CLICK HERE]

LOCAL ANESTHESIA A local anesthetic is a drug that causes reversible local anesthesia (loss of sensation), inducing the blocking of pain impulses to the brain with the aim of performing a pain-free procedure.

Topical anesthetics are usually in the form of a cream, gel, or spray and are applied to the skin or mucous membrane before penetrating it with a needle. Applications include ophthalmology, dentistry, the relief of symptoms (e.g., sun burn), and before venipuncture.

Topical anesthetics when used before venipuncture penetrate mucosa with ease (mucosa will be fairly numb within 1-3 minutes), but are slow to penetrate skin. Clinicians need to follow instructions precisely. The anesthetic cream is required to be in contact with the skin for 30-60 minutes!

Infiltration local anesthesia is widely used for minor surgery on the skin and mucous membranes, as well as for dental procedures. The local anesthetic is deposited diffusely in the region of intended surgery.

PARENTERAL NUTRITION(TPN)

ANESTHESIA

http://www.merckmanuals.com/professional/nutritional_disorders/nutritional_support/total_parenteral_nutrition_tpn.html

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PROJECT 14 INFILTRATING A WOUND WITH LOCALANESTHETIC BEFORE SUTURING

INFORMATIONMost minor cuts and some not so minor lacerations can easily be sutured under local anesthetic as opposed to subjecting the patient to a general anesthetic. This is, in most cases, a much more cost-effective option and can be done on an outpatient basis.Keep in mind the basic principles of assessing a wound for suturing – remember the acronym “LACERATE”:

Look at the Wound (Assess it)Anesthetic ConsiderationsClean the WoundEquipment (Set Up)Repair the WoundAssess the Results and Anticipate ComplicationsTetanus Immunization StatusEducate the Patient Regarding Wound Care

REQUIREMENTSYou will need:• The Venipuncture Trainer• Gloves• 5ml syringe• 20G needle• Clean work surface cover• IV fluid bag• Alcohol hand rub• A suitable volunteer (as usual)

VIDEO

Two methods of infiltrating a wound with a local anesthetic solution before debridement and suturing

video/14.mp4

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METHOD 1 FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION:

STEP 1Remember the basics: take a medical history, prepare your hands hygienically, and don clean gloves.

STEP 2Withdraw some of the fluid from one of the IV fluid bags from the ‘out’ port. This will be used as a fake local anesthetic solution.

STEP 3Draw a 5 cm (2 inch) line on the Venipuncture Trainer to represent the laceration.

STEP 4Insert the needle into the tissue, about 5 mm (1/4 inch) away from the laceration, beside one end of the laceration.

STEP 5Deposit 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 6Aspirate to ensure that you are not in a blood vessel, to avoid accidentally injecting the local anesthetic solution intravenously.

STEP 7Inject 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 8If 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.

STEP 9Repeat the same procedure on the other side of the laceration.

STEP 10Wait 2-3 minutes; test the effectiveness of the local anesthetic by poking the wound area with a probe or pinching it with a forceps. You are now ready to prepare the wound for suturing.

Information: Do you want to learn all the basics about suturing, such as how to tie a surgeons knot and learn 12 different suturing techniques? Get your very own Apprentice Doctor® How to Suture Wounds Course and Kit

STEP 11Lift the skin, dry the trainer, and discard used needles in the mini sharps waste container. Clean up and replace all reusable items in your kit. Keep in a safe place and out of reach of children!

www.theapprenticedoctor.com/how-to-suture-a-wound/

www.theapprenticedoctor.com/how-to-suture-a-wound/

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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.

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Local and general adverse effects and complications include:

LOCAL ADVERSE EFFECTSThe local adverse effects of anesthetic agents include prolonged anesthesia (numbness) and paresthesia (tingling or ‘pins and needles’ of the affected area). Permanent nerve damage after a peripheral nerve block is rare. The vast majority of symptoms are likely to resolve within four to six weeks.

GENERAL SYSTEMIC ADVERSE EFFECTSCentral nervous system

Dangerous side effects involving the central nervous system usually follow when the safety dosage margins of the specific drug were exceeded or when an inadvertent intravenous or intra-arterial injection of the local anesthetic has occurred. It may either excite or depress the central nervous system which may manifest at lower blood levels as convulsions or coma, respiratory arrest, and death at higher concentrations

Cardiovascular systemComplications related to the conductive system of the heart include heart palpitations (innocent and usually due to the vasoconstrictor’s effects), arrhythmias, and a complete heart block (extremely rare but potentially fatal if not treated promptly)

Allergic reactionsAn allergy may vary from hypersensitivity (e.g., skin rash and itchiness) to a life-threatening anaphylactic shock. A patient may be allergic to any one of the components in a local anesthetic solution:

• The local anesthetic (The two main groups are esters and amides.)

• The vasoconstrictor• The preservative

Ask specifically about allergies to local anesthetics when preparing for suturing under local anesthetic.Be prepared with all the emergency equipment to resuscitate a patient in the case of an allergic reaction.

Local anesthetic block – a local anesthetic solution is deposited in the region of a specific nerve stem to numb the sensory distribution area of that specific nerve. The clinician needs to know the regional anatomy in detail. A nerve block should be effective within 3-5 minutes. An example of a local anesthetic block is the blocking of the lingual and inferior alveolar nerves before performing a surgical/dental procedure involving the lower jaw, the lower teeth, as well as the lip and chin on the side of injection.

IMPORTANT: It is wise to aspirate before depositing the local anesthetic to avoid intravascular injections.The clinician needs an understanding of the relevant pharmacology, physiology, anatomy, as well as the knowledge and skills to treat and manage complications.

NOTE: Great numbers of local anesthetic injections are given daily without aseptically preparing the mucosa. Despite the hordes of bacteria in the oral cavity, septic complications related to these injections are extremely rare. One researcher concluded: “…the application of an antiseptic to the mucosa before injection would appear to be questionable except for patients in whom special hazards are known to exist.” Reference: [CLICK HERE]

Regional anesthesia is anesthesia affecting only large parts of the body such as a limb or the lower half of the body, as opposed to local anesthesia, which affects a fairly small part of the body such as a tooth or an area of skin. Central regional anesthesia includes procedures like epidural anesthesia and spinal anesthesia, while peripheral techniques include procedures like plexus blocks (e.g., brachial plexus blocks) and single nerve blocks. Regional anesthesia may be performed as a single shot or with a continuous catheter through which medication is given over a prolonged period. Intravenous regional anesthesia (Bier block) is a specific type of regional anesthesia in which the clinician injects a local anesthetic solution directly into a vein, (e.g., of an arm) with the venous flow impeded by a tourniquet.

POINTSOF INTEREST

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1645866/pdf/procrsmed00314-0089.pdf

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General anesthesiaPrerequisite before starting the administration of a general anesthetic is a dependable venous access route for injecting the induction agent, various other medications, as well as possible emergency medications.Total Parenteral Anesthesia (TPA) is the term used when the anesthetist administers a general anesthetic using intravenous drugs, which are infused with an infusion pump, instead of maintaining the anesthetic with volatile anesthetic gasses.

Infusion pumpsExternal infusion pumps are medical devices that deliver fluids, including nutrients and medications (such as anesthetic agents, antibiotics, chemotherapy drugs, and pain relievers) into a patient’s body in controlled amounts. Many types of pumps, including large volume, patient-controlled analgesia (PCA), elastomeric, syringe, enteral, and insulin pumps, are used worldwide in healthcare facilities such as hospitals and in the home.

Scientists and bioengineers are developing amazing new technologies. Here are a few examples:

Microprobes for continuous monitoringInstead of frequently sampling blood and then sending it to the lab and waiting for results, certain biochemical substances can be monitored very accurately and in real time using an indwelling microprobe. This has especially useful applications in diabetics with real time monitoring of blood glucose.[CLICK HERE] for more information

Needleless injectionsIn future, people who have a fear of needles one may barely perceive receiving a needleless injection—at most they may feel the discomfort of a nail-scratch!

How it works: Commercially available needleless injection systems:Have a look at this pain-free, needleless dental injection: [CLICK HERE]And other pain-free injections: [CLICK HERE]

NEWDEVELOPMENTS

http://www.probescientific.com/

http://www.injexuk.com/dental/

http://www.bioject.com/

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SALIVA The term saliva is used for the watery substance freshly secreted from the ducts of the salivary glands. Saliva is secreted by the six major salivary glands (the paired parotids, submandibular, and sublingual glands), as well as the multiple hundreds of minor salivary glands situated within the submucosa of the lips, cheeks, and palate.

The laboratory testing of saliva samples is a fairly new and exciting field of clinical pathology, measuring various hormones, biochemical substances, drugs, etc. It has a number of applications in forensic medicine as well.

Saliva testing has many advantages over blood testing. Saliva specimen collection does not require a blood draw and there are no risks to patients. Saliva collections are convenient and can be done at work or at home. When stored properly, saliva samples are stable for several weeks.With an accuracy of 92-96%, saliva testing is as accurate as blood testing and, in some cases, more accurate. Another advantage of saliva testing is the ability to collect specimens over a period of time with ease. This offers providers more information than a single collection would. Compared to blood testing, saliva testing is also more affordable.

SPUTUMSputum refers more to the mucous substance secreted by the mucous glands in the throat and upper airways (nasal mucosa, trachea, bronchi, and bronchiole). Sputum needs to be coughed up and spit out by the patient into a specimen collection container. Sputum is usually sent to the microbiology lab and is especially useful in the diagnosis of tuberculosis (deep early morning sputum collected three consecutive days).

BREAST MILK Breast milk may be analyzed for nutritional composition/values. Measured nutritional components are glucose, lactose, triglyceride, and protein. Deficiency of any of the measured or calculated parameters is suggestive of decreased nutritional quality of human breast milk. It can also be analyzed for the presence of pollutants such as heavy metals (Mercury) or organic pollutants (Persistent Organic Pollutants or POP).

SEMEN Basic semen analysis: Almost all laboratories will report on the following information using values established by the World Health Organization.

• Concentration: This is a measurement of how many million sperm there are in each milliliter of fluid. There are various techniques for obtaining this number; some prove to be more accurate than others. Average sperm concentration is more than 60 million per milliliter (>60 million/cc). Counts of less than 20 million per milliliter (<20 million/cc) are considered sub-fertile.

