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FOR FUTURE MEDICAL PROFESSIONALS

Venipuncture
Course &
Training Kit
A product developed and marketed by THE APPRENTICE CORPORATION Author: Dr. Anton Scheepers Copyright The Apprentice Corporation 2013 All rights reserved.

A 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: enquiries@TheApprenticeDoctor.com We appreciate your integrity in this regard.

First edition - October 2013

Venipuncture Course and Kit |

PREFACE
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 eectively. The Apprentice Doctor Venipuncture Skills Course and Kit are not intended to be used as a substitute for clinical training. Instead, The Apprentice Doctor oers a rm foundation so students can successfully master the initial learning curve in a non-clinical setting before condently 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 oered 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 specics may dier from the information or protocol of your local hospital or training institution. In a clinical eld, there are often a number of acceptable protocols, knowledge of more than one oers students a fuller picture. Protocols and standards may vary in dierent regions and countries, as well as in dierent 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 dierent 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 arent 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 oering future medical professionals a chance to join like-minded students and by providing a platform for learning from practicing healthcare professionals. You will nd a suitable community in your area, and youll receive lots of free advice and support. Dr. Anton Scheepers, The Apprentice Corporation sta, and The Apprentice Doctor community leaders would like to wish you a successful future and look forward to being of assistance towards fullling your dreams! The Apprentice Doctor Venipuncture Course and Kit is recommended training material for all healthcare professionals whether prospective, in training, or qualied: Medical students Pre-medical students Paramedics and EMT students Nursing students Phlebotomy students Dental students Veterinary students Surgery interns/registrars Advanced rst 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.

Venipuncture Course and Kit |

FOREWORD
In any practical endeavorfrom writing a book, to painting a picture, to performing a surgical operationa 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 denite guidelines to follow, and parameters to evaluate the students progress. Students need to train in a non-clinical setting until they have the prociency, knowledge, and condence 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 aordable 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

WARNINGS
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 uids, etc.). Refer to your local hospitals policies and protocols. For any cut or needle prick injuriessqueeze 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 leaets inside the package and on the DVD-ROM before proceeding.

Venipuncture Course and Kit |

KEYS TO SYMBOLS USED IN THE PRACTICAL PROJECTS

VIDEO
Sharps will be used!
Sharp or potentially sharp medical items or objects (e.g., glass medicine vials) will be used. Perform the procedures in these projects with great caution and care. Discard sharp and potentially sharp items ONLY in the sharps waste container. Study the section ASPECTS OF SAFETY before doing these projects.

Blood hazard
A denite possibility of blood contamination exists when performing these procedures in a real clinical setting. Ensure that all relevant aspects of sterility and asepsis are in place, and use appropriate barrier techniques (gloves, masks, visors, protective glasses, etc.).

SIMULATION PROCEDURE
Venipuncture Trainer is required see PROJECT 10 to set up the Venipuncture Trainer. Practice as much as you wish, within the limits of the safety guidelines and the restrictions regarding age. It is essential that all students take great care with handling sharps while doing these practical projects.

Venipuncture Course and Kit |

CLINICAL PROCEDURE: RESTRICTED

Procedure may only be performed on real patients in a proper medical setting by either qualied medical professionals or students under proper supervision in a formal training facility with all relevant legalities and medical indemnities in place.

CLINICAL PROCEDURE: VOLUNTEERS ALLOWED

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

DISCLAIMER
The producer or supplier of this application does not: Oer 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 oered on the functional status or tness for the specic 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 damagesspecic or consequentialrelated in any way to the information and instrumentation or to any items contained in this application. All practical exercises are performed exclusively at the users 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 diering points of view in medicine and medical knowledge changes quickly. If you think that any information is incorrect, contact us at enquiries@theapprenticedoctor.com. 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 institutions guidelines and protocols.

Venipuncture Course and Kit |

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 Kitthe instruments, items, and information supplied on the CDROMis conditional upon your acceptance of this disclaimer and commitment to honor copyrights. For further information on copyright see Copyright Information.

REIMBURSEMENT POLICY
The Apprentice Corporation is condent that you will be satised with this product in each and every way, as supported by our extremely low return statistics. If for any reason, you are dissatised 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: enquiries@TheApprenticeDoctor.com For more information see the Basic Terms and Conditions available on our website: www.TheApprenticeDoctor.com

Venipuncture Course and Kit |

RECOMMENDATIONS ON HOW TO USE THE APPRENTICE DOCTOR VENIPUNCTURE KIT

VIDEO
To gain maximum benet 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 specic 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 oers 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 oers the opportunity to practice relevant basic skills. For business and reseller information email us at enquiries@theapprenticedoctor.com.

Venipuncture Course and Kit |

OBJECTIVES OF THE COURSE


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 eective Venipuncture Trainer is included. Professional simulation arms are available for group training. Take the IV kit with you wherever you go its 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 oers 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

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INDEX
PREFACE FOREWORD WARNINGS KEYS TO SYMBOLS DISCLAIMER REIMBURSEMENT POLICY HOW TO USE THE APPRENTICE DOCTOR VENIPUNCTURE KIT OBJECTIVES OF THE COURSE

Venipuncture Course and Kit |

4 5 5 6 7 8 9 10 11

INDEX SECTION 1: INTRODUCTION


Case study 1: An Avoidable Accidentan Unnecessary Death Types of intravenous uids PROJECT 1A FAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT SAFETY PROTOCOL AND SAFETY ITEMS PROPER SHARPS DISPOSAL AND ILLEGAL INJECTION DRUG USERS PROJECT 1B HOW TO USE A SAFETY NEEDLE/DEVICE BASIC ANATOMY OF THE CIRCULATORY SYSTEM Main Blood VesselsFull Body Veins and arteries of the head and neck Arteries of the arm Veins of the arm Veins of the arm (close-up) Veins of the hand Arteries of the leg Veins of the leg Anomalous supercial arteries in the arm Blood Blood plasma Whole blood Blood cells Packed red blood Hemoglobin Hematology

15 16 18 19 22 24 25 28 28 29 30 31 32 33 34 35 36 36 36 37 37 37 37 37 39 40 41 42 42 43 43 43 46 46 47

SECTION 2 : PREPARATION
Case study 2: Contracting One of the Most Feared Diseases in the World Today SHORT NOTES ON MEDICAL HISTORY Patient information PROJECT 2 TAKE A MEDICAL HISTORY SHORT NOTES ON STERILITY AND ASEPSIS PROJECTS 3A 3I PROJECT 3A A TECHNIQUE FOR PROPER HANDWASHING PROJECT 3B CLEANING HANDS WITH AN ANTISEPTIC RUB PROJECT 3C HOW TO DON (PUT ON) CLEAN GLOVES PROJECT 3D HOW TO SAFELY REMOVE USED GLOVES

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Venipuncture Course and Kit |

*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 3H HOW TO DON STERILE GLOVES *PROJECT 3I HOW TO REMOVE CONTAMINATED GLOVES PATIENT POSITIONING TOURNIQUETS PROJECT 4A HOW TO APPLY A TOURNIQUET (DISPOSABLE) PROJECT 4B HOW TO APPLY A TOURNIQUET (TOURNISTRIP) PROJECT 4C HOW TO APPLY A TOURNIQUET (REUSABLE) PROJECT 4D HOW TO APPLY A TOURNIQUET (BLOOD PRESSURE CUFF) PROJECT 5A IDENTIFY THE VEINS OF THE UPPER EXTREMITY PROJECT 5B IDENTIFY THE VEINS OF THE LOWER EXTREMITY PROJECT 5C OTHER IMPORTANT VEINS (FACE, NECK AND CHEST) PROJECT 5D MAP THE VALVES IN VEINS PROJECT 6A PREPARE TO GIVE AN INJECTION PROJECT 6B HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (ROUTINE VENIPUNCTURE) PROJECT 6C HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FOR BLOOD CULTURE) PROJECT 6D HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FROM BLOOD DONOR)

47 47 47 48 48 49 51 51 53 54 54 55 57 59 61 63 69 71 73

SECTION 3: VENIPUNCTURE SKILLS


Case study 3: My Life Changed Drastically in a Split Second CAPILLARY BLOOD COLLECTION USING A LANCET PROJECT 7A DRAW CAPILLARY BLOOD (ADULT) PROJECT 7B DRAW CAPILLARY BLOOD (BABY) PROJECT 8 HOW TO GIVE A SUBCUTANEOUS INJECTION Intradermal injections PROJECT 9 HOW TO GIVE AN INTRAMUSCULAR INJECTION PROJECT 10A SET UP THE VENIPUNCTURE TRAINER PHLEBOTOMY PROJECT 10B SET UP THE VENIPUNCTURE TRAINER FOR IV PROJECTS PROJECT 10C SET UP THE VENIPUNCTURE TRAINER FOR ARTERIAL BLOOD Taking care of the Venipuncture Trainer Relling the IV uid bag THERAPEUTIC PHLEBOTOMY (LETTING BLOOD) MAXIMUM ALLOWABLE TOTAL BLOOD DRAW VOLUMES PROJECT 11A DRAW VENOUS BLOOD USING A VACUUM TUBE PROJECT 11B DRAW VENOUS BLOOD USING A SYRINGE PROJECT 11C DRAW BLOOD USING A BUTTERFLY NEEDLE PROJECT 11D HOW TO SETUP AND START AN IV LINE PROJECT 11E HOW TO REMOVE THE IV LINE SPECIAL GROUPS OF PATIENTS The neonate patient The pediatric patient VETERINARY VENIPUNCTURE The animal patient AIDS TO ASSIST THE CLINICIAN VeinViewer AccuVein Breastlight Ultrasound

75 76 77 77 79 81 84 85 88 89 90 90 90 90 90 91 96 99 102 106 107 107 107 108 108 109 109 109 109 109