• Motility (sometimes referred to as the ‘mobility’): This describes the percentage of sperm that are moving. Fifty percent or more of the sperm should be moving.

• Morphology: This describes the shape of the sperm. The sperm are examined under a microscope and must meet specific sets of criteria for several sperm characteristics in order to be considered normal. Most commercial laboratories will report World Health Organization morphology. By WHO criteria, 30% of the sperm should be normal.

• Volume of the ejaculate: Normal is 2 milliliters (2 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.

SHORT NOTESON OTHER BODILY SECRETIONS

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The sweat chloride test (sweat test) measures the concentration of chloride that is excreted in sweat. It is used to screen for cystic fibrosis (CF).

Sweating is stimulated by applying a colorless, odorless chemical that causes sweating. An electrode is applied

over a circumscribed area of the body for about five minutes. Sweat is collected on a piece of filter paper and then sent to the laboratory for testing. Increased chlorine levels will make the diagnosis of CF ‘unlikely’, ‘possible’, or ‘likely’, depending on the specific level.

SHORT NOTESON OTHER BODILY EXCRETIONS

URINEUrine tests are very useful for providing information to assist in the diagnosis, monitoring, and treatment of a wide range of diseases and conditions. Hormonal levels in the urine test can indicate whether a woman is ovulating or pregnant.Urine can also be tested for a variety of substances, including illegal drug use in general, as well as in the world of professional sport.Urine may be submitted to the cytology lab to detect cancerous cells or to the microbiology lab for microscopy and culturing to identify specific microbes involved in urinary tract infections.

URINALYSISThe urine can be tested very quickly using a strip of special paper, which is dipped in urine just after urination. This will show if there are any abnormal products in the urine such as sugar, protein, or blood.If more tests are needed to get more details, the urine will be analyzed at a laboratory.Normally urine is sterile, but skin contaminant bacteria may be added to the sample during urination.The patient should be instructed to wash genital areas before taking the sample, specifically taking the ‘mid-stream’ urine. A urine sample for the lab is collected in a standard lab collection container (100-150 ml required).

FECESA doctor may order a stool collection to test for a variety of possible conditions, for example to:• Evaluate certain allergies, such as milk protein allergy

in infants.• Assist with identifying diseases of the digestive tract,

liver, and pancreas. • Screen for colon cancer by checking for hidden

(occult) blood.• Examine for the presence of parasites, such as

pinworms or Giardia lamblia.• Ascertain the cause of an infection, such as bacteria

(e.g., Salmonella, Shigella, fungi, and viruses). • Assist with finding the cause of symptoms affecting

the digestive tract, including prolonged diarrhea, bloody diarrhea, increased flatulence, nausea, vomiting, loss of appetite, bloating, abdominal pain, cramping, and fever.

• Check for poor absorption of nutrients by the digestive tract (malabsorption syndrome).

A fresh stool sample is collected in a sterile container. Stool samples should be taken to the laboratory within an hour after collection. Infant stool samples are usually collected with a rectal swab.

Notes: • Wash hands thoroughly before and after sampling.• Use clean gloves and other barrier techniques if

indicated!

SWEAT

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SHORT NOTESON OTHER BODILY FLUIDS

Cerebrospinal fluid (CSF) is a clear, colorless bodily fluid produced in the choroid plexus of the brain and occupies the subarachnoid space, the ventricular system around and inside the brain, as well as the central canal of the spinal cord.CSF can be tested for the diagnosis of a variety of neurological diseases. It is commonly obtained by a procedure called a lumbar puncture. Lumbar puncture is performed in an attempt to count the cells in the fluid and to detect the levels of biochemical constituents like protein and glucose. These parameters alone may be extremely beneficial in the diagnosis of subarachnoid hemorrhage and central nervous system infections such as encephalitis and meningitis. Microbiological CSF culture examination may yield the specific microorganism causing the infection. By using more sophisticated methods, such as the detection of the oligoclonal bands, conditions like multiple sclerosis may be recognized. Beta-2 transferrin is almost exclusively found in the cerebrospinal fluid. It is not found in blood, mucus, or tears, thus making it a specific marker of cerebrospinal fluid and the detection of leakage like CSF rhinorrhea.

Figure 44: Cerebrospinal fluid fills the ventricles and surrounds the brain and spinal cord.

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.

Diagnosis of the cause is usually done with blood tests, an ultrasound scan of the abdomen, and direct removal of the fluid by needle (paracentesis). Treatment may be with medication (diuretics), paracentesis, or other treatments directed at the cause.

Diagnostic blood tests should include a complete blood count (CBC), basic metabolic profile, liver enzymes, and coagulation profile. Most experts recommend a diagnostic paracentesis be performed; the fluid is then examined for its gross appearance, protein level, albumin, and cell counts (red and white). Additional tests will be performed if indicated, such as Gram stain and cytopathology.

The Serum-Ascites Albumin Gradient (SAAG) is probably a better discriminant than older measures for discerning the causes of ascites. A high gradient indicates the ascites is due to portal hypertension, while a low gradient points away from portal hypertension as the primary etiology.

EFFUSION is the escape of fluid from the blood or lymphatic vessels into the surrounding tissues or into a body cavity.

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• Other tests as suggested by the clinical situation

– lipids, fungal culture, viral culture and specific immunoglobulins

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JOINT EFFUSION is the presence of increased intra-articular fluid, a fairly common finding in the inflamed knee joint, but any joint may be affected. It may happen as a result of trauma, inflammation, hematologic conditions or infections.

EXUDATES AND TRANSUDATESAN EXUDATE is any fluid that filters from the circulatory system into lesions or areas of inflammation.It is rich in the protein and cellular elements that ooze out of blood vessels due to inflammation and is deposited in surrounding tissues. The altered permeability of blood vessels permits the passage of large molecules and cells through the blood vessel walls.

A TRANSUDATE is an accumulation of fluid that passed through a membrane due to increased pressure in the veins and capillaries forcing the fluid through the vessel walls. This process filters out most of the protein and cellular elements, thus yielding a watery solution. Transudates are caused by disturbances of hydrostatic or colloid osmotic pressure and not by inflammation. There is an important distinction between transudates and exudates. Exudates have a higher protein content and thus a higher specific gravity, while transudates have a lower protein content and thus a lower specific gravity.

PUSPus is a viscous, yellowish-white fluid formed in infected tissue, consisting of white blood cells, cellular debris, necrotic tissue and masses of bacteria, both dead and alive.The following are recommended steps to take for sending a pus sample from a closed abscess to the microbiology lab for MC&S (Microscopy, Culture and Sensitivity).

FOLLOW THESE STEPS:• Ensure sterile conditions and have relevant barrier

techniques in place.• Test for fluctuation and determine the point of

maximum fluctuation.

• Clean the skin/mucosa with an appropriate antimicrobial agent. If needed, remove excess cleaning agent with a sterile gauze square to avoid contamination.

• 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 of wisdom regarding the local anatomy). Aspirate enough pus; more is better than less.

• Transfer to an aerobe as well as an anaerobe lab transfer medium/bottle.

• Mark as urgent, for immediate transfer to the lab.• Proceed with the formal surgical incision and drainage

procedure. (Needle aspiration is an insufficient method of evacuating all the pus in an abscess cavity.)

• Alternatively, incise the abscess then use a pus swab to take the sample when pus emerges and then insert the swab in a dedicated transport medium.

• Warning: Use safety needles and take extreme care not to inoculate yourself or someone else with this septic content!

COMMENT:• Pus aspirated in a syringe is always preferable to a

swab.• Sample pus, if possible, before initiating antibiotic

therapy. • 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 the lab giving valueless results.

• The empirical treatment of an abscess is ‘incision and drainage’.

• External heat therapy increases the blood flow to the area and assists with localizing the pus.

• Antibiotics and analgesics play a supportive role in treating infections. Not even the strongest antibiotic will clear a pus-producing abscess!

• As far as possible, use a narrow spectrum antibiotic with proven sensitivity rather than treating the infection blindly.

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Venipuncture Course and Kit | COMPLICATIONS

Judy has always had a problem with difficult veins. Questions like, “Are your veins hiding today?” and “Did you leave your veins at home?” are common remarks by medical professionals when attempting to draw blood or put up an IV line. Today is no exception as Candice, RN on duty, tries to draw blood from Judy’s arm veins. The nurse tries three unsuccessful attempts on the right arm and two on the left arm. Finally she successfully draws blood from the right foot. But the next day, the leg starts swelling. A physician is called in, but while waiting for some hours for the busy physician, Judy starts to have difficulty breathing and slowly gravitates into a coma. When the physician

eventually arrives, ‘all hell breaks loose.’ The physician demands action STAT*!! Emergency medications are called for and emergency procedures follow, after which an urgent transfer to the Intensive Care Unit is done. Despite the brave efforts of competent medical professionals, Judy drifts deeper into the coma. Two days later, the consulting neurosurgeon declares her brain dead. The autopsy findings report a massive pulmonary embolism as the cause of death. Although not recommended for routine venipuncture, the veins of the lower extremity are quite permissible. This particular patient, however, had a history of

CASE STUDY 5:A “ROUTINE” VENIPUNCTURE CASE

http://youtu.be/i5ioXC5nrqE

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VASOVAGAL RESPONSEAND VASOVAGAL SYNCOPE

repeated episodes of DVTs (deep venous thrombosis). This venipuncture was complicated by a phlebitis and thrombus formation, triggering the cascade of events, leading to the fatal outcome.*STAT is short for statim, the Latin word for immediately.

Important to remember:• Always take a short medical history (or check the

medical history in the patient’s records) before performing venipuncture or setting up an IV line.

• Use the veins of the foot as a last resort, especially if any contraindications are noted.

A vasovagal attack is a disorder that causes a rapid drop in blood pressure and heart rate, resulting in decreased blood flow to the brain, followed by fainting. It is most often evoked by emotional stress associated with fear or pain. The clinician will notice the following signs: pallor, nausea, sweating, bradycardia, a rapid fall in arterial blood 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, 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.

• Not drive home (and not drive at all) on the day blood is drawn.

The emergency treatment to simply restore the patient’s blood flow to the brain is to reposition the body. Use one of the following positions:

Figure 45: Various patient positions

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A number of different allergic reactions may be encountered during routine venipuncture procedures, including the following:

CONTACT DERMATITISThis usually manifests as an increased redness of the skin where a specific strapping was placed.• Remove strapping• Apply a suitable cortisone-containing ointment

and give instructions on further use.• Inform the patient regarding the specific brand

of strapping. Ask them to avoid it in future and to inform medical professionals when necessary.

SKIN RASH/urticaria following the infusion of medication or administration of a local anesthetic• Stop the infusion immediately and inform the

medical professional in charge of the patient.• Treatment with IV or oral antihistamines and/or

cortisone will usually suffice as definitive treatment.• Inform the patient regarding the specific

medication so that they can avoid it and inform medical professionals accordingly in the future.

• The patient should arrange for a Medical Alert bracelet engraved with relevant information.

ALLERGICRESPONSES

ANAPHYLAXIS (ANAPHYLACTIC SHOCK)Anaphylaxis is a life threatening allergic reaction that is rapid in onset.

Figure 46: Anaphylactic shock diagram

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NEEDLE PENETRATIONTHROUGH THE VEIN

HEMATOMA

Withdraw the needle somewhat, re-angulate the needle a bit more superficially, and enter the vein lumen. If unsuccessful, apply pressure and move to another site. As a general rule, if performing phlebotomy (drawing blood

for the lab), move to a more distal site from the previous attempt (not proximal), or move to another extremity. If putting up an IV line, change to a more proximal site from the previous attempt (not distally).

If a hematoma forms under the skin adjacent to the puncture site release the tourniquet immediately and apply firm pressure while withdrawing the needle. Move to another site. Older patients are prone towards forming hematomas.Considerations for preventing a hematoma:Use the major superficial veins.

Puncture the uppermost wall of the vein only.Remove the tourniquet before removing the needle.Ensure that the needle fully penetrates the upper most wall of the vein as partial penetration will cause blood leaking into the surrounding soft tissue. Apply pressure to the venipuncture site following phlebotomy.

Any medication may potentially trigger anaphylaxis. Other causes include severe latex allergy and food allergens.

DIAGNOSISAnaphylaxis is diagnosed based on clinical criteria.• When two or more of the following signs occurs

within minutes or hours of exposure to an allergen, there is a high likelihood of anaphylaxis:

a. Involvement of the skin or mucosal tissue (an itchy rash and/or urticaria)b. Respiratory difficulty c. Low blood pressured. Gastrointestinal symptoms

TREATMENTAnaphylaxis is a medical emergency that may require resuscitation measures such as airway management, supplemental oxygen, large volumes of intravenous fluids, and close monitoring.

• If not qualified to treat the emergency—call for assistance!

• Administration of epinephrine (adrenalin) is the first line of treatment, with antihistamines and steroids often used as an adjunctive treatment. Nebulized salbutamol may be effective for bronchospasm that does not resolve with epinephrine.

• It is recommended that an epinephrine solution be given intramuscularly (e.g., the mid-anterolateral thigh) as soon as the diagnosis is suspected. The injection may be repeated every 5 to 15 minutes if there is insufficient response. You may consider an IV as an alternative route, but ensure that you administer 1/10 diluted epinephrine in sterile water SLOWLY.

• Position the patient in the supine or Trendelenburg position.

• Apply an oxygen mask or nasal cannula and supplement oxygen intake.

• Monitor the vital signs, especially blood pressure and oxygen saturation.

• A 24-hour period of in-hospital observation is recommended for patients once they have recovered due to the possibility of biphasic anaphylaxis.

CAUSES

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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.

If the needle lands up in the tissue during IV infusion of fluid/medication, the IV fluid will infiltrate into the surrounding tissue. The tissue will swell around the IV needle, becoming edematous and cool to the touch. The patient will complain about pain and discomfort.• Stop the infusion immediately!• Start the IV in a new spot on the patient’s body at

the correct rate for the given dosage.• Observe the infiltrated area for 24 hours for

possible complications. Treat these complications empirically.

Most infiltrations have only minor sequelae. However, certain drugs infused can cause serious complications such as compartment syndrome, permanent nerve damage, necrosis, soft tissue loss, scarring around nerves, joints, and tendons leading to contractures and deformity. Severe tissue injuries may require extensive surgical debridement, tissue grafting, surgical release of contractures to restore function, or even an amputation.

NEEDLE/CANNULA IN THE TISSUE

TISSUE INFILTRATION(EXTRAVASATION)

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

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Central venous catheter-related infections are common and an estimated 80,000 central venous catheter related bloodstream infections occur in intensive care 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

infection the CDC advises in their guideline that the catheter needs to be replaced every 96 hours (4 days).See [SUPERFICIAL PHLEBITIS] for more information.

Figure 48: A blocked peripheral IV cannula

Prevention is better than cure!• Keep the IV fluid running; don’t close the infusion for

long periods of time. Don’t let it run dry.• The IV fluid bag must be at least 1 meter (3 feet)

above the patient for gravity to overcome the venous pressure and guarantee a positive flow of IV fluid. Don’t allow the IV fluid bag to be at the level of the 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.

• 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?

Check the IV bag and line. Is the IV bag empty? Inspect the tubing and cannula for kinks.

If you can’t find a remediable reason, remove the IV cannula and place the IV line at a new site.

Warning: Do not force flush with saline! You may just cause a small embolus by doing this!More information: [CLICK HERE]

CANNULA/CATHETER BLOCKED (OCCLUDED)

CATHETER-RELATEDINFECTIONS

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

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If you are drawing blood and you suspect an intra-arterial position: • If you haven’t started withdrawing blood, remove

the needle/cannula, apply pressure for at least five minutes, then move to a positively identified vein and proceed with the phlebotomy procedure.

• If you are more than halfway finished with the task and then suspect that you are in an artery, complete the task, then remove the needle/cannula and apply pressure for at least 5 minutes (or until the bleeding stops).

Some drugs can cause severe endothelial damage to the arteries, but worse damage to the capillary bed of the tissues within the arterial blood supply area. This can cause tissue damage or necrosis, resulting in disfigurement or loss of function. In severe cases, it can require the amputation of a hand, foot, or other extremity.

This complication is much better avoided than treated afterwards.• If you suspect an accidental intra-arterial injection

and if you haven’t injected any medication, remove the needle/cannula, apply pressure for five minutes and move to positively identified vein for venipuncture.

• If you start injecting and the patient experiences

pain in the extremity distal to the injection site, stop immediately and presume an intra-arterial injection. Observe the hand/foot for any changes in color.

• If some medication has been injected, keep the arterial access; it may be required by the medical professional (experienced vascular surgeon or anesthesiologist) treating the complication.

• Get urgent assistance from an experienced vascular surgeon or anesthesiologist.

• Treatment may require a combination of intra-arterial flushing, local anesthetics, cortisone, and sympathetic blocks. Later surgery may be necessary if the following ensue: compartment syndrome, tissue necrosis, or scarring around nerves, joints, and tendons.

INTRA-ARTERIAL POSITION OF NEEDLE/CANNULA DURING PHLEBOTOMY

INADVERTENT INTRA-ARTERIAL INJECTION OF MEDICATION—INSTEAD OF INTRAVENOUS INJECTION

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• Position: Veins are usually more superficial while arteries anatomically run a deeper course. Keep in mind that there are exceptions; arteries may run a superficial course in areas or as an anomaly.

• Color: Veins often have a bluish hue, especially noticeable in fair skinned people.

• On palpation: Arteries pulsate (throb/thump). Arterial walls are firmer and thicker than those of veins.

• On puncturing: The pressure in arteries is much higher than the pressure in veins, thus arterial blood may squirt spontaneously into the syringe (but not always).

• During an ultrasound examination: While exerting light pressure with the examination probe, you will notice pulsating movement with arteries, while veins will simply collapse with mild pressure.

• On setting up an IV fluid bag/drip set: You will notice either a retrograde flow of bright red blood into the plastic tubing or you will notice that the

intravenous fluid resists flowing into the blood vessel. You may also see the drop of fluid in the drip chamber growing bigger and smaller in a pulsatile manner. (Attaching a ‘drip’ to the needle/line can assist one in differentiating between an intravenous and an intra-arterial position).

• On removal of a needle: Arteries are more prone to bleed profusely due to the high pressure (compared to veins). Therefore, after removing a needle, always apply firm pressure on the spot for at least five minutes. Inspect the area, if it is bleeding, repeat the pressure.

WARNINGS:NEVER inject any medication or fluids into a blood vessel unless you are 100% sure you are inside a VEIN!When setting up an IV line and if you suspect that the needle has entered an artery – stop the procedure, remove the needle, and apply firm pressure as instructed above.

CLINICAL DIFFERENTIATIONBETWEEN ARTERIES AND VEINS

SUPERFICIALPHLEBITIS

Superficial phlebitis, also called superficial throm bophlebitis, is a condition where a vein close to the surface of the body becomes tender, swollen, red, and develops a blood clot. This is differentiated from thrombophlebitis of the deep veins of a limb (usually a lower limb), which is called deep vein thrombosis or DVT.

Sometimes phlebitis may occur at the site where a peripheral intravenous (IV) line was started. The surrounding area may be sore and tender along the vein.Thrombophlebitis may be caused by damage to a vein’s 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

ramify to smaller feeder veins as it progresses. On palpation, the vein will feel hard and warm with tenderness. The area will begin to burn and throb if acute inflammation ensues. The patient may become febrile.

The initial treatment for phlebitis, especially if associated with pain, is to stop the infusion and remove the peripheral venous cannula (PVC).

Elevate the affected limb and apply an anti-inflammatory cream or gel to the area. In addition, anti-inflammatory medication and analgesics can be used when necessary.

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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.

It is not recommended to use veins, for either phlebotomy or setting up an IV line, in the lower extremities of adults due to possible complications that include, but are not limited to, phlebitis and/or DVTs – especially in high risk individuals: • Patients with a history of thrombosis • Patients who will be immobile for an extended

period of time (e.g., orthopedic traction patients)• The elderly• Diabetics• People with blood disorders• Women who take oral contraceptives (birth control

pills)• People who have just undergone major surgeries or

have just suffered a bone fracture

Signs and symptoms of deep vein thrombosis include:• 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

region to relieve pain.• Compression stockings. Physicians frequently

recommend compression stockings to reduce DVT symptoms and to improve the venous return of blood to the heart.