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Radiography PROJECT 12A IDENTIFY THE BODYS PULSE POINTS PROJECT 12B PERFORM A MODIFIED ALLENS TEST PROJECT 12C DRAW ARTERIAL BLOOD BLOOD TRANSFUSIONS Blood types (Blood Groups) Agglutination Blood donations PROJECT 13 DONATING BLOOD FOR THE BLOOD BANK

109 110 112 114 117 117 118 119 120 123 124 125 126 127 127 128 129 129 130 130 130 130 130 131 134 134 135 135 135 135 135 136 136 136 136 136 137 137 137 137 137 138 138 138 138 138 139 139 139

SECTION 4: RELATED TOPICS OF INTEREST


Case study 4: Despite All the Training and the Necessary Care, Accidents Do Happen CENTRAL VENOUS LINE ARTERIAL CATHETERIZATION CORONARY ARTERIOGRAPHY INTERVENTIONAL RADIOLOGY KIDNEY DIALYSIS KIDNEY DIALYSIS PORTS TOTAL PARENTERAL NUTRITION (TPN) ANESTHESIA Topical Anesthetic Local Anesthesia Inltration Local Anesthesia PROJECT 14 INFILTRATING A WOUND WITH LOCAL ANESTHETIC BEFORE SUTURING Local Anesthetic Block Regional Anesthesia General Anesthesia Infusion Pumps NEW DEVELOPMENTS Microprobes for continuous monitoring Needleless Injections SHORT NOTES ON OTHER BODILY SECRETIONS Saliva Sputum Breast milk Semen Sweat SHORT NOTES ON OTHER BODILY EXCRETIONS Urine Urinalysis Feces SHORT NOTES ON OTHER BODILY FLUIDS Cerebrospinal uid (CSF) Ascites Eusion Pleural Joint eusion Exudates and transudates Pus

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SECTION 5: COMPLICATIONS
Case study 5: A Routine Venipuncture Case Vasovagal response and vasovagal syncope Allergic responses Contact dermatitis Skin rash/Urticaria Anaphylaxis (Anaphylactic Shock) Needle penetration through the vein Hematoma Ecchymosis Needle/cannula in the tissue Tissue inltration (extravasation) Cannula/catheter blocked (occluded) Catheter-related infections Intra-arterial position of needle/cannula Inadvertent intra-arterial injection of medication Dierentiation between arteries and veins Supercial phlebitis Septic thrombus Deep vein thrombosis (DVT) Embolism Air embolism Local tissue damage Nerve damage Arterial cannulation Needle prick injuries

141 142 143 144 144 144 144 145 145 146 146 146 147 147 148 148 149 149 150 150 151 151 153 153 153 153 153 155 156 156 156 157 160

SECTION 6: CONCLUSION
ASSESSMENT MODULE EPILOGUE REFERENCES CREDITS GLOSSARY

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Venipuncture Course and Kit | INTRODUCTION

CASE STUDY 1: AN AVOIDABLE ACCIDENTAN UNNECESSARY DEATH

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Venipuncture Course and Kit | INTRODUCTION

A 32-year-old nurse with an infectious smile cheerfully reported for duty, but she had no idea that this would be her nal, 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 HIVnegative. 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 ne.

That evening, Helosini complained to her sister that her leg was turning blue and that she had u-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 u medication. On Christmas Eve, Helosini was so sick that she went to her doctor who diagnosed her with bronchitis. A few days later, Helosinis sister, Yogeshini, found her unconscious on the bathroom oor. Yogeshini rushed her sister to the hospital where it was conrmed 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.

The Venipuncture Trainer in this kit has been designed with eectiveness and aordability 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 articial arms available for sale. Keep in mind that no training system can replace the clinical phase of your training. Practice, gain condence, then face real clinical situations under supervision and always learn from both your successes and your failures.

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 exible 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 uid/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 patients vein.

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Venipuncture Course and Kit | INTRODUCTION

TYPE Isotonic

SOLUTION (EXAMPLE) Dextrose 5% in water (D5W)

USES Fluid loss Dehydration Hypernatremia Shock Hyponatremia Blood transfusions Resuscitation Fluid challenges DKA (diabetic ketoacidosis)

SPECIAL CONSIDERATIONS Use cautiously in renal and cardiac patients Can cause uid overload Can lead to overload Use with caution in patients with heart failure or edema

Isotonic

0.9% Sodium Chloride

Isotonic

Ringers Lactate/Lactated Ringers (LR)

Dehydration Burns Lower GI uid loss Acute blood loss

Hypovolemia due to third spacing Contains potassium, dont use with renal failure patients Dont use with liver disease (cant metabolize lactate) Use with caution May cause cardiovascular collapse or increased intracranial pressure Dont use with liver disease, trauma, or burns

Hypotonic

0.45% Sodium Chloride (1/2 normal saline)

Water replacement DKA Gastric uid loss from NG or vomiting

Hypertonic Hypertonic

Dextrose 5% in normal saline Dextrose 5% in normal saline

Later in DKA treatment Temporary treatment for shock if plasma expanders arent available Addisons crisis

Use only when blood sugar falls below 14 mmol/l (250 mg/dL) Dont 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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Venipuncture Course and Kit | INTRODUCTION

PROJECT 1A FAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT


Use the Content List and follow these steps to ensure that your Apprentice Doctor Venipuncture Kit and Trainer is complete. Learn the names and functions of each item as you go.

VIDEO
WARNING
This kit contains sharp items that can be potentially 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 1517. 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 leaets inside the package.

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Venipuncture Course and Kit | INTRODUCTION

REQUIREMENTS
Venipuncture Kit and Trainer and a clean, uncluttered work surface. Follow these steps:

STEP 1

[CLICK TO PRINT KIT CONTENT PAGE]

Do not unwrap or open any items at this point in time! Unpack all of the items on your uncluttered working surface. Identify all the components of your Venipuncture Kit and Trainer using the Content List. Learn the names and functions of all items as you check them against the list.

CHECK LIST OF MEDICAL ITEMS INCLUDED IN THE KIT

The Apprentice Doctor Venipuncture Course DVD-ROM

IV Catheter

Venipuncture Trainer

Lancets Safety and Regular

Connectors / Lumen stoppers

Disposable Tourniquet

Syringe for SQ Injections

Butterfly Needles

Regular Syringes

IV Fluid Bag

Regular Needles

IV Lines

Safety Needles

Glass Vial

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Venipuncture Course and Kit | INTRODUCTION

Plastic Vial

Alcohol Prep Swabs

10

Safety Vacuum Container Device

Gauze Squares

10

Vacuum Container Hub and Needles

1
pairs

Work Surface Cover

Blood Vacuum Tubes

5
pairs

Gloves

pairs

Cotton Wool

Sharps Waste Container

Roll of Strapping

More information [CLICK HERE]

Reusable Tourniquet

* 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 Enquiries@TheApprenticeDoctor.com Regarding the use of safety needles: The Apprentice Doctor Venipuncture Kit contains safety needles. For the sake of keeping the kit aordable, 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.

Tournistrip


Transparent Dressing

Ruler and Pen

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Venipuncture Course and Kit | INTRODUCTION

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

STEP 4
Replace 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
The trainer is simple, eective, and functional. The Apprentice Doctor oers realistic trainer simulation arms for group training. [ORDER ONLINE]. 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 uids are often used in restoring the body temperature of hypothermic patients. IV uids should be warmed to approximately 43C or (109.4 F) prior to administration. As most hypothermic patients are also dehydrated, warm intravenous uids serve a dual purpose. Contaminated IV uids 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 uids. If in doubt about the sterility of the uid (unusual color, change in transparency, etc.), do not use the uid and report this to your hospitals infection control ocial for further investigation.

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

BEFORE STARTING, YOU MUST FIRST READ THE FOLLOWING:


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 immunodeciency virus (HIV). Needlestick injuries are common events in the healthcare environment; Mario Saia et al in 2010 reported an estimated 384,000 cases in the USA alone. 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.

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Venipuncture Course and Kit | INTRODUCTION

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 uid 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 patients 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 manufacturers 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.

All students, especially those in USA, should acquaint themselves with the relevant legalities in the OSHA Occupational Safety & Health Administrations documents: Read OSHAs 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]

Download CDC Posters on preventing injuries with sharps: [POSTER 1 HYPERLINK] [POSTER 2 HYPERLINK] [POSTER 3 HYPERLINK] [STUDY CDC GUIDELINES FOR HANDLING SHARPS] 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.

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 ood 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

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Venipuncture Course and Kit | INTRODUCTION

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 selfaddressed box. Return with your sharps container for safe disposal. Email to enquiries@theapprenticedoctor.com

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Venipuncture Course and Kit | INTRODUCTION

PROJECT 1B HOW TO USE A SAFETY NEEDLE/DEVICE


It is all about safetyfor your patients AND YOU!

VIDEO
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 needles safety features will make a needle injury unlikely but in the nal analysis there is no substitute for caution. Follow the instructions accurately!

INFORMATION
The 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 needle These needles are VERY easy to use however, in order for them to be eective, one needs to use them correctly.

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Venipuncture Course and Kit | INTRODUCTION

FOLLOW THESE INSTRUCTIONS EXACTLY:


STEP 1
Look at the diagram of the needle with its various parts

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

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

STEP 9
Remove the protective sleeve of the needle.

STEP 10
Perform a simulation IMI (intramuscular injection) by injecting the Venipuncture Trainer. Penetrate the skin at 90 and insert the needle up to the level of the safety device. See PROJECT 9 How to Give an Intramuscular Injection for more information.

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

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

STEP 11
Inject 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 3
Wash your hands. Start now to develop this simple but eective habit. If you like, don clean gloves (gloves optional).

STEP 12
Remove your index nger from the safety mechanism.

STEP 4
Orientation is important when opening the AutosafeReex 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 13
Withdraw the needle; you will notice the reex mechanism activates spontaneously and passively. The sharp needle tip will be covered by the safety cap, in a somewhat ocenter position.

STEP 14
Remove 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).

STEP 5
Lift 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 6
Fit the needle to the syringe, and withdraw the safety needle from the package while maintaining the needles orientation.