• Anticoagulation medication (blood-thinning drugs). The anticoagulant drugs, heparin and warfarin, are used primarily to prevent the formation of new clots and reduce the chance of pulmonary embolism.

• Thrombolytic agents are used to help dissolve existing clots and reopen clogged veins. The most commonly used thrombolytic agents are urokinase and streptokinase.

• Surgery. Surgery is considered a last resort. Removal of the thrombus (venous thrombectomy) or the insertion of a filter device into the inferior vena cava to trap any blood clots headed towards the lungs are procedures that may be considered.

SEPTIC THROMBUS

DEEP VEIN THROMBOSIS (DVT)

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Lung embolism from a dislodged deep vein thrombus is a life-threatening condition requiring treatment in an intensive care environment by suitable qualified and experienced specialists in this field.

Clinical signs and symptoms for pulmonary embolism are nonspecific and may include unexplained difficulty in breathing, fast respiratory rate, and chest pain.

Definitive diagnosis is usually by a D-dimer blood test, pulmonary artery angiography, or CT scan.Immediate full anticoagulation is mandatory for all patients suspected of having pulmonary embolism.

EMBOLISM

An air embolism is caused by air bubbles in the vascular system. Venous air embolism can result from the introduction of air through intravenous lines, especially central lines, and generally must be substantial to block pulmonary blood flow and cause symptoms.Small amounts of air often get into the blood circulation accidentally during surgery and other medical procedures, but most of these air emboli enter the veins and are stopped at the lungs. Thus, a venous air embolism that shows any symptoms is very rare.The risk of catheter-related venous air embolism is increased by a number of factors:• Breakage or detachment of catheter connections • Failure to occlude the needle hub/catheter during

insertion or removal• Dysfunction of self-sealing valves in plastic

introducer sheaths• Presence of a persistent catheter tract following the

removal of a central venous catheter• Deep inspiration (inhalation) during insertion

or removal, which increases the magnitude of

negative pressure within the thorax• Hypovolemia, which reduces central venous

pressure• Upright positioning of the patient, which reduces

central venous pressure

Treatment: The primary aim is to identify the reason for air entry and prevent further air embolization. Supportive care includes the use of mechanical ventilation, vasopressors, and volume restoration.

The following may be of value:• High-flow supplemental oxygen • Hyperbaric therapy • Placing the patient in the Trendelenburg position

and other positional maneuvers may help in dislodging the air embolus

• Closed-chest cardiac massage• Aspiration of air from the venous circulationWith air embolism, prevention is better than cure!

AIR EMBOLISM

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Needlestick injuries may involve the patient or the medical professional.There are very specific legalities to be aware of, ways to minimize you and your patient’s risk factors and steps to take if such an incident should occur.Kindly familiarize yourself with the most current information on the subject.Study the legalities: (USA) [OSHA Occupational Safety & Health Administration]Medical professionals outside of the USA, contact your country’s Health and Safety authorities for information regarding legalities and other specifics.For sensible guidelines and more information see: [Click Here]

Also read: WHO Publication on Sharps injuries: Assessing the Burden of Disease From Sharps Injuries to Health-Care Workers at National and Local Levels.[Click Here]

In conclusion, a number of comments from the author:• Take great care to avoid this type of injury.• Use appropriate barrier techniques.• Use safety items and equipment at all times, if at all

possible.• Accurately follow the guidelines of your unit or

institution.• If an accident occurs, immediately contact the

hospital’s Infection Control Officer and follow the appropriate directives as soon as possible. Initiate the correct antiretroviral medication if applicable.

NEEDLESTICK INJURIES

VIDEO




http://www.who.int/quantifying_ehimpacts/publications/ebd11/en/

video/fc_with_sound_effects.mp4

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The skin surrounding the venipuncture site may (rarely) break down, usually due to infection.Applying a local antiseptic or antibiotic ointment may be all that is required.

NERVE DAMAGEThe two nerves with the highest risk of being injured during a venipuncture procedure are the radial and median nerves. Permanent nerve damage is a difficult complication for the patient to come to grips with and carries a high medicolegal risk.

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.

• Avoid wrist veins.• Do not probe excessively.• Do not make an excessive number of attempts (two

or, at most, three attempts).• 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

occur.• Recognize the signs and symptoms of nicking a nerve

and take appropriate action.• 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 minimize nerve injury.

Danger areas:• The distal part of the radial nerve just above the

thumb (radial nerve)• 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 50: Diagram of the main nerves of the arm

Arterial cannulation Brachial artery cannulation is associated with an increased risk of median nerve injury.

LOCAL TISSUE DAMAGE

hyperlinks/nerves_of_the_arm.pdf

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Venipuncture Course and Kit | EVALUATION MODULE

Congratulations – you have completed The Apprentice Doctor® Venipuncture Course!May we remind you carefully close the sharps waste container and to hand it to a medical professional at a hospital, a medical clinic, or to your family doctor for proper sharps waste disposal.Warning:Never discard the sharps into a regular waste bin or bag!

Dr. Anton Scheepers and the staff at the Apprentice Corporation wish you all of the best with your studies and trust that we may have contributed in a small way to your success in practicing venipuncture!Let us know if you liked the course, and in you didn’t, inform us as well. [CLICK HERE] to access The Apprentice Doctor® Venipuncture Course and Kit evaluation questionnaire. Thank you for your time!

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.

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.

ASSESSMENTMODULE

EPILOGUE

CONGRATULATIONSAND FINAL REMINDERS

REFERENCES

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)

(Available online) [CLICK HERE]



http://www.theapprenticedoctor.com/venipuncture_training/ASSESSMENT/index.html

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CREDITS

Facilities for videos and photography: Rhesa Van Der Merwe: Hospital Manager, Union and Clinton Hospitals Hans Van De Zee: Specialist Veterinary Surgeon, Valley Farm Animal Hospital in PretoriaOur gratitude to all the skillful veterinary practitioners and staff at Valley Farm Animal Hospital.[CLICK HERE] to meet the team.

Final proof reading: American Proofreading Company, Peggy Wendel, Sr. Copy Editor, www.ameriproof.com

Graphic design:Maria AndorPackage, DVD, EBook, Brochure, and various other graphic design aspects.Portfolio site:http://www.behance.net/marcsiandor

Illustrations: Kevin Berry: Medical and General Illustrator Drawing Conclusions: www.drawingconcusions.co.za

Linguistic care: Eizabeth Scheepers Jacqui Summerville Natalie Scheepers

Model: Gizela Marais Box/package cover and DVD Email: [email protected]

Patient models:Anton ScheepersElna Van Der HeverJacquiline SumervilleRégardt ScheepersRuan KlutStéfan Scheepers

Production:Open Window School of Visual Communication Hub

Arthur Twigge (Coordinator)Chase Jordan Coetzee (Assistant videographer)Dagan Read (Software development and final compiling)Natalie Scheepers (Photography - Dip Visual Communication)Stephan Calitz (Games and other interactive components)Wihann Strauss (Videographer and editing of videos)

Professional RNs: Adelle Du Toit, RPN Annette Klut, RPN Lili Van Der Zee, RPN

Voiceovers:Female: Suehyla El-Attar Voice123.comMale: Craig Gildner Voice123.comStories (narration): Dave Pettitt Voice123.com

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):48-539. Laura L et al. Difficult Venous Access in Children: Taking Control. JOURNAL OF EMERGENCY NURSING September

2009; 35:510. 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.

http://www.valleyfarmvet.co.za/vf_team.htm

http://www.ameriproof.com/

http://www.behance.net/marcsiandor

http://www.drawingconcusions.co.za/

[email protected]

http://voice123.com/suehyla

http://voice123.com/craiggildner

http://voice123.com/davepettitt

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OTHER PRODUCTSBY 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• How to tie a surgeon’s knot and various other knots• How to suture wounds correctly and avoid common

mistakes• Why eversion is important in suturing skin lacerations• How to use the tools and instruments medical

professionals use for suturing

The theory is clearly explained and well-illustrated. Suturing and knot tying skills are acquired as students perform over 20 fun practical projects, and what’s more – this 18-piece suture kit contains all the necessary real medical instruments and items are included: imitation skin, needle holder, scissors, suture material, suture needles.

This training material is recommended for all healthcare professionals whether prospective, in training or qualified:Medical students – Pre-medical students – Paramedics and EMT students – Dental students – Veterinary students – Nursing students – Surgery Interns/Registrars – Advanced First Aid practitioners – Medics in the military – Practicing Healthcare professionals who would like to improve or refresh their suturing technique – Individuals with a keen interest in the practical aspects of medicine, and High School students interested in a career in medicineOrder your kit online – today! [CLICK HERE]

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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

ATTENTION ALL FUTURE DOCTORS IN HIGH SCHOOL!

• Get insight into the methods doctors use to make an accurate diagnosis.

• Understand the human body from a doctor’s perspective.

• Use real medical instruments and items (included in the kit) to practice what you learn on the CD-ROM.

• Listen to numerous bodily sound samples and learn how to identify abnormalities like heart murmurs.

• Increase your dedication and love for medical science as well as the human body.

• Make sure, beyond any doubt, that you are suited to become a doctor.

• Discover which specialty would best suit you after you become a doctor.

What are people saying about The Apprentice Doctor® How to Examine Patients Foundation Course and Kit?

“... It took me 12 days to work my way through the course for the first time. I am working my way through the material a 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

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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.ABO blood group The major human blood type system which depends on the presence or absence of antigens A and B.Absorb To suck up or take in, as through pores.Acid-citrate-dextrose (ACD) An anticoagulant containing citric acid, sodium citrate, and dextrose. Acquired immunodeficiency syndrome (AIDS) A disease caused by an infection of the human immunodeficiency virus (HIV-1, HIV-2).Acute Of short duration. Rapid and abbreviated in onset in reference to a disease process.Adsorb To attract and retain other material on the surface.Adult Respiratory Distress Syndrome (ARDS) A life threatening inflammatory reaction of the lungs in response to various forms of injuries or acute infection.Aerobic Referring to organisms requiring an oxygenated environment to grow and live.Agglutination The process of cells clumping together, such as red blood cells or bacteria, with the formation of clumps of cells.AHF Antihemophilic Factor. See Factor VIII.AIDS Acquired Immune Deficiency Syndrome, caused by human immunodeficiency virus (HIV).Air Embolism (Emboli) An air embolism is a potentially fatal pathological condition caused by air bubble/s in a blood vessel and/or one or more of the heart chambers. Albumin Main protein in human blood.Allen’s test (Modified Allen’s test) Allen’s test is used to test blood supply to the hand, specifically, the patency of the radial and ulnar arteries.Allergen A substance capable of producing a hypersensitivity reaction (allergy).Allergy An unusual sensitivity to a normally harmless substance that provokes a strong reaction in a person’s body.Ambulatory Mobile, walking around. Anaerobic Organisms that can grow, live, and multiply in the absence of oxygen.Anaphylaxis (Anaphylactic Shock) A serious allergic reaction that is rapid in onset and may cause death. It

typically causes a number of symptoms including an itchy rash, throat swelling, and low blood pressure.Anastomosis Refers to connections between tubular structures such as blood vessels or between loops of intestine.Anatomy The branch of science that studies the physical structure of animals, plants, and other organisms.Anemia The condition of having less than the normal number of red blood cells or hemoglobin in the blood.Anesthetic A drug that causes unconsciousness or a loss of local or general sensation. Anomalous Deviating from the norm or from what people expect.Antecubital fossa See cubital fossa.Antecubital vein See cubital vein.Anterior Towards the front of the body.Antibacterial agent A synthetic preparation or drug that destroys or inhibits the growth of bacteria. It is used to treat bacterial infections in patients.Antibiotic Antibacterial substances used to treat infection. Antibody A molecule produced by immune cells with an affinity for a specific antigen.Anticoagulant A natural or synthetic agent that prevents the formation of blood clots.Antifibrinolytics Used to inhibit fibrinolysis (the process of dissolving a blood clot).Antigen A substance that is capable of producing a specific immune response with a specific antibody.Antihemophilic factor Coagulation (clotting) factor number VIII.Antihistamine A drug that antagonizes the action of histamine. It is used to treat allergies.Anti-platelet agents Medications that, like aspirin, reduce the tendency of platelets in the blood to clump and clot.Antiseptic A substance that discourages the growth of microorganisms.Antiseptic rub An agent that reduces or prevents infection, especially by eliminating or reducing the growth of microorganisms that cause disease.

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Apheresis A technique in which blood products (e.g., platelets) are separated from a donor, the desired elements collected, and the rest returned to the donor.Arterial catheterization The placement of a thin, hollow tube into the lumen of an artery to measure real time arterial pressure. The catheter can also be used to get repeated blood samples to frequently measure the levels of oxygen and/or carbon dioxide in the bloodstream.Arterial line Catheter inserted into an artery. It may be used for withdrawing blood, measuring arterial pressure, and rarely IV Infusion under pressure. Arterial Referring to a blood vessel that is part of the system carrying blood under pressure from the heart to the rest of the body.Arteriole A small branch of an artery that leads to a capillary. Arteriovenous fistula The surgical joining of an artery and a vein under the skin for the purpose of hemodialysis.Artery Blood vessel carrying blood from the heart to the cells of the body. Ascites An accumulation of serous fluid in the peritoneal cavity, causing abdominal swelling.Aseptic Pertaining to protocols used by medical professionals to prevent microbial contamination.Aseptic technique Protocols used by medical professionals to prevent microbial contamination.Aseptically Preventing infection from pathogenic microorganisms.Aspirate (aspiration) Exerting negative pressure with the plunger of a syringe before injecting to ensure an intravascular position of the needle or to avoid an inadvertent intravascular injection. Aspiration is the act of removing liquid or gas by suctioning (e.g., blood or pus from a body cavity).Auscultation Gathering information about the patient by listening to bodily sounds, usually with a stethoscope.Autohemolysis Hemolysis of red blood cells of a person by his own serum.Autopsy The medical examination of a dead body in order to establish the cause and circumstances of death.Autosafe®-Reflex® The branded commercial name of safety needles designed to prevent or minimize needle stick injuries.Backflow Refers to the reflux of blood into the catheter lumen upon disconnection of a cannula or needle. Bacteremia The presence of viable bacteria circulating in the bloodstream. Diagnosed with blood cultures.Barrier techniques Methods of using a variety of items intended to protect the medical professional, as well as the patient from transferring infection to either, and to

minimize the chances of cross infection.Basal state Early in the morning, approximately 12 hours after the last ingestion of food or other nutrition. Basilic vein Large vein on the inner side of the arm. Basophil A subtype of leukocyte with a granular cytoplasm staining with basophilic dyes.Betadine™ The trade name of a popular topical antiseptic agent that contains iodine; povidone-iodine.Bicarbonate (HCO3) Bicarbonate is alkaline, and a vital component of the human body’s pH buffering system (maintaining acid-base homeostasis).Bleeding time A test that measures the time it takes for small blood vessels to close off and stop bleeding. Blind stick Performing a venipuncture with no apparently visible or palpable vein. Blood The fluid in the body that contains red cells, white cells, platelets, proteins, plasma, and other elements. Blood bank A blood bank is a cache of blood or blood components, gathered through blood donation, then stored and preserved for later use in blood transfusion.Blood cells Cells normally found in blood (red blood cells or erythrocytes, white blood cells or leukocytes, and blood platelets or thrombocytes). Blood clot The conversion of blood from a liquid form to solid through the process of coagulation. Blood clotting factor A number of different factors, which work together when activated to form a blood clot.Blood count The determination of the proper number of red blood cells, white blood cells, and platelets present in the patients’ blood. Blood culture A test which involves the incubation of a blood specimen overnight to determine if bacteria are present. Blood culture A microbiological culture of blood used to detect infections that spread through the bloodstream.Blood donation Donated blood used for transfusions or to be made into specialized blood components or medications by a process called fractionation.Blood donor A person who regularly donates blood.Blood film A sample of blood that is applied to a microscope slide and then studied under the microscope. Blood groups A specific antigen manifesting on specific persons’ red blood cell surfaces – for example A, B, or Rh antigens. Bloodletting The act of letting blood or bleeding, by opening a vein or artery, or by cupping or leeches, especially as applied to venesection.Blood plasma The pale yellow or gray-yellow, protein-containing fluid portion of the blood in which blood cells and platelets are normally suspended.

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Blood serum Blood serum is whole blood minus both the cells and the clotting factors.Blood smear A sample of blood is applied to a microscope slide and then studied under the microscope. Blood Stream Infection (BSI) Blood infection often believed to be introduced via an IV catheter. Blood transfer device A safety device designed to transfer blood from one container into another. Blood transfusion The process of receiving blood or blood products intravenously into the circulation. Transfusions are used in a variety of medical conditions to replace lost blood or blood components.Blood types See blood groups.Blood vessel All the vessels lined with endothelium through which blood circulates.Bloodborne pathogen Microorganism present in blood that can cause disease.Bloodborne pathogens Any disease-producing microorganisms that are spread through direct contact with contaminated blood. Blunt cannula A non-sharp plastic or metal needle. Also refers to a needleless system where the blunt cannula accesses a pre-slit injection port. Bodily secretions Bodily fluids produced by exocrine glands such as the salivary and tear glands.Bolus Dosage of medication, usually administered within a short period of time, given via IV push, either directly into a vein or through a port on the IV tubing. Breast milk Milk produced by the breasts (or mammary glands) of mammal females (including human females) for infant offspring.Bruise A reddish-purple traumatic injury of the soft tissues, which results in breakage of the local capillaries and leakage of red blood cells. Also called a contusion.Bruit The term for the unusual sound that blood makes when it rushes past a partial obstruction due to turbulent flow in an artery.Butterfly A small needle with two plastic wings attached which are squeezed together to form a tab that is used to manipulate the needle.Butterfly needle See winged infusion set.Cannula A flexible tube for insertion into a duct, vein, or cavity in order to drain away fluid or to administer drugs.Capillaries An extensive network of microscopic blood vessels that supply oxygen and nutrients to cells and remove CO2 and waste products.Capillary Any one of the minute vessels that connect the arterioles and venules. Together, capillaries form a network in nearly all parts of the body. Carbamate hemoglobin A hemoglobin compound

bound with carbon dioxide in the red blood cells.Carbon Dioxide (CO2) One of the mediators of the local autoregulation of blood supply. When levels are high, capillaries expand to allow a greater blood flow to that tissue.Carboxyhemoglobin Hemoglobin that has been bound with carbon monoxide.Catheter Hollow tube of variable size used for intravenous, arterial, as well as body cavity/organ (e.g., bladder) access. Catheter introducer Needle device that is used to insert a catheter into the artery or vein. The catheter slides off the introducer needle, which is then disposed of. Catheter Malposition/Migration Movement of a catheter which can cause trauma within the vein or artery and interrupt IV therapy. Catheter Related Sepsis (CRS) Blood infection believed to be introduced through an IV catheter.Cathflo Activase (Alteplase) A medication used for the restoration of function to central venous access devices (CVADs) as assessed by the ability to withdraw blood.CBC Complete Blood Count.CDC (Centers for Disease Control and Prevention) A United States federal agency that protects public health and safety by providing information to enhance health decisions. CDC promotes health through partnerships with state health departments and other organizations.Central Line See central venous line.Central Venous Catheter (CVC) A small, flexible plastic tube inserted into a large vein in the neck, chest or groin where the tip of the catheter resides in the superior vena cava. Central venous line Also called a central venous catheter or central venous access catheter. It is a catheter placed into a large vein in the neck, chest, or groin, which is used to administer medication or fluids, obtain blood tests, and directly obtain cardiovascular measurements such as the central venous pressure.Centrifuge A laboratory apparatus that separates mixed samples into homogenous component layers by spinning them at high speed. Cephalic vein One of the larger arm veins that empty into the axillary vein.Cerebrospinal fluid (CSF) Cerebrospinal fluid is a clear, colorless bodily fluid produced in the choroid plexus of the brain.Chelate Combining with a metallic ion into a ring complex.Chemotherapy Treatment of disease with chemical reagents that have a specific and toxic effect upon the disease-causing microorganism or cancer cells.