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Venipuncture Course and Kit | INTRODUCTION

NOTE:
In rare instances, after activating the AutosafeReflex needles 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]!

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Venipuncture Course and Kit | INTRODUCTION

BASIC ANATOMY OF THE CIRCULATORY SYSTEM


Note: Student should already have a fair understanding of the basic anatomy and physiology of the cardiovascular system. Study the following illustrations before proceeding with the course:

THE MAIN BLOOD VESSELS OF THE BODY

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

VEINS AND ARTERIES OF THE HEAD AND NECK

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

ARTERIES OF THE ARM

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

VEINS OF THE ARM

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

VEINS OF THE ARM (CLOSE-UP)

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

VEINS OF THE HAND

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

ARTERIES OF THE LEG

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

VEINS OF THE LEG

[DOWNLOAD PDF]

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Venipuncture Course and Kit | INTRODUCTION

ANOMALOUS SUPERFICIAL ARTERIES IN THE ARM


The word anomaly is used when something is normal, but only occurs in a minority of the general population. The arteries of the extremities normally run a deeper course compared to the equivalent veins. Both the radial artery and the ulnar artery occasionally run an anomalous supercial course and may be mistaken for a vein by the well-intended clinician. The supercial ulnar artery (SUA) is present in almost 4% and the supercial radial artery (SRA) in about 0.2% of the population. An inadvertent arterial-puncture instead of a venipuncture could have catastrophic results. See the Complications Section on handling this type of situation in more detail. For more information [CLICK HERE]

BLOOD
Blood is classied as a specialized connective tissue from an embryological point of view. Blood is the uid 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 uid 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.

Figure 3a: A typical hematology lab centrifuge apparatus

Figure 3b: Centrifuged blood in tube

Blood can be separated into 3 layers by a process of centrifugation (fast spinning of blood lled tubes in a laboratory apparatus called a centrifuge). 1. The upper yellowish layer is blood plasma. 2. The thin, middle, buy 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 brinogen or the other clotting factors.

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

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

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Venipuncture Course and Kit | INTRODUCTION

Globulins are mainly the immune systems antibodies. Fibrinogen plays a major role in blood clotting. Blood serum is blood plasma without brinogen or the other clotting factors.

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

BLOOD CELLS
If a drop of human blood is thinly smeared across a microscopy slide, you can see various dierent blood cells. The pink roundish structures with white centers are the erythrocytes (red blood cells).

Hemoglobin 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.

HEMOGLOBIN

Figure 4: A normal blood smear

Figure 4: A graphic illustration of hemoglobin

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 buy 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. Its a very exible 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. Its packed mostly with large numbers

A heme is ring shaped molecule with an iron ion (Fe+2). Oxygen has a high anity 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 aects 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

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Venipuncture Course and Kit | PREPARATION

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 realthe 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 rst diagnosed victim to contract the deadly Ebola virus. For three weeks, she bravely fought for her life in isolation at Johannesburg Hospital, while medical ocials desperately scrambled to nd the source of the virus. Marilyn Lahana was a nurse working at a private clinic in Johannesburg. Ocials 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 HISTORY


The taking of a comprehensive medical history by a qualied 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, dicult venous access, and accidental intra-arterial injections). Infectious diseases (e.g., hepatitis, HIV). Allergies specically regarding cleaning agents (e.g., Iodine, strapping, plasters, and drugs or medications to be administered via the IV route). Specically 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 patients severe latex allergy may become life threatening in a matter of minutes!

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Venipuncture Course and Kit | PREPARATION

PROJECT 2 TAKE A MEDICAL HISTORY


Gather the relevant information and prevent avoidable mishaps! See The Apprentice Doctor Foundation Course for information on how to take a comprehensive medical history[CLICK HERE]

PATIENT INFORMATION
When a physician orders a laboratory blood test, a lab requisition form needs to be lled out accurately and signed by the physician. It is important to have a double-check system on requisition forms and sample labeling to ensure that the correct blood samples are taken from the correct patient and that the correct results are allocated to the correct patient.

SAMPLE REQUISITION FORM


An accurately completed requisition form must accompany each sample submitted to the laboratory. This information is essential to process the specimen correctly. The patients information is required: Full names Identication 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, uid analysis, or other testing where analysis and reporting is site specic.) Phlebotomists name Indicate the test(s) requested An example of a simple requisition form with the essential elements is shown below:

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

LABELING THE SAMPLE


A properly labeled sample is essential so that the results of the test match the patient. NOTE: The information MUST match the information on the requisition form. It should show: The patients full name The patients identication number Date, time and name (or initials) of the phlebotomist must be on the label of each tube Automated systems may include labels with bar codes. Examples of labeled collection tubes are shown below:

Figure 5: Examples of labeled collection tubes

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Venipuncture Course and Kit | PREPARATION

SHORT NOTES ON ASEPTIC TECHNIQUE


Study this section carefully as it can make the difference between frequent and occasional complications and possibly the difference between life and death! Follow an acceptable hands-hygiene protocol: Handwashing techniques Wash your hands with an acceptable method before and after every venipuncture procedure. Alcohol rub Hygienically preparing your hands with an alcohol-based hand sanitizer before and after procedures is a permissible way to prepare uncontaminated hands aseptically. Contamination may be any environmental dirt, bodily uids (e.g., blood) secretions (e.g., saliva) or excretions (e.g., feces.) Don clean gloves

Figure 6: A surgeon scrubbing before surgery

PROJECTS 3A 3I
PROJECT 3A A TECHNIQUE FOR PROPER HANDWASHING
Learn to wash your hands prepare them hygienically before examining a patient

VIDEO
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Venipuncture Course and Kit | PREPARATION

It is recommended that students study the WHO Guidelines on Hand Hygiene 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 eective, 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. Sta 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.

INFORMATION

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

STEP 3
Repeat 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 ngers interlaced and vice versa. 3.3 Palm to palm with ngers interlaced. 3.4 Backs of ngers to opposing palms with ngers interlocked. 3.5 Rotational rubbing of left thumb clasped in right palm and vice versa. 3.6 Rotational rubbing, backwards and forwards with clasped ngers of right hand and vice versa. 3.7 Rotational rubbing of wrist by opposing palm and vice versa.

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.

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

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 workers nails should ALWAYS be kept neat, short, and hygienically clean!

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

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

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

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Venipuncture Course and Kit | PREPARATION

HINTS:
Use disposable paper towels. Cloth towels are not suitable in a healthcare setting as they harbor and retain bacteria and become more contaminated with use. Frequent handwashing will remove the skins 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 sta 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 eective alternatives for routine sanitization of uncontaminated (without blood, bodily uids and dirt) hands (see PROJECT 3B).

Surgeons and operating room sta 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 dierences: -- 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.

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Venipuncture Course and Kit | PREPARATION

PROJECT 3B CLEANING HANDS WITH AN ANTISEPTIC RUB


Print out the World Health Organizations (WHO) guideline diagram and follow the steps

VIDEO

PROJECT 3C HOW TO DON (PUT ON) CLEAN GLOVES


Print out the World Health Organizations (WHO) guideline diagram and follow the steps

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Venipuncture Course and Kit | PREPARATION

Touching only the cu, take the rst glove out of the original box. Try to touch only the wrist area of the glove, i.e., the top end of the cu. Don the rst glove by sliding it over the ngers, palm, and wrist. With the bare hand, take a second glove from the box again, only touching the gloves cu 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.

PROJECT 3D HOW TO SAFELY REMOVE USED GLOVES


Print out the World Health Organizations (WHO) guideline diagram and follow the steps Pinch one glove at the wrist level to remove it, without touching the skin of the forearm, and peel away from the hand, thus allowing the glove to turn inside out Hold the removed glove in the gloved hand and slide the ngers 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 rst glove Discard the removed gloves in a suitable biological waste container Perform hand hygiene

PROJECT 3E * HOW TO CHANGE INTO THEATER ATTIRE


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

PROJECT 3F * HOW TO SCRUB FOR A STERILE PROCEDURE


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

PROJECT 3G * HOW TO GOWN FOR A STERILE PROCEDURE


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

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Venipuncture Course and Kit | PREPARATION

PROJECT 3H HOW TO DON STERILE GLOVES


Print out the World Health Organizations (WHO) guideline diagram and follow the steps

PROJECT 3I* HOW TO REMOVE CONTAMINATED GLOVES


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

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Venipuncture Course and Kit | PREPARATION

PATIENT POSITIONING
PERFORMING VENIPUNCTUREON A VEIN OF THE UPPER EXTREMITY
Position the patient comfortably with their arm at heart level or just below. Outpatients should be placed in the sitting position and hospital patients lying in bed, in the semi-Fowlers or supine position. Inspection and palpation are essential components for selecting a suitable vein; therefore the intended venipuncture site must be exposed. Good lighting is required. If needed, position the light at an angle to enhance inspection of the veins. Place a clean linen-saver below the arm to protect bed sheets. Ensure that all the venipuncture equipment and items that you need are within easy reach.

Figure 8a: Patient in Semi-Fowlers position

Figure 7: Patient in sitting position

Figure 8b: Patient in supine position

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Venipuncture Course and Kit | PREPARATION

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

PATIENT POSITIONING FOR ARTERIAL BLOOD SAMPLING FROM THE RADIAL ARTERY
The patient should be seated comfortably (patients in bed in the semi-Fowlers 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.

Figure 9a: Trendelenburg

PATIENT POSITIONING FOR ARTERIAL BLOOD SAMPLING FROM THE FEMORAL ARTERY
The femoral artery is generally not recommended for ABG sampling. Place the patient in the supine position, with the groin and leg extended and slightly abducted.

Figure 9b: Reverse Trendelenburg position

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Venipuncture Course and Kit | PREPARATION

TOURNIQUETS - PROJECTS 4A 4D
PROJECT 4A HOW TO APPLY A TOURNIQUET (DISPOSABLE)
A simple technique to facilitate easier venipuncture

INFORMATION
A 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 specic time limits to stop the arterial blood ow 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 ow of venous blood back to the heart while allowing the arterial blood to ow undisturbed to the extremity. Blood will thus ll 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-ow, 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. Aordable 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 hospitals infection control section.

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Venipuncture Course and Kit | PREPARATION

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

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

STEP 6
Tuck 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 st to help distend the veins. Inspect and palpate the veins.

FOLLOW THESE STEPS FOR DRAWING BLOOD FROM THE CUBITAL FOSSA AREA:
STEP 1
Take a short medical history, especially regarding allergies (latex, Iodine and IV drugs, etc.). The tourniquet and gloves in this kit are latex-free

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

POINTS OF INTEREST
If 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 ow 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.

STEP 2
Remove 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 3
Place the tourniquet under the patients arm with an end in each hand. Ensure that it lies at on the skin surface

STEP 4
Swap 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.

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Venipuncture Course and Kit | PREPARATION

PROJECT 4B HOW TO APPLY A TOURNIQUET (TOURNISTRIP)


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

INSTRUCTIONS
STEP 1
Remove 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 2
Expose the adhesive panel on Tournistrip (see peel here)

Peel the removable section before wrapping the tourniquet around arm.

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

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

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

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

STEP 5
Release Tournistrip.

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

Order Tournistrips [Click Here]

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Venipuncture Course and Kit | PREPARATION

PROJECT 4C HOW TO APPLY A TOURNIQUET (REUSABLE)


Print out the World Health Organizations (WHO) guideline diagram and follow the steps 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]

The BOA IV constricting band is an innovative reusable tourniquet that is simple to use and makes applying a tourniquet both eective and simple visit www.NARescue.com for more information.

PROJECT 4D HOW TO APPLY A TOURNIQUET (BLOOD PRESSURE CUFF)


Apply a blood pressure cu 7-10 cm (3-4 inches) above the intended venipuncture site. Inate the cu to about 60 mmHg. Proceed with the venipuncture procedure. Deate as soon as the task is completed (1 minuteno more than 2 minutes if drawing blood for the lab).

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Venipuncture Course and Kit | PREPARATION

PROJECTS 5A 5D

PROJECT 5A IDENTIFY THE VEINS OF THE UPPER EXTREMITY


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

REQUIREMENTS
You 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

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Venipuncture Course and Kit | PREPARATION

FOLLOW THESE STEPS


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

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

STEP 2
Have a look at the simplied diagrams:

STEP 4
Prepare your hands hygienically and don clean gloves. (Gloving is optional for this project.) See PROJECTS 3A, 3B and 3C

STEP 5
Use the simplied 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 ngers.

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

STEP 7
Figure 10a: The ventral arm veins

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

STEP 8
Use the skin marker pen to draw the veins on the hand. Feel free to take a photograph of the venous pattern of your volunteers arm. You may also want to label the veins using the diagrams in Step 2.

POINTS OF INTEREST
The anatomical patterns of veins vary more than those of the arteries of the body. Look at this excellent anatomical study and publication: Cubital Fossa Venipuncture Sites Based on Anatomical Variations and Relationships of Cutaneous Veins and Nerves by Kouji Yamada and coworkers. [Click Here] The ow of blood in the venous system is complex for several reasons: The relatively low pressure within the veins. The ow rate varies and is somewhat dependent on the contraction of muscles. Gravity aects the ow rate and intravenous pressure. The collapsible nature of the relatively thin venous walls. Valves are present within the lumens of most veins. Veins carry a large volume of blood: about 64% of the blood volume!

Figure 10b: The dorsal hand veins

Figure 10c: The cubital fossa veins

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Venipuncture Course and Kit | PREPARATION

PROJECT 5B IDENTIFY THE VEINS OF THE LOWER EXTREMITY


INFORMATION REQUIREMENTS
You 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

STEP 3
Ask 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 ll the veins with blood. Apply the tourniquet somewhere at least 10-15 cm (4-6 inches) above the knee joint.

FOLLOW THESE STEPS


STEP 1
Study the detailed illustration of the veins of the lower extremity (leg).

STEP 2
Have a look at the simplied diagram:

Figure 12: Examining the veins of the leg

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

Figure 11: The anterior leg veins

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Venipuncture Course and Kit | PREPARATION

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

the supercial veins into the deep venous system through small perforator veins. Supercial, deep, and perforator veins have one-way valves that allow blood to ow 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 o (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 supercial veins might cause discomfort and pain, but it is usually not a cause for pulmonary embolism.

IMPORTANT WARNINGS
As a general rule, always use the veins of the upper extremities as your rst choice for routine venipuncture. Venipuncture on the lower extremities, in particular the feet, is contraindicated in most situations because of the increased bacteria ora 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 suer 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 sta are required to get permission from the attending physician before using a vein of the lower extremity for venipuncture/ phlebotomy.

Figure 13: Identifying the greater saphenous vein

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

POINTS OF INTEREST
There are two types of veins in the legs: supercial veins and deep veins. Supercial 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 ows from

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Venipuncture Course and Kit | PREPARATION

PROJECT 5C OTHER IMPORTANT VEINS (FACE, NECK AND CHEST)

INFORMATION
The external jugular vein has two pairs of valves: the lower pair is located at its entrance into the subclavian vein and the upper in most cases is about 4 cm above the clavicle. If you position a patient in the Trendelenburg position (body tilted about 15 with the head lower than the feet) you may notice the external jugular vein pulsating. This is caused by retrograde pressure from atrial systole (keep in mind that the entrances of the atriums are valveless and the venous valves are imsy [SEE VIDEO CLIP].

REQUIREMENTS
You will need: Alcohol hand rub A pair of clean gloves A skin marker pen A suitable same-gender volunteer (A person with a low BMI and a fair skin will show the veins more clearly.) If no volunteer available, use your own neck in the mirror Good lighting

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Venipuncture Course and Kit | PREPARATION

FOLLOW THESE STEPS


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

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 uid, 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 veins 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.

STEP 2
Have a look at the simplied diagram:

Figure 14: The head and neck veins

STEP 3
Ask the volunteer to expose the neck area. Place the person in the Trendelenburg position (head and neck about 15 down), tilt the head slightly to the opposite side, and apply light pressure just above the clavicle. You can also ask your volunteer to forcefully exhaling against resistance (closed lips) so you can see the veins more clearly. This will increase the intra-thoracic pressure and help to engorge the external jugular veins. Keep in mind that the course of the neck veins may vary to some extent; some patients have double external jugular veins.

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

STEP 5
Identify the external jugular vein on both sides by inspection and palpation as it crosses the sternocleidomastoid muscle as shown in the diagram. Identify the anterior and posterior jugular veins if possible.

STEP 6
Use the skin marker pen to indicate the course of the vein. With permission, take a photograph of the venous pattern of your volunteers neck. You may also label the veins using the diagrams in Step 2.

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Venipuncture Course and Kit | PREPARATION

PROJECT 5D MAP THE VALVES IN VEINS


INFORMATION
There are valves in most veins; exceptions include the portal, the hepatic, and the internal jugular veins. Venous valves are bicuspid (two) flap-like structures made of elastic tissue. The valves function to keep blood moving in one direction only. Once the blood has passed from the arteries through the capillaries, it flows at a slower rate because little pressure remains to move the blood along towards the heart. In the veins below the heart, blood flow is facilitated by muscular contraction. When the muscles contract, blood within the veins is squeezed forward in the vein and the valves open. When the muscle is at rest, the valves close, which helps prevent the backward flow of blood. This is called the muscle pump. The direction of venous return in the extremities is from finger and toe tips towards the body

REQUIREMENT
You 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

STEP 3
Occlude the vein distally (on the fingers 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 4
Stop 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.

METHOD 1 FOLLOW THESE STEPS


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

STEP 5
Mark the position of the valves with the skin marker pen and photograph the valve-mapped arm.

STEP 2
Identify a suitable volunteer: someone with clear and prominent superficial veins on their arms. Ask this person to make a fist and extend the arm, with the palm up and slightly below elbow level. Locate a prominent section of vein of about 10 cm (4 inches) on the inside of the forearm.

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Venipuncture Course and Kit | PREPARATION

METHOD 2 FOLLOW THESE STEPS


STEP 1
Prepare your hands hygienically and don clean gloves. (Gloving optional but strongly recommended.) See PROJECTS 3A, 3B and 3C going towards the wrist. Exert mild pressure to empty the blood from the lumen of the vein.

STEP 4
Blood 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 2
Have 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 3
Starting near the elbow, run your finger along the vein

STEP 5
Mark the position of the valves with the skin marker pen. Take a photograph of the valve-mapped arm.

POINTS OF INTEREST
When drawing blood, injecting into a vein or putting up an IV line, insert the needle above or some distance below a valve. Avoid injecting straight into a valve to avoid damage or complications. In some individuals, the valves show up as small nodular enlargements of the vein and are easily identified. Venous valve malfunction
Figure 16a and b: Example of varicose veins leg

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.

Predisposing factors for developing varicose veins include: Ageaging causes wear and tear on the valves in your veins. Genderwomen are more likely than men to develop this condition. Hormonal changesespecially during pregnancy, pre-menstruation, or menopause. Geneticsvaricose 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!

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Venipuncture Course and Kit | PREPARATION

BLOOD SAFETY INSTRUCTIONS


The following Projects, when performed on a patient in a real clinical setting, will expose you to blooda potentially hazardous substance! For your own and your patients 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 guidelinesincluding the wearing of gloves, gowns, plastic aprons, masks, eye shields, and goggles [See PROJECTS 3C to I]. Appropriate procedures for the handling and disposal of contaminated wastes. Appropriate procedures for the handling and disposing of sharps. Guidelines and procedures for the prompt handling of blood and body fluid spills. Appropriate waste disposal measures must be in place to ensure that blood, other body fluids/substances, and other potentially infectious materials are disposed of safely. An established protocol for preventing, reporting, and handling sharps injuries and other infective agent transfer incidents (e.g., body fluid splash on a mucous membrane).