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Chlorhexidine Antiseptic agent commonly used to eliminate, reduce, or weaken microorganisms. Circulation The movement of blood in a circuitous course. Circulatory system The circulatory system is composed of the heart, arteries, capillaries, and veins.Citrate Citrate chelates (binds) calcium ions, preventing blood clotting. It is, therefore an effective anticoagulant.Citrate phosphate dextrose (CPD) A type of anticoagulant.Citrate phosphate dextrose adenine (CPDA-1) An anticoagulant used for the preservation of whole blood and red cells.Cleaning The removal of all visible foreign material from objects using water, detergents, or mechanical means.Clot A semisolid mass of blood found outside of the circulatory system.Coagulate The process of clot formation.Coagulation factors Group of plasma protein substances (Factor I thru XIII) contained in the plasma, which act together to bring about blood coagulation.Collateral circulation Blood which is carried through secondary channels after the primary vessels of a particular area has been obstructed.Colloid solution IV fluid containing large proteins and molecules that tends to stay within the blood vessels.Coma A coma is a state of unconsciousness lasting more than six hours, in which a person cannot be awakened and fails to respond normally to painful stimuli, light, or sound. The comatose person lacks a normal sleep-wake cycle and does not initiate voluntary actions.Comatose Unconscious (in a coma).Complete blood count (CBC) The number of red blood cells, white blood cells, and platelets present in a blood sample (per cubic millimeter).Complications A disease or problem that arises in addition to the initial condition during or following the medical or surgical treatment of a patient.Conduction anesthesia A comprehensive term which encompasses a great variety of local and regional anesthetic techniques. Contact dermatitis Inflammation of the skin due to contact with an allergen, resulting in a range of symptoms such as redness, swelling, itching, or blistering.Contagious May be transmitted from one person to another person.Contamination The introduction of pathogenic organisms into a wound.Contusion A bruise or injury without a break in the skin.Coronary arteriography A test that uses X-rays to help a doctor/radiologist/cardiologist find narrowing or blockage

in the coronary arteries.Cortisone A steroid hormone secreted by the adrenal cortex. Synthetic cortisone medications used to treat allergic responses and other medical conditions.Coumadin Trademark name for warfarin, an anticoagulant.Crystalloid solutions IV fluids containing varying concentrations of electrolytes.CT scan (CAT scan) Computed Tomography or Computed Axial Tomography. A medical imaging procedure that utilizes computer-processed X-rays to produce “slices” of specific areas of the body.Cubital fossa (antecubital fossa) The cubital fossa (or elbow pit) is the triangular area on the anterior view of the elbow of a human. It contains the radial and median nerves, the brachial artery, the tendon of the biceps muscle, as well as several more superficial veins.Cubital vein The cephalic vein when it crosses the cubital fossa. It communicates with the basilic vein in the cubital fossa via the median cubital vein.Cutaneous Referring to the skin and its appendages. Cytoplasm The cell contents excluding the nucleus with all the organelles suspended in it.D5W Dextrose 5% in water.D-dimer blood test D-dimer is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis.Dead space (residual volume) The residual volume withheld in an IV device. Refers to the amount of fluid remaining in a connector, not delivered to the patient. Deep Vein Thrombosis (DVT) A thrombus that formed in one of the deep veins, usually of the leg. Defibrinated blood Blood that has been deprived of fibrin.Dehydration The lack of water in the body resulting from inadequate intake of fluids or excessive loss of water and electrolytes through sweating, vomiting, or diarrhea.Dermatitis Inflammation of the skin from any cause, resulting in a range of symptoms such as redness, swelling, itching, or blistering. Dextrose A carbohydrate (sugar) solution used in intravenous drips.Dialysis The process of cleansing the blood by passing it through a special machine. Dialyzer The dialyzer is the heart of the hemodialysis machine used to replace the functions of the kidneys in kidney failure patients. Differential A count of the different types of leukocytes in a stained blood smear. The proportion is expressed as a percentage.

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Disinfectant A substance capable of killing a wide range of microorganisms.Disinfection Process that eliminates many or all infectious micro-organisms except bacterial and fungal spores.Displacement The volume of fluid displaced in a catheter when a needleless intravenous (IV) connector is connected or disconnected. Distal Further away from the torso. Further away from the IV solution bag. Distended Expanded, swollen, or inflated.Dorsal Referring to or situated on the back of the body, the upper parts of the hands (opposite side of the palms), and feet (opposite side of the soles). Drip chamber Clear, plastic tube (chamber) used as a reservoir and measuring device on IV lines just below the solution bag. D5W Short for 5% dextrose in water.Ebola (Ebola hemorrhagic fever) A viral disease transmitted by contaminated blood or body fluids, often recognized by the leakage of blood and bodily fluids, usually resulting in death.Ecchymosis A diffuse collection of blood outside the blood vessels within the tissue.Edema The swelling of soft tissues as a result of excess fluid accumulation.EDTA (Ethylenediaminetetraacetate) A calcium chelating (binding) agent that is used as an anticoagulant for laboratory blood specimens.Effluent An outflow, usually of fluid.Effusion The oozing of fluids from blood or lymph vessels into body cavities or tissues as a result of inflammation.Electrolytes Ions in cells, blood, or other bodily fluids with many physiological functions like assisting with maintaining normal pH levels, nerve impulse conduction, and muscle contraction.Embolism The blockage of a blood vessel due to an embolus, usually a blood clot formed at one place in the circulation and then lodging in another area.Embolus A dislodged and displaced blood clot, or some other substance, causing obstruction in blood vessels at a distant site.EMLA cream A topical anesthetic cream used locally on children for mildly invasive procedures such as venipuncture. Endothelium The layer of cells lining the closed internal spaces of the body such as the blood vessels and lymphatic vessels.Eosinophil An eosin (red) staining leukocyte with a nucleus that usually has two lobes connected by a slender thread of chromatin.

Epidemiology The science concerned with the study of factors influencing the distribution of disease and their causes in a defined population.Epidermis The upper or outer layer of the two main layers of cells that make up the skin.Epithelium The outermost layer of skin, mucous membranes, as well as the lining of the digestive and respiratory systems.Erythrocytes Red blood cells, which primarily carry oxygen and collect carbon dioxide using hemoglobin.Etiology The cause or origin of a disease or disorder.Excretions A body’s waste products (e.g., carbon dioxide, sweat, urine and feces).Extension Set IV tubing used to provide additional length or access to the primary IV line. Extracellular space The space outside the cells consisting of the intravascular and the interstitial spaces.Extravasation The leaking of blood or other fluid from a vessel into surrounding tissue as a result of injury, burns, or inflammation. Extremities Limbs of a person or animal, or the parts of a limbs that are farthest from the body (e.g., hands or feet).Exudate A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues.Exudates (verb) Fluid leaking from a blood vessel, tissue, or organ.Factor VIII An important clotting factor known as antihemophilic factor (AHF). Faint Sudden loss of consciousness.Fasting Abstaining from all food and liquids, with the exception of small sips of water, usually overnight.Feces The body’s solid waste matter, composed of undigested food, bacteria, water, and bile pigments, discharged from the bowel through the anus.Fibrin Sleeve A buildup of platelets on the exterior of and indwelling catheter that can lead to thrombus formation. Fibrin The protein chains formed during normal blood clotting that is the essence of the clot.Fibrin Tail A fibrin formation that hangs off the tip of the catheter like a tail. Fibrinogen The protein from which fibrin is formed.Fibrinolytic (Thrombolytic) Fibrinolytic or thrombolytic drugs are used to dissolve (lyse) blood clots (thrombi).Finger prick See finger stick. Finger stick A procedure in which a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing.

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Fistula An intentional or pathological shortcut between a vein and an artery. An opening or passage between two organs or between an organ and the skin.Flashback The appearance of a small amount of blood when inserting the needle of a syringe or the tubing of a butterfly or cannula in a vein indicating that venous access has been successful.Flexion In the bent position.French size Term used to describe external diameter of catheter. Numerical increase = size increase. Gauge Typically refers to the inside diameter of a needle or catheter. Numerical increase = size and flow rate decrease. General anesthesia A medically induced coma and loss of protective reflexes resulting from the administration of general anesthetic agents.Germicide An agent that kills pathogenic microorganisms.Glucose The sugar measured in blood and urine specimens to test for diabetes. Graft An implant or transplant of any tissue or organ.Harvesting The collection and preservation of tissues or cells from a donor for the purpose of transplantation.Hb Blood hemoglobin level. Normal hemoglobin values are 14-18 g/dl in adult males and around 12-16 g/dl in adult females.Heel prick (heel stick) A procedure in which an infant’s heel is pricked with a lancet to obtain a small quantity of capillary blood for testing.Hematocrit The ratio of the total red blood cell volume to the total blood volume, expressed as a percentage.Hematology The branch of medicine devoted to the study of blood, blood-producing tissues, and diseases of the blood.Hematoma A hematoma is a localized collection of blood outside the blood vessels within the tissue.Hematopoiesis (hemopoiesis) The formation of the cellular components of blood in the blood-forming tissues of the body, mostly the red bone marrow.Hemoconcentration A decrease in the fluid content of the blood (plasma), resulting in an increase in the hematocrit. Hemodialysis The removal of certain components of the blood by virtue of the difference in their rates of diffusion through a semipermeable membrane. Hemoglobin An iron-containing protein in red blood cells that transports oxygen around the body.Hemolysis The breaking of the red blood cells membrane releasing free hemoglobin into the circulating blood or blood sample.Hemostasis To stop bleeding either by vasoconstriction, coagulation, or by surgical means.Heparin A natural anticoagulant formed in the liver and

used to reduce or prevent blood clotting.Heparin cap Injection port. Heparin Lock The function of administering heparin into a catheter after use to reduce intraluminal clotting of blood. Used for intermittent therapies where the catheter is not being utilized for fluid delivery. Hepatitis Inflammation of the liver.Hepatitis B A sometimes recurring or fatal form of hepatitis that is caused by a virus and transmitted through contact with infected blood, blood products, and bodily fluids.Hepatitis C Inflammation of the liver, caused by a virus. Symptoms include fever, jaundice, abdominal pain, and weakness.Hickman catheter A hollow silicone (soft, rubber-like material) tube inserted and secured into a large vein in the chest for long-term use to administer drugs or nutrients.HIV Human Immunodeficiency Virus known to be responsible for producing Acquired Immunodeficiency Syndrome (AIDS).Hub Female connection of an IV device or catheter into which the male luer is inserted. Huber needle A needle bent at an acute angle used for accessing implanted ports. Humoral Pertaining to humoral (or hormonal) control or relating to the immune response that involves antibodies circulating in bodily fluids.Hyperalimentation Total parenteral nutrition (TPN). Hyperbaric oxygen therapy The medical use of oxygen at a level higher than atmospheric pressure.Hyperbaric Referring to pressures higher than normal.Hyperglycemia An abnormally high glucose in the blood.Hypersensitivity A state in which the body reacts with an exaggerated immune response to a foreign substance.Hypertonic crystalloid A crystalloid solution that has a higher concentration of electrolytes than the body’s plasma.Hypodermic needle A needle that attaches to a syringe for the purpose of injections or withdrawal of fluids such as blood.Hypoglycemia An abnormally low glucose level in the blood.Hypotonic crystalloid A crystalloid solution that has a lower concentration of electrolytes than the body’s plasma.Immunoglobulins Antibodies formed by cells of the immune system that are present in blood and saliva.Implant Object or material, such as tissue, partially or totally inserted or grafted into the body of a recipient.Implantable Port Subcutaneous (below the skin) injection port having no exterior components when not in use. In vitro Outside the living body.