PROJECT 6A PREPARE TO ADMINISTER AN INJECTION


Choose a suitable syringe and needle and draw up medication from various medicine vials

PLEASE TAKE NOTE:


This project oers 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.

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Venipuncture Course and Kit | PREPARATION

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.

IMPORTANT NOTES:
Always keep your and your patients 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 manufacturers instructions and discard in a dedicated sharps safety container after use. In all cases when preparing more than one syringe of dierent 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.

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 SYRINGES


Commonly used for IM injections or for mixing or drawing up other medications. Use the smallest syringe that will hold the dose properly.

10ML 12ML SYRINGE


Used for mixing or drawing up other medications, for central line ushing, and to inate/deate Foley catheter balloons, as well as for urine specimen collection from a Foleys 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 (11 inch) Drawing up from vials: 18-21 gauge, 25mm (1 inch)

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

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Venipuncture Course and Kit | PREPARATION

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

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 ll the syringe. Withdraw the required amount of medication as specied. Avoid drawing air by keeping the needle tip below the uid 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 injectionappropriately discard the needle used to draw up the medication and place a new needle (preferably a safety needle) on the syringe.

HOW TO DRAW UP MEDICATION


In 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 VIAL FOLLOW THESE STEPS


General preparation (*see above) Hold the vial upright between your ngers 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 ick your nger against the vial as you may break the vial and injure your nger. Identify the small dot on the vial and face it towards you. Hold the main body of the vial between the thumb and index nger of the one hand and the top part of the vial between the thumb and index nger of the other hand. Crack the vial open by bending the top backwards in a single denite action, and place it upright on the work surface.

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Venipuncture Course and Kit | PREPARATION

IMPORTANT NOTE REGARDING WITHDRAWING MEDICATION FOR AN IM INJECTION


Most training centers recommend a standard twoneedle protocol when performing an IMIthe rst 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 ne, 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 rst needle may touch a non-sterile surface and become contaminated with microbes.

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. 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.

HOW TO DRAW UP MEDICATION FROM A GLASS VIAL WITH A RUBBER MEMBRANE YOU WILL NEED:
Syringe with attached needle Vial of medication Alcohol wipes Sharps container

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 ll the syringe. Withdraw the required amount of medication as specied. Avoid drawing air by keeping the needle tip below the uid 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. If IMI injection appropriately discard the needle used to draw up the medication and place a new needle on the syringe.

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 syringePROJECT 1B ) Important: Do not touch the needle!

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Venipuncture Course and Kit | PREPARATION

SAFETY
Plastic 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. Press down on the plastic activator to force diluent into the lower compartment. Gently agitate to eect 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 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 specic 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 syringes 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 ll the syringe, and withdraw the required amount of medication as specied. Avoid drawing air by keeping the needle tip below the uid 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)

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 eects by diluting it and injecting it slowly!

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Venipuncture Course and Kit | PREPARATION

POINTS OF INTEREST
STUDY 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 singleuse 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 identied 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 ush IV lines and catheters; Administration of intramuscular (IM) vaccines. The medications used in these procedures were in singledose 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

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


A simple but essential step to prevent infections

INFORMATION
The skin harbors, in large numbers, a variety of bacterial species, as well as other microorganisms. These microbes (also called ora) can be divided into two groups: resident ora (lives in and on the skin) and transient ora (temporary visitor microorganisms). Resident and transient ora 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 patients 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, ammable chemical compound with a strong odor with the molecular formula C3H8O. It is used in medical disinfecting pads (alcohol preps), which typically contain a 6070% 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.

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

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FOLLOW THESE STEPS:


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

POINTS OF INTEREST
The total number of microorganisms on a persons 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

STEP 2
Prepare your hands hygienically (wash or alcohol hand rubPROJECT 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.

IMPORTANT:
Adhering to a meticulous sterility and aseptic protocol will dramatically reduce the number of infective complications that your patients could experience. Insignicant deviations from the recommended protocol make a big dierence! 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.

STEP 4
Cleanse 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 dont 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.

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PROJECT 6C HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FOR BLOOD CULTURE)
Minimize the chances of contaminant bacteria of entering the blood culture bottle

This project is for your information only as there are no blood culture bottles supplied in the kit. Labs usually supply dedicated cleaning kits for the purpose of aseptically preparing the puncture site before taking blood samples for culturing.

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

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

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

STEP 6
Perform hand hygiene for the second time.

STEP 7
Put 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 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 8
Using 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.)

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

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

better tolerated, doesnt negatively aect wound healing, and leaves a deposit of active iodine thereby creating the so-called remnant or persistent eect. 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 eectiveness and is safer, cheaper, and preferred by sta. (Of course it should not be used on patients who are sensitive or allergic to Chlorhexidine.)

POINTS OF INTEREST:
Using a sound skin preparation technique and protocol the specimen contamination rate should be in the low single gures range (denitely < 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

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PROJECT 6D HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FROM BLOOD DONOR)
Prevent bacterial contamination of donated blood

WHO GUIDELINES (2010) ARE AS FOLLOWS:


If the site selected for venipuncture is visibly dirty, wash the area with soap and water, and then wipe it dry with single-use towels.

ONE-STEP PROCEDURE
(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 eective 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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CASE STUDY 3: MY LIFE CHANGED DRASTICALLY IN A SPLIT SECOND

Dr. Louise Weimar wore a cream wedding gown and her groom, Scottish engineer Mark Mynhardt, wore a kilt. From an outsiders 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 rst attempt she reached for a second needle to re-attempt the procedure but just as she turned around, the baby pulled loose from the nurses arms and bumped Dr. Louises hand right into the rst needle. It penetrated the little nger of her right hand to the bone. Dr. Louise followed protocol and reported the incident. A sample of the babys 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 anc 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. Lets 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.

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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 wont 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!

PROJECT 7A DRAW CAPILLARY BLOOD ADULT


A useful method of sampling a couple of drops of blood

VIDEO
The student is allowed to perform this project under supervision of a suitably qualified medical professional. If you have friend or family member who is a diabetic then offer to test their blood glucose level.

INFORMATION
Blood from a nger stick diers 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 uid. If properly executed, blood collected from a nger (or heel stick) will oer surprisingly accurate bio-chemical information. Keep in mind that the following readings may be slightly dierent: Lower concentrations of potassium, total protein, and calcium. Higher glucose. Relative contraindications for nger prick blood collection: General contraindications: Patients with general edema and patients with severe dehydration may not be good candidates. Local contraindications: Injury of the nger or hand, infection of the nger/nail area, scar tissue, previous burns, mastectomy with axillary lymph gland resection (on the side of the intended nger puncture site), Raynauds disease. Patients with cold ngertips: Warm to increase the blood-ow before puncturing.

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REQUIREMENTS
You 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

STEP 6
The puncture should be made perpendicular to the ngerprint ridges to prevent the drop of blood running in the grooves. Stab the nger with the sterile lancet in a single brisk stab movement. Puncture the esh right up to the shoulder of the lancet at 90 to the skins surface.

STEP 7
Wipe away the rst drop of blood which may contain excess tissue uid.

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

FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION:


STEP 1
Open the above items on the clean work surface cover.

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

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

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

STEP 11
Dispose 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 3
Prepare your hands hygienically.

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

STEP 4
The patient should be comfortably positioned sitting or lying down. Extend the patients arm, keeping the hand relatively open. Choose a suitable puncture site. Use the pads of the middle or fourth ngers of the non-dominant hand and somewhat to the side of the nger pad. Avoid: The thumb, index nger, as well as the fth ngers if possible The tip-area and central pad area of the nger Puncturing a nger that is cold or cyanotic, swollen, scarred, or covered with a rash

POINTS OF INTEREST
A 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 nger sticks or heel sticks generally hold one-half ml or less.

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

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PROJECT 7B DRAW CAPILLARY BLOOD BABY


A useful method of sampling a couple of drops of blood

VIDEO
Figure 6: A surgeon scrubbing before surgery

INFORMATION
Warning: This project is intended for your information only. Under no circumstances may you use a baby to practice this technique! A blood sample obtained from a heel puncture is a useful and simple way of collecting a blood sample from a newborn baby up to about 6 months of age. It is commonly used for the following purposes in 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

REQUIREMENTS
You 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

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FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION:


STEP 1
Open the above items on the clean work surface cover.

STEP 2
Check the patient for correct identity. Check the medical history with the babys parent (allergies, bleeding tendencies, medication, etc.). Verify the patients status regarding the physicians specic orders. Properly ll out and make appropriate notes on the lab requisition form including the specic test(s) requested.

STEP 3
Ensure that the baby is lying comfortably, warm and secure (for example, safely on a bed or on a persons 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.

Figure 21: Permissable areas to perform a heel prick procedure

STEP 5
Gently but rmly compress the babys heel (avoid excessive pressure). Release the tension, wipe away the rst 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 4
Hold the babys heel with the non-dominant hand. It may be necessary to compress the foot beforehand to get a good ow of blood. With the foot exed (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 skins surface in a single, brisk stabbing movement.

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

STEP 7
Apply 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 8
Dispose of contaminated materials in designated containers. Important note: All lancets are single-use only and must be disposed of in an approved sharps container immediately after use.

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

STEP 10
Figure 20: How to hold the heel when performing a heel prick procedure

The person performing the skin puncture should wash their hands.

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

POINTS OF INTEREST
To 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

PROJECT 8 HOW TO GIVE A SUBCUTANEOUS INJECTION


Deposit medication in the subcutaneous layer of the skin

VIDEO
*If you have an insulin dependent diabetic friend or family member, offer to administer their next insulin subcutaneous injection. Strictly follow the physicians orders!

INFORMATION
The skin is made up of dierent 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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CROSS SECTION OF THE SKIN

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 specications 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.

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

FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION:


STEP 1
Greet 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.

REQUIREMENTS
You 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

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

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

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of the body suitable for giving subcutaneous injections, as shown in gure 17. Enquire about the patients previous injection site.

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

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

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

STEP 6
Spread the index nger 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 nger. 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 advisableespecially in a clinic or hospital where medical professionals need to maintain a sterile chain, unlike the home-care situation.

Figure 23: Permissible areas for giving a subcutaneous injection

STEP 9
Press 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 7
Continue 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 10
Discard 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 11
Mark the puncture site, date, and time of the injection on a suitable chart or diagram.

STEP 8
Push 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!

STEP 12
Simulate 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 uid from the In of one of the IV uid bags to use as medication when doing the simulation exercise.

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POINTS OF INTEREST
Safe 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 midsection 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 nger 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 rst two ngers. 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, dont 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 llers and Botox into the skin for cosmetic reasons.

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PROJECT 9 HOW TO GIVE AN INTRAMUSCULAR INJECTION


Deposit medication in a suitable muscle

VIDEO
Figure 6: A surgeon scrubbing before surgery

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

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 patients 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 patients weight and amount of subcutaneous fat.

REQUIREMENTS
You 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

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 specics 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).

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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 1
Greet and positively check the patients 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 6
It 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 7
If 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 8
When 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 2
Follow the step-by-step instructions on withdrawing medication for an IM injectionsee PROJECT 6A.

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

STEP 9
Discard 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 4
Choose 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 10
Document the time, medication, dose, route, site, and patients response to injection.

STEP 5
Swab 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 nger 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 nger 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 ngers. Take great care not to prick your own nger!

STEP 11
Perform 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 uid from the In of one of the IV uid bags as medication when doing the simulation exercise.

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POINTS OF INTEREST
Relatively safe sites for IM injection are the deltoid, dorsal gluteal, ventrogluteal, and vastus lateralis (especially for children under two years of age). Deltoid Muscle: The deltoid muscle is located in the 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 ngers in an upside down V shape. Ensure that the middle of the patients arm is centered in your V. You will want to give the injection into the middle of this V. 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 ngers pointed towards the patients head. You should feel the border of the bony iliac crest along the middle nger to small nger. Spread your index nger and middle nger into a V and give the injection between those ngers.

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 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 26a and b: Giving an intramuscular injection in the vastus lateralis muscle Figure 28a and b: Giving a intramuscular injection in the dorsal gluteus muscle

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PROJECT 10 A SET UP THE VENIPUNCTURE TRAINER FOR PHLEBOTOMY


How to prepare the trainer for performing various practical projects

VIDEO
INFORMATION
In 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 lets start setting up this effective yet simple training apparatus.

REQUIREMENTS
You will need: Venipuncture Trainer Lumen stoppers/connectors IV line adult Small IV uid 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.

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FOLLOW THESE STEPS (SEE THE ACCOMPANYING DIAGRAM):


STEP 1
Inspect 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]

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

stand

STEP 2
Inspect the IV fluid bag. Note the two ports marked as In and Out. IV bag in port out port

STEP 3
Connect the syringe and needle. Draw up 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.

drip chamber

STEP 4
Connect the adult IV line to the bag using the Out port. Connect the other end to one of the tubes (Venipuncture Trainer veins) using a connector. Ensure that the connection is secure and doesnt leak. IV line flow-control clamp

STEP 5
Place or suspend the IV-fluid bag about a meter ( 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. connector IV Trainer simulation veins

STEP 6
Keep the lumen stoppers nearby. Place a shallow container at the outflow end of the Venipuncture Trainer. Open the infusion flow-speed mechanism. Press and release the drip chamber once or twice to fill it lumen stoppers

PROJECT 10 B SET UP THE VENIPUNCTURE TRAINER FOR IV PROJECTS


For PROJECT 11D HOW TO SETUP AN IV LINE, you will have to modify the Venipuncture Trainer setup as follows: Close or occlude the near side of both veins with the lumen stoppers. Place a shallow container (e.g., a kidney dish) at the far, open ends of the veins to receive the IV uid following a successful venipuncture procedure. Proceed with PROJECT 11D.

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PROJECT 10 C SET UP THE VENIPUNCTURE TRAINER FOR ARTERIAL BLOOD


For PROJECT 12C DRAW ARTERIAL BLOOD you will have to modify the Venipuncture Trainer setup as follows: Fill a 10 ml syringe with fake blood and connect to the smaller vein, and let it run through the tube. Now tightly occlude one side of the smaller vein. Ask another person to sit opposite you and then to press down on the plunger of the syringe. They can use a moderate pulsing pressure to simulate the pulsations of an artery. Perform the simulation procedure for drawing arterial blood PROJECT 12C.

TAKING CARE OF THE VENIPUNCTURE TRAINER


Put your Venipuncture Trainer away when you are nished with projects: Close the ow-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.

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 rarely Specic 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 eective in treating most diseases and frankly, may be detrimental (the above list excluded).

REFILLING THE IV FLUID BAG


If the IV uid runs dry, rell 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.

MAXIMUM ALLOWABLE TOTAL BLOOD DRAW VOLUMES


The maximum allowable total blood draw volumes depends on the patients 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.

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PROJECT 11A DRAW VENOUS BLOOD USING A VACUUM TUBE


One of a number of methods to draw venous blood

VIDEO
INFORMATION
It is strongly recommended that the student read the WHO 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 supercial artery. Inspect the area further to identify a denite 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 dicult to penetrate skin through scar tissue. The arm on the side of a previous mastectomy. Test results may be aected 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 uid may dilute the specimen. Collect from the opposite arm if possible. Cannula/stula/heparin lock. In general, blood should not be drawn from an arm with a stula or cannula. Edematous extremities. Tissue uid may cause inaccurate test results. Extremities with extensive injuries (external wounds or fractured bones). Extremities with a joint replacement. Use an alternative site/extremity.

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REQUIREMENTS
You 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).

Correct procedurescheck 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 2
Open 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).

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]

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

STEP 4
Select 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 ngers 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.

FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER:
STEP 1
Greet the patient; introduce yourself and then pause to conrm the following: Correct patientpositively identify the patient.

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

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

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Important note: Dont ask the patient to pump (repeatedly open and close) the st.

STEP7
Put on clean (non-sterile) gloves.

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 8
Disinfect 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 rst to aseptically treat your glove.

STEP 13
Withdraw the needle gently and then give the patient a clean gauze or dry cotton-wool ball to apply to the site with rm 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 9
Anchor the vein by holding the patients 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 14
Discard sharps (e.g., the used needle/s and broken glass and syringe or blood-sampling device) into a punctureresistant sharps container. Place other items like used gloves and all items contaminated with blood or body uids into the infectious waste.

STEP 10
Enter 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 15
Check the labels and forms for accuracy.

STEP 16
Perform hand hygiene.

STEP 17
Simulate the project by following Steps 1-16 using the fully setup Venipuncture Trainersee PROJECT 10A. Ensure that the tubes are lled with fake blood, that the IV uids tubing ow-speed regulation device is set on open, and that the ends of the tubes have lumen stoppers in position.

STEP 11
Support the Vacutainer tube holder, then push the Vacutainer tube into the hub and check for blood ow. Allow the tube to ll 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 ow stops, remove the tube by holding the hub securely and pulling the tube o the needle.

STEP 12
If tube used has additives mix the contents by gently inverting the tube 5-8 times (do not shake). Fill the remaining tubes and repeat the mixing routine after each tube has been lled. Once sucient blood has been collected, release the tourniquet BEFORE withdrawing the needle. Note: When lling 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).

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POINTS OF INTEREST
Tubes Yellow Blue Red Additives SPS Sodium Citrate No Additive (Serum tube) Contains a gel at the bottom to separate blood from serum on centrifugation Sodium Heparin or Lithium Heparin Lithium heparin anticoagulant and a gel separator EDTA Acid citrate dextrose Potassium Oxalate, Sodium Fluoride Tests Blood Culture Tube PT,PTT, APTT All Coagulation Studies Electrolyte, Lipid Panel, Hepatic Function, Digoxin, Bilirubin, HCG (pregnancy) Chemistries, immunology and serology Ammonia Level Various chemical studies CBC, Hemoglobin, Hematocrit, ESR (Erythrocyte Sedimentation Rate) HLA tissue typing, paternity testing, DNA studies All Glucose Studies Anticoagulant

Red-gray or gold top Green Light green Lavender Pale yellow Gray

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

DO DO carry out hand hygiene (use soap and water or alcohol rub), and wash carefully, including wrists and spaces between the ngers for at least 30 seconds DO use one pair of non-sterile gloves per procedure or patient DO use a single-use device for blood sampling and drawing DO disinfect the skin at the venipuncture site DO discard the used device (a needle and syringe is a single unit) immediately into a robust sharps container Where recapping of a needle is unavoidable, DO use the one-hand scoop technique (see gure xx) DO seal the sharps container with a tamper-proof lid DO place laboratory sample tubes in a sturdy rack before injecting into the rubber stopper 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
Table 4: The rules of safety when performing phlebotomy

DO NOT DO NOT forget to clean your hands DO NOT use the same pair of gloves for more than one patient DO NOT wash gloves for reuse DO NOT use a syringe, needle or lancet for more than one patient DO NOT touch the puncture site after disinfecting it DO NOT leave an unprotected needle lying outside the sharps container DO NOT recap a needle using both hands DO NOT overll or decant a sharps container DO NOT inject into a laboratory tube while holding it with the other hand DO NOT delay PEP after exposure to potentially contaminated material; beyond 72 hours, PEP is NOT eective

PEP (post-exposure) prophylaxis - for more information [CLICK HERE] Credit: WHO, World Health Organization Always use the one-hand scoop technique for recapping a needle see Figure 18

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ADDITIONAL SAFETY RECOMMENDATIONS:


If at all possible, use specially designed safety devices to minimize the risk of accidental needle injuries Dont 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 nal analysis there are simply no substitutes for taking CARE. Be careful at all times. You and your patients 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

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PROJECT 11 B DRAW VENOUS BLOOD USING A SYRINGE AND NEEDLE


One of a number of methods to draw venous blood

VIDEO
INFORMATION
It 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 specic 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 labs blood sample tube/s using specic methods with the emphasis on avoiding accidental needle prick injuries and minimizing the risk of cross infection.