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In vivo Inside the living body.Infection Control Officer The person in a hospital in charge of the prevention and management of hospital infections and related issues.Inferior Towards the lower aspects of the body.Infiltration Fluid seeping into the tissue. Local anesthetic injected diffusely into tissue. Infusate IV solution to be administered. Infusion pumps A programmable medical device used for infusing controlled amounts of fluid or medication into a patient’s body – usually into the bloodstream.Injection cap Access point of a catheter where the IV line administration line is connected. Inspection The act of gathering visual information about a patient, done by a medical professional.Intermittent Therapy Administration of IV therapy which occurs at intervals. Interstitial fluid Fluid surrounding the cells of the body (excluding blood).Interventional radiology A medical sub-specialty of radiology that utilizes minimally invasive image-guided procedures to diagnose and treat diseases in nearly every organ system. Intra-arterial Pertaining to the inside of an artery or the arterial system.Intracellular fluid The fluid within the cells.Intradermal injections An injection of medication into the skin’s dermis layer (below the epidermis).Intramuscular injection (IMI) An injection of medication into one of the large muscles of the body.Intrathecal injection An injection into the sub-arachnoid space.Intravascular volume The volume of blood contained within all the blood vessels (arteries, veins, and capillaries).Intravenous fluids Chemically prepared solutions that are administered to a patient via an IV route.Intravenous (IV) Therapy Infusion therapy given to a patient via intravenous access. Intravenous line A tube with a needle or cannula placed directly into a vein and used to correct electrolyte imbalances, to deliver medications, for blood transfusion, or as fluid replacement to correct conditions such as dehydration.Iodine Usually used in an alcohol solution, called tincture of iodine, as a pre- and post-operative antiseptic and occasionally for preparing the skin aseptically before venipuncture.Irrigation To push fluid though an IV line, usually with normal saline solution. Isotonic crystalloid A crystalloid solution that has the

same concentration of electrolytes as the body plasma.IV line See intravenous line.IV Setup Equipment and items required for starting an IV infusion. IV Skills (Intravenous skills) The ability to perform phlebotomy and to put up an intravenous line.IVH Intravenous hyperalimentation. Joint A part of the body where bones are connected (e.g., the knee, elbow, or skull). Keep Vein Open (KVO) Refers to a slow continuous IV infusion for keeping the vein open and the cannula unobstructed. Kidney dialysis Kidney dialysis is a process for removing waste and excess water from the blood, and is used primarily to provide an artificial replacement for lost kidney function in people with renal failure.Lactated Ringer’s (LR) See Ringer’s LactateLaminar flow hood Safety cabinets with air flow in such a direction as to carry any harmful materials or fumes away from the worker.Lancet A small sharp blade for puncturing the skin for collecting small amounts of capillary blood.Lateral Away from the midline of the body.LAV Luer activated valve. Leukocytes (leucocytes) White blood cells or leukocytes are cells of the immune system involved in defending the body against both infectious disease and foreign materials.Lipids (Interlipids) Emulsified fat for IV infusion for nutritional therapy. Lipohypertrophy Medical term that refers to a lump under the skin caused by accumulation of extra fat at the site of many subcutaneous injections of insulin.Local anesthesia The prevention of sensory impulses, especially pain impulses, in a localized area of the body from reaching the brain by depositing a local anesthetic solution in the area or near a sensory nerve stem supplying the area.Luer lock A secure connecting and locking mechanism between a male luer fitting and a female luer fitting. The female fitting screws into threads in the sleeve on the male fitting.Luer slip Conical male luer that achieves a friction connection when inserted into a female hub and turned a quarter turn clockwise. Lumen The internal space within catheter artery, vein, intestine, or tube. Lymph Fluid found in lymphatic vessels and nodes derived from tissue fluids.

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Lymphedema A type of swelling that occurs in lymphatic tissue when excess fluid collects in the arms or legs because the lymph nodes or vessels are blocked or removed. Lymphocytes Mononuclear, non-phagocytic leukocytes that are found in the blood and lymph; the body’s immunologically competent cells.Macrophage Any of the many forms of mononuclear phagocytes found in tissues and originating from stem cells in the bone marrow.Magnetic resonance imaging (MRI) A medical imaging technique used in radiology to visualize internal structures of the body in detail by using nuclear magnetic resonance (NMR) to produce “sliced” images of the body.Malaria An infectious disease caused by a parasite transmitted by the bite of carrier mosquitoes.Mandible Lower jaw.MCH (Mean Corpuscular Hemoglobin) The average hemoglobin content in a red blood cell.MCHC (Mean Corpuscular Hemoglobin Concentration) The average hemoglobin concentration in red blood cells, expressed as a percentage (g/dL). MCV (Mean Corpuscular Volume) Average volume of red blood cells (erythrocytes), expressed in cubic micrometers.Medial (mesial) Towards or closer to the midline of the body.Medial cubital vein The communicating vein between the cephalic and basilic veins in the cubital fossa commonly used for venipuncture.Median antecubital vein See medial cubital vein.Medical history The systematic questioning of a patient by a medical professional to gather information for diagnosing a condition or disease.Medication A drug used to treat a disease or condition or to alleviate a symptom (e.g., pain). Mesial See medial.Micron Filter IV filter used to capture and eliminate air and contaminates in the IV system. Microorganism A microscopic organism or microbe. Some types can cause a variety of diseases, wound, and blood infections.Milliliter A thousandth of a liter; it equals a cc (cubic centimeter).Monocyte A mononuclear, phagocytic leukocyte with an oval to kidney shaped nucleus.Mononuclear A cell containing only one nucleus.Multi-sample adapter A device used with a butterfly and Vacutainer ™ holder to allow for the withdrawal of multiple tubes of blood during a venipuncture.Mural Thrombosis A fibrin buildup on the wall of the vessel often caused by trauma during catheter insertion

and can lead to vein thrombosis. Needle A thin, sharp metal tube attached to a syringe for injecting a patient or the sharp usually semi-curved metal structure at the one end of a suture thread.Needlestick injury Accidental injuries sustained by medical professionals while working with sharp needles. Injuries may be clean (before injecting) or contaminated (after injecting a patient).Negative air pressure Pressure less than that of atmosphere. Neonate A newborn child, especially one less than one month old.Neutrophil A polymorphonuclear granular leukocyte having a nucleus with 3-5 lobes connected by slender threads of chromatin and cytoplasm containing fine inconspicuous granules. Normal saline solution An isotonic crystalloid solution that contains 0.9% sodium chloride dissolved in sterile water. Nosocomial infection An infection whose origin is from the hospital environment.Occluded The stopping of flow of intravenous fluid or blood due to a blockage (e.g., a blood clot (thrombus), pressure tourniquet, or kinking of the plastic tube or cannula). Occlusion Blocked artery, vein, IV catheter, or tubing. Also, refers to an occlusion alarm on a pump that sounds when the IV setup becomes blocked. OHASA Acronym for Occupational Health and Safety Act.Oncology Scientific and medical study of cancer. Order of draw The order in which blood sample tubes should be drawn using a multi-sample technique.OSHA Occupational and Health Safety Administration, part of the United States Department of Labor.Osmosis The movement of water across a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration. Oxygen-carrying solutions Chemically prepared solutions that can carry oxygen to the cells.Oxygen saturation (SpO2) Oxygen saturation or (O2 sats) measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen.Oxyhemoglobin Hemoglobin that has been bound with oxygen in the lungs for the purpose of transport of oxygen to cells of the body.PCA Patient-Controlled Analgesia (pain medication). Packed red blood cells In transfusion medicine, packed red blood cells are red blood cells that have been separated from whole blood for transfusion purposes.

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Pallor Paleness; increase in the absence of skin color; the absence of color in skin.Palmar Referring to the palm surface or side of the hand.Palpate To examine or feel with the hand.Palpation The act of gathering information about the patient with the medical professional using the sense of touch.Parafilm™ A thin film of paraffin used primarily in the laboratory to seal open containers such as test tubes.Parenteral nutrition (PN) Parenteral nutrition is feeding a person intravenously, bypassing the usual process of eating and digestion.Patent (patency) Generally referring to an open, clear (not occluded) IV catheter. Pathogen Any microorganism that produces disease.Pathogenesis The development and progression of a disease.Pathogenic Having the capability of producing disease.Pediatric Referring to the medical care of children including the prevention and treatment of children’s diseases.PEP (Post-exposure prophylaxis) Steps to take to prevent or minimize the risk of infection after a patient or healthcare worker has been exposed to a known pathogen (e.g., HIV).Peripheral blood Blood circulating in blood vessels outside of the heart and major blood vessels.Peripheral Line Any IV line placed on the periphery of the body (e.g., arm, leg, hand, or foot). Peripherally Inserted Catheter (PIC) Catheter that is placed on the periphery of the body (e.g., arm, leg, hand, or foot).Peripherally Inserted Central Catheter (PICC) Catheter that is placed on the periphery of the body, generally from the arm with the catheter tip positioned in the superior vena cava. Peritoneal dialysis Dialysis through the peritoneum.Peritoneum The membrane lining the abdominal and pelvic wall.PH A scale from 0-14 indicating the level of acidity or alkalinity (< 7 is acidic, 7 = neutral and > 7 is alkaline).Phagocytosis A phagocyte is any cell capable of ingesting particulate matter.Phlebitis Inflamed, irritated vein. Phlebotomist One who practices phlebotomy.Phlebotomy Needle puncture of a vein for the purpose of drawing blood (venipuncture).Physician A doctor who diagnoses and treats diseases and injuries using methods other than surgery.Physiology The branch of biology that deals with the internal workings and functions of living organisms.