REQUIREMENTS
You 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 Trainersee PROJECT 10A A phlebotomist will in addition to the above items, also need leak-proof transportation bags and containers.

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MEMORIZE THESE STEPS TO BE FOLLOWED IN A REALLIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER:
STEP 1
Greet the patient, introduce yourself, and then pause to conrm 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 4
Select 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 ngers 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 5
When you are ready to draw blood, apply the tourniquet about 45 finger widths above the selected venipuncture site.

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

STEP 7
Ask the patient to form a fist so that the veins are more prominent. Important note: Dont ask the patient to pump his/her st.

STEP 8
Disinfect 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 rst to aseptically treat your glove.

STEP 2
Open 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. Briey 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 rmly 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 9
Anchor the vein by holding the patients 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 10
Enter 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 lled 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.

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

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STEP 11
Once you collect sucient blood, ask the patient to relax the st, 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 15
Discard 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 uids into the infectious waste.

STEP 16
Recheck the labels and forms for accuracy.

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

STEP 17
Perform hand hygiene.

STEP 18
Simulate the project by following Steps 1-17 using the fully setup Venipuncture Trainersee PROJECT 10 A. Ensure that the tubes are lled with fake blood, that the IV uids tubing ow-speed regulation device is set on open, and that the ends of the tubes have lumen stoppers in position.

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 tubes stopper and let the blood passively ll 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 o thus creating a spray of blood droplets with the danger of exposing you and others to bloodborne pathogens.

POINTS OF INTEREST:
Comments on safety and avoiding injury to you and your patient Students 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 countrys governmental Occupational Health and Safety Department.

STEP 14
If 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 lled.

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PROJECT 11C DRAW BLOOD USING A BUTTERFLY NEEDLE


One of a number of methods to draw venous blood

VIDEO
INFORMATION
Winged infusion sets, commonly known as buttery infusion sets or buttery 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 dicult to access or when veins are in a location that would make a standard evacuated tube system dicult 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 exible 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 dicult 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 ash of blood can be seen. The ash is a small amount of blood that ows 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.

REQUIREMENTS
You will need: Laboratory specimen labels Pen for writing Laboratory forms The sharps container Alcohol wipe Clean gloves Clean work surface cover Winged infusion set21 gauge Syringe (10ml or 20ml) Cotton wool or gauze square Strapping (adhesive bandage strip) Fully setup Venipuncture Trainersee 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 1
Greet, 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 6
Put on clean (non-sterile) gloves.

STEP 7
Ask the patient to form a st to make the veins more prominent. Important note: Dont ask the patient to pump the st.

STEP 8
Disinfect 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, rst touch a clean alcohol pad to aseptically treat your glove.

STEP 2
Assemble equipment (see REQUIREMENTS above). Set out all of the tubes needed and have all the necessary tools (tourniquet and alcohol swabs, etc.) nearby. The buttery needle should be a 21 gauge or wider in order to minimize hemolysis. ALL needles and syringes are singleuse only. Open the outer packaging of all items to be used, including the buttery needle and syringe. Insert the nozzle of the Vacutainer or the syringe rmly into the hub end of the buttery needle tubing. Note: Use safety buttery needles in all clinical settings. When simulating the procedure you may use a regular needle but take great care not to prick yourself.

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

STEP 10
Use the buttery 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 ash-back of blood appearing in the tube lumen indicating a successful venipuncture.

STEP 11
Draw 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 rst specimen, then draw blood using a clear top* (no additive) vacuum tube before the citrate tube in order to ll 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 3
Perform hand hygiene. See PROJECT 3A A technique for proper handwashing and PROJECT 3B Cleaning hands with an antiseptic rub

STEP 4
Select 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 ngers 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 12
Once you collect sucient blood, ask patient to relax the st, 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.

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

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

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

STEP 13
Gently withdraw the buttery needle and give the patient a clean gauze or dry cotton-wool ball to apply rm 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.

POINTS OF INTEREST:
Notes on safety: Two examples of buttery 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.

STEP 14
Always 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 tubes stopper and let the blood passively ll 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 o, thus creating a spray of blood droplets with the danger of exposing you and other people to bloodborne pathogens.

Figure 29: The Angel Wing Safety butterfly needle [For more information]

STEP 15
If the tube used has additives, mix the contents by gently inverting the tube 5-8 times (do not shake). Fill remaining tubes and repeat the mixing routine after each tube has been lled.

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 dicult or impossible to access due to obesity, vascular collapse, or thrombosis.

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

STEP 17
Recheck the labels and forms for accuracy.

STEP 18
Thank the patient and perform hand hygiene.

STEP 19
Simulate the project by following Steps 1-18 using the fully set up Venipuncture Trainer. See PROJECT 10B SET UP THE VENIPUNCTURE TRAINER FOR IV TRAINING. Ensure that the tubes are lled with fake blood, the IV uids
Figure 30: How to cut down a vein

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

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PROJECT 11 D HOW TO START AN IV LINE


How to place a venous cannula into a vein

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

Figure 31b: Two examples of needle for introducing a peripheral venous catheter with their protective caps. The example on the top has a side port with cap for injecting medication.

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

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 ow 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 uid to correct dehydration. The IV route is the fastest manner in which to deliver uids 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 exible 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.

REQUIREMENTS
You 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 uid stand (something to hang the IV bag from about 3 feet/1 meter above your work area level) IV uid bag IV tubing The Venipuncture Trainer (modied setup required). See PROJECT 10B A linen saver (not supplied in the kit)

MEMORIZE THESE STEPS TO BE FOLLOWED IN A REALLIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER:
STEP 1
Greet the patient, introduce yourself, and then pause to confirm the following: Correct patientpositively identify the patient Correct procedurescheck and follow the physicians orders, including specics regarding IV uid and medications (if applicable) to be used. Then: Place the patient in the Semi-Fowlers or supine position. Do a short medical history (allergies, bleeding disorders, etc.) See PROJECT 2 Make notes on patients clinical chart

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

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

STEP 5
Select 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 identied (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 ngers above the intended venipuncture site to facilitate inspection and palpation. Remove the tourniquet until ready to proceed. Place a linen saver under the patients arm to protect the bed linens as it is dicult to avoid a couple of drops of blood from occasionally owing 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!

STEP 2
Assemble 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.

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STEP 6
Choose your IV catheter needle size with care. The size will depend primarily on the size of the vein; however the patients age and gender may also inuence your gauge selection. Adultsan 18 or 20 gauge catheter will work well for most cases. Elderly and pediatric patientsuse a smaller catheter (larger number, e.g., 22 or 24 gauge). Emergency uid replacementuse a larger catheter (smaller number, e.g., 14 or 16 gauge).

STEP 12
Look for the ashback of blood in the catheters plastic applicator. Once you see this ash 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 13
Remove the tourniquet. If required, take the opportunity to draw blood before attaching the IV line.

STEP 7
When ready to perform the venipuncture, apply the tourniquet about 45 ngers above the selected venipuncture site.

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

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

STEP 9
Ask the patient to form a st to make the veins more prominent. (Some clinicians will rst ask the patient to form a st rst, 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 st a couple of times to facilitate vein distention.

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

STEP 16
Open up the IV line. If you were successful, you will see uid dripping in the drip-chamber of the tubing. Observe the area for a couple of minutes. If the surrounding tissue swells, the drip is inltrating the tissue. Stop the drip, apologize, and move to another site. Important note: If you see a drop of IV uid 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 ve minutes. To avoid grave complications, never inject medication into an artery!

STEP 10
Disinfect 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 rst to aseptically treat your glove.

STEP 11
Remove the protective cap from the needle section of the catheter. Anchor the vein by holding the patients 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 17
Adjust 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 18
Discard sharps (e.g., the used needles) into a punctureresistant sharps container. Place other items like used gloves and all items contaminated with blood or body uids into the infectious waste container.

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

STEP 20
Simulate 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 ow-control mechanism. If you were successful, uid will ow out of the open end of the fake vein. If no ow is observed, close the ow-control mechanism and try again. Keep practicing!

How to calculate IV flow rates: Intravenous uid must be given at a specic rate. The specic rate is measured as milliliter per hour (ml/h) or drops/minute. To control or adjust the ow 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 drops 2. Time in minutes. The formula for working out flow rates is:

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

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 patients condence in your abilities for the next attempt! If you fail for a third time, apologize and ask for assistance from a more experienced medical professionalunless 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 nger of your other hand and puncture the skin on the side of the targeted vein.

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?
3000 (ml) x 15 (drops/ml) = 31.25 drops/minute 24 hrs. x 60 (gives us total minutes)

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PROJECT 11 E HOW TO REMOVE THE IV LINE


How to remove a venous cannula from a vein

VIDEO
Shut o the IV by closing the roller clamp of the ow 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)

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].