Piggyback Accessing a primary IV line at a secondary port (Y-site). Pipet A glass or transparent plastic tube used to accurately measure small amounts of liquid.Plasma Blood plasma is the liquid component of blood, making up around half of the total blood volume. It consists of about 90% water, the balance being proteins, minerals, clotting factors, hormones, and immunoglobulins.Plateletpheresis The selective separation and removal of platelets from withdrawn blood. Platelet-rich plasma (PRP) Platelet-rich plasma has been used as an adjunct to wound healing for several decades.Platelets See thrombocytes.Pleural Pertaining to the thin transparent membrane that lines the chest wall and doubles back to cover the lungs. Plunger Piston-like part of a syringe for exerting pressure for injecting or negative pressure for aspirating.Polymorphonuclear A white blood cell with a nucleus so deeply lobed so as to appear to have multiple nuclei.Ports A port is a small medical appliance that is installed beneath the skin with a catheter connecting the port to a vein. Under the skin, the port has a septum through which drugs can be injected and blood samples can be drawn many times.Posterior Towards the back of the body.Povidone-iodine A topical antiseptic occasionally used in phlebotomy.Primary Line Main IV tubing. Secondary lines will be piggy-backed into the main line. Priming The elimination of air in the IV setup by infusing solution prior to IV administration. PRN Adapter Injection port. P.r.n. (Latin: pro re nata) Means ‘as needed’ or ‘as the situation arises’. Used when prescribing medication only to be used if necessary. Prone Lying face down, as opposed to supine.Prophylaxis A preventative treatment; medication prescribed with the intent to prevent complications that may develop following a surgical procedure.Protocol Guidelines written to prescribe safe and effective clinical practice. Intended to be followed by all clinical personnel and set as a benchmark for what and when specific procedures or steps of procedures should happen and in what order it should happen. Proximal Nearer to the head and torso or nearer to the IV fluid bag. Pulse points Specific areas or points on the human body where an arterial pulse or throb can be palpated on mild digital (fingertip) pressure.

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Pus The yellowish or greenish fluid that forms at sites of infection, consisting of dead white blood cells, dead tissue, bacteria, and blood serum.QNS Quantity Not SufficientRadiography The use of X-rays to view the internal structures of a human or an animal body.Radiology The branch of medicine that deals with the use of X-rays and radioactive substances such as radium in the diagnosis and treatment of diseases.Red blood cells See erythrocytes. Regional anesthesia Anesthesia that affects a large part of the body such as a limb or the lower half of the body.Residual Volume The volume withheld in an IV device. Refers to what amount of fluid resides in a connector and is not delivered to the patient. Reverse isolation An isolation procedure for protecting patients whose immune response has been greatly reduced from contracting disease. Reverse Trendelenburg Patient lying on the back with the bed angulated so the feet are about 15°-30° lower than the head.Rh system A specific type of human blood group responsible for hemolytic disease of the newborn.Ringer’s Lactate An isotonic crystalloid solution containing the solutes sodium chloride, potassium chloride, calcium chloride, and sodium lactate, dissolved in sterile water.RN (Registered Nurse) A nurse who has graduated from a nursing program at a college or university and has passed a national licensing exam.Safety-engineered needles Needles designed to prevent or minimize needle stick injuries.Saline Solution of salt and water used as a carrier for all IV drugs and hydration. Normal saline is a 0.9% solution with the same osmotic pressure as that of blood. Saliva The clear liquid consisting of water, mucin, protein, and enzymes, secreted into the mouth by the salivary glands. It moistens food and starts the breakdown of starches. SASH Saline flush→Antibiotic→Saline flush→Heparin. Sclerosis The hardening of an artery or vein, usually seen in the elderly. Scrubs The shirts and trousers or gowns worn by nurses, surgeons, and other operating room personnel when ‘scrubbing in’ for surgery. Scrubs are now commonly worn by any hospital personnel in any clean environment. Secondary Line IV line used to access a main/primary line at a secondary port (Y-site). Seldinger Technique Over the wire insertion method used for catheter insertion.

Semen The liquid that contains sperm produced by the male sex organs.Semipermeable Permitting the passage of certain molecules and hindering others.Sepsis A localized or systemic state of inflammation caused by disease forming bacteria and their products (e.g., toxins).Septic See sepsis.Serum Referring to blood, the clear liquid portion of blood that separates out after clotting has taken place.Sharps injury An injury occurring when a sharp object penetrates the skin or mucous membranes.Sharps Objects or devices with acute rigid corners, edge, points, or protuberances capable of cutting or penetrating the skin (hypodermic needles, scalpels, blades, lancets, broken glass, etc.).Sodium The most common electrolyte found in animal blood serum.Solute Particles that are dissolved in the sterile water (solvent) of an IV fluid.Solvent The liquid portion of an IV solution that the solute dissolves into. The most common solvent is sterile water.Sputum A mucus or phlegm-like substance coughed up from the respiratory tract.SQ See subcutaneous injection.Standard precautions The routine use of safe work practices and protective barriers to minimize the spread of infectious diseases and prevent sharps injuries. Stat Abbreviation for the Latin word statim, meaning immediately. Sterile procedure Referring to an invasive procedure where a special sterile and aseptic protocol is followed to minimize the risk of causing and transmitting infection.Subcutaneous injection (abbreviated as SQ or SC) An injection of medication into the subcutaneous layer of the skin (below the dermis and epidermis).Submucosa A layer of loosely meshed microscopic fibers and associated connective tissue cells beneath a mucous membrane.Superficial Relating to, affecting, or located on or near the surface of something.Superior Towards the upper aspects of the body.Supine Patient lying on the back and with the face upwards.Suturing The closure of a wound by joining the edges. Swan-Ganz® Catheter A catheter with a balloon at the tip, passed via one of the major veins into the right side of the heart and the arteries leading to the lungs, which monitors the heart’s function, blood flow, and intravascular pressure in these vessels.

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Sweat The clear salty liquid that passes through minute pores to the surface of the skin when somebody is hot as a result of strenuous activity, fear, anxiety, or illness.Syncope Fainting.Syringe A medical device commonly used for injecting medication into the body or withdrawing fluid (e.g., blood or pus) from the body. The basic parts of a syringe are the barrel, plunger, and tip.Therapeutic phlebotomy (letting blood) A therapeutic procedure to remove blood from the bloodstream primarily for medical reasons.Therapeutic Promoting healing or a healing agent.Third space The third space is space in the body where fluid does not normally collect in larger amounts, or where any significant fluid collection is physiologically non-functional (e.g., peritoneal, pleural space, etc.).Thrombocytes Very small, irregularly shaped, clear cells derived from fragmentation of precursor megakaryocytes. Platelets are involved in hemostasis leading to the formation of blood clots.Thrombocytopenia Decrease in the number of blood platelets below normal values.Thrombosis A buildup of blood fibrin and platelets in the circulatory system which can lead to embolism or clotting. Thrombus A blood clot that forms in a blood vessel and remains at the site of formation.Tissue infiltration Intravenous fluid seeping into the surrounding tissue instead of flowing into a vein.Topical anesthetic The numbing of the surface of a mucous membrane or the skin in an attempt to avoid or reduce pain experienced by the patient on needle pricking or minor surgical procedures.Total body water The total amount of water contained within the cells, around the cells, and in the bloodstream. Total Parenteral Nutrition (TPN) IV fluids used as a complete nutritional replacement for a period of time. Tourniquet A band applied around an arm or leg in order to temporary reduce or stop the venous or arterial blood flow in a limb.Tournistrip® The registered trade name of an easy to use, single-use tourniquet.Transplant An organ or tissue taken from the body for grafting into another part of the same body or into another individual. Transudate A transudate is a bodily fluid that passes through a membrane, filtering out most of the protein and cellular elements, thus yielding a watery solution.Transudates A fluid that passes through the pores or interstices of a membrane.Trendelenburg Patient lying on their back with the bed

angulated so the head is about 15°-30° lower that the feet.Ultrasound A technique that uses high-frequency sound waves for medical diagnosis and treatment (e.g., to create images of internal organs).Urinalysis The analysis of the physical, chemical, and microbiological properties of urine, carried out to help diagnose disease, monitor treatment, or detect the presence of specific substances.Urine The yellowish liquid containing waste products that is excreted by the kidneys and discharged through the urethra.Urticaria A skin rash, usually occurring due to an allergic reaction, marked by itchiness and small pale or red swellings.Vacutainer® The brand name and often generically term used to describe the equipment used to draw or aspirate blood from a vessel by venipuncture.Vacutainer® holder A cylindrical shaped holder that accepts a Vacutainer® tube on one end and a Vacutainer needle on the other.Vacutainer® needle The needle used to attach to a Vacutainer holder. Vacutainer® system The combination of a Vacutainer holder, needle, and sample tube which allows for a more automated method of drawing blood.Vacutainer® tube Blood sample tubes containing a vacuum. Vacuum tube A sterile glass or plastic tube with an evacuated closure to create a vacuum inside the tube facilitating the draw of a predetermined volume of liquid.Valve A membranous structure in a hollow organ or vessel such as the heart or vein that ensures the unidirectional flow of blood passing through it by closing intermittently.Vascular graft Harvesting an artery or vein and transplanting it to another site.Vascular Pertaining to or composed of blood vessels. Vasoconstriction A decrease in the inside diameter of blood vessels leading to a decrease in blood flow.Vasovagal response The vasovagal response is the development of inappropriate cardiac slowing and arteriolar dilatation.Vasovagal syncope Fainting due to a vasovagal response. Vein A blood vessel that carries blood towards the heart.Venesection Surgically opening of a vein for the purpose of collecting blood. Venipuncture The puncturing of a vein for any medical purpose (e.g., to take blood, to feed somebody intravenously, or to administer a drug). The act of inserting a needle or catheter into a vein.

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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.

venipuncture course version 1.0

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