Figure 32: Performing an Intraosseous infusion

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SPECIAL GROUPS OF PATIENTS


THE NEONATE PATIENT
A neonate is a newborn infant, especially one less than four weeks old. The neonate patient has specic challenges due to anatomical and physiological variables that dier substantially from an adult patient. This is why neonatologists need specialized knowledge and prociency with dicult skills. Below is an excellent article about venous access in neonates with the abstract below: Vascular access in neonates and infantsindications, routes, techniques and devices, complications. By Mller 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 PATIENT


The basic principles of phlebotomy and venipuncture in the pediatric patient are similar to the adult patient yet dier 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 phlebotomy Especially 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: Dicult Venous Access in Children: Taking Control by Laura L. et al. Download this excellent article: [Click Here]

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

VIDEO
Generalized differences include: Most animals do have fur or lots of hair covering the areas with veins suitable for venipuncture. Removal of fur or hair is often necessary to visualize the veins and successfully perform phlebotomy or set up an IV line. The temperaments of animals are quite varied and dierent from the human patient. Communicating with animals is quite dierent 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 dicult to penetrate. When treating wild animals, levels of aggression may be dangerous or life threatening. A sedative (i.e., administered by darting) may be a prerequisite before a successful venipuncture procedure may be safely performed. Clinicians may need to take specialized protective measures to protect themselves from injury when treating animal patients. In veterinary practice, vascular access has many variables and techniques specic to many dierent 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:

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

Acquisition of vascular access in the emergent small animal patient is one of the keys to successful management of a population of patients that are often unstable with regard to their major body systems. Venous and intraosseus cannulation allow for the administration of a variety of fluids and potentially life-saving medications. In addition, central venous and arterial access also serves as conduits for atraumatic blood sampling and intravascular pressure monitoring. A thorough knowledge of vascular access theory, the dynamics of fluid flow, vascular anatomy, catheter selection criteria, and placement techniques are critical to the proper and safe use of the vascular access options that are available to small animal clinicians today. 2. Vascular access techniques in the dog and cat Abstract The rapid and reliable attainment of vascular access may prove crucial for the provision of an effective therapeutic solution in the critically ill or emergency small animal patient. Although in such cases it is more common to consider venous vascular access for the administration of medication and for the measurement of venous pressures, the attainment of arterial vascular access may prove just as important, allowing the direct measurement of arterial blood pressure and the sampling of arterial blood. This article provides guidelines on appropriate catheter selection for vascular access, placement techniques for both venous and arterial access, and procedures required for the long-term maintenance of these access sites. Veterinary students will nd The Apprentice Doctor Venipuncture Course and Kit a valuable resource for attaining the basic venipuncture knowledge and skills required by their curriculum. Here are a number of clinical examples of Venipuncture procedures in the animal patient: [SEE VIDEO CLIP ON PAGE 108]

AIDS TO ASSIST THE CLINICIAN


VeinViewer VeinViewer is a medical imaging device that uses nearinfrared light to produce a digital image of a patients veins and project it directly on their skin. See this YouTube video: [CLICK HERE] AccuVein is a similar medical imaging device that uses a specic frequency of light to produce a digital image of a patients 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 aordable 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 ow 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 supercial or deep veins and to dierentiate between veins and arteries. [CLICK HERE] Anesthetists use ultrasound to guide them to correctly place the needle when performing regional anesthesia. Radiography Central 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 uids or medications. Also see section on interventional radiology.

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PROJECT 12A IDENTIFY THE BODYS PULSE POINTS


How to identify the bodys pulse points and how to determine a persons heart rate

INFORMATION
Each 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 rm 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.

HINTS
Use the middle three ngers 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 ngers in the area where you want to feel for a pulse. You may have to move the position of these ngers slightly over the specic 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.

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

Take note of the following characteristics of the pulse: The forcefulness of each individual beat indicates a weak pulse or a strong pulse. Is the pulse regular or irregular?

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

STEP 2
Identify 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 thumbs side of the wrist and the ulnar pulse on the little ngers side, as indicated in the illustration.

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Figure 35a h: Various pulse points of the body

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

STEP 3
Identify the bony angel of the mandible. Place two ngers on this point. Move these ngers 3-5 cm (1-1 inches) forward and feel for the facial artery pulsating as it crosses the lower border of the mandible. Place your ngers on the angle of the mandible again. Now go down 3-5 cm (1-1 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.

STEP 6
To 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 specic person it is measured in BPM (beats per minute).

STEP7
Practice 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. Its 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.

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

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

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

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PROJECT 12 B PERFORM A MODIFIED ALLENS TEST


Check the collateral circulation of the hand

VIDEO
INFORMATION
In the majority of the population, two arteriesthe radial and ulnar arteriessupply the hand with oxygenated blood. These arteries anastomose in the hand. In a minority number of people, this dual blood supply is absent. The Allens test and the modied Allens tests are used to test the collateral blood supply to the hand, specically 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.

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FOLLOW THESE STEPS TO PERFORM THE MODIFIED ALLEN TEST:


STEP 1
With the middle two or three ngers (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 dicult to locate.

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 ow. Negative Allens test: The normal color (ushing) returns within 7 seconds. Positive Allens test: The normal color of the hand does not return (ushing) within the specied time. A negative modied Allens test indicates that ulnar circulation is inadequate or nonexistent.

SIGNIFICANCE
Despite the fact that some researchers question the validity of the Allens test, the following guidelines are still recommended: Negative: Allens 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 sucient for supplying blood to the hand, even without a patent radial artery, should occlusion complications occur. Positive: Allens test (normal pink color doesnt return): Dont use the radial artery for blood sampling, cannulation, or harvesting as a graft in order to avoid serious ischemic (insucient blood supply) complications to the hand. Instead, use the radial artery of the opposite hand (remember to do an Allens Test rst) or use another artery of the body for the specic clinical task or surgical procedure.

Figure 36: The radial and ulnar arteries

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

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

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

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

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PROJECT 12 C DRAW ARTERIAL BLOOD


Sample arterial blood from an artery

VIDEO
INFORMATION
This 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 bodys ability to take in oxygen and eliminate carbon dioxide. Often the patients 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 bloods 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 dicult as you may think. Arteries pulsate, making them easier to locate and unlike some veins they dont roll.

REQUIREMENTS
You 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 Trainersee PROJECT 10C For ABG sampling use: Sterile gloves* (in most centers) Eye protection glasses* (recommended) An ice lled 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 preheparinized syringe, as well as all the necessary items required for the procedure.

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FOLLOW THESE STEPS IN A REAL-LIFE CLINICAL SITUATION THEN SIMULATE DRAWING BLOOD USING THE VENIPUNCTURE TRAINER:
STEP 1
Assemble 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 6
Position is important! The patient should be seated comfortably (patients in bed should be in the semirecumbent 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. Inltrate (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 8
Perform 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 2
Greet, 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 9
With the fingertips of your gloved left hand, nd 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 ngers. With the ngers of your left hand over the radial artery, visualize the course of the radial artery underneath your ngers in three dimensions.

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

STEP 4
Site selection: as a rst choice, select the radial artery of the non-dominant wrist. See PROJECT 12A IDENTIFY THE BODYS PULSE POINTS. Warning: Radial arteries are contraindicated in patients who have a stula 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 10
Hold the syringe with the attached exposed needle in your right hand like a pencil. Approach the skin at 3045, in line with the radial artery, pointing in the direction towards the elbow. The needle should enter the radial artery immediately below the gloved ngers 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 5
Perform a modied Allens test. See PROJECT 12B PERFORM A MODIFIED ALLENS TEST. If you have a positive Allens test (normal pink color doesnt return): dont use the radial artery for blood sampling or cannulation so as to avoid serious ischemic (insucient blood supply) complications to the hand. Rather use the radial artery of the opposite hand (remember to do an Allens Test rst) or choose another artery.

STEP 11
Once 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 ashback of blood pulsating into the syringe. If you dont see blood you may have missed the artery or may have gone right through it. If so, withdraw the needle until blood starts lling the syringe or you may have to try again by re-aiming the syringe towards the pulsating artery.

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STEP 12
Instruct the patient not to move the arm or wrist. If they do, the needle may become dislodged. Blood gas syringes ll 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 lled or once sucient blood has been collected, hold it steady to prevent air aspiration and then withdraw the needle.

STEP 21
Simulate the project by following Steps 1-20 using the fully setup Venipuncture Trainer. See PROJECT 10C. Unfortunately you wont be able to feel a pulse on the simulator.

POINTS OF INTEREST:
Although arterial puncture is a fairly complicationfree 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 sucient pressure over the puncture site for 5-10 minutes. Hemorrhage Hemorrhage is especially a problem with patients receiving anticoagulant therapy or patients with blood coagulation disorders. A longer compression time will be necessary. Nerve damage Compression 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) Fistula These rare complications usually occur with repeated punctures. An aneurism will cause the artery to balloonout due to a weakened muscular wall. An AV stula is a communication between an artery and a vein before the capillary bed. Arteriospasm Arterial spasm may decrease the pulse volume and cause pain but fortunately is temporary. Thrombus formation Injury to the artery can lead to clot (thrombus) formation. A large thrombus can obstruct the ow of blood and impair circulation to the hand. Infection of the puncture site Use sterile/aseptic protocol as recommended by your institution/hospital.

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

STEP 14
Inspect 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 ngers.

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

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

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

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

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

STEP 20
Thank the patient and perform hand hygiene.

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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.

BLOOD TRANSFUSIONS, BLOOD TYPE (BLOOD GROUPS) AND AGGLUTINATION


A persons 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 system In 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).

Figure 37: The ABO antigens and antibodies

On average the general population has the following percentages of blood groups (percentages vary from country to country):
0+ 36% A+ 28% B+ 21% AB+ 5,0% 04% A4% B1,5% AB0,5%

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

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Genotype (Genetic type) AA or A0 BB or B0 AB 00


Table 8: The ABO Genotype and Phenotype

Phenotype (Biochemical expression) A B AB 0

RH BLOOD GROUP SYSTEM


The Rh system (another type of protein that is exposed on RBC is called Rh-factor) is the second most signicant blood-group system in human blood. The most signicant Rh antigen is the D antigen. You either have it or you dont. The person who has the D antigen is positive and one who doesnt 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. Lets say a woman is Rh- and the Rh+ father gave the baby the genes to be Rh+ as well. This will be ne, as the babys blood isnt mixing with the mothers or vice-versa. When it becomes important is when she gives birth to the baby because theres a break in the blood systems and small tears cause some of the blood cells from the baby to cross over into the mothers bloodstream during birth, which causes the mothers 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 mothers anti-Rh antibodies can cross over to the babys system and attack the babys 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 theres 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 anyones blood (types A or B or AB or O blood Rh+ or Rh-) because they dont have antibodies to ght antigens. Type AB is known as a universal recipient.

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Recipient 00+ AA+ BB+ ABAB+

0+

A+

B+

AB

AB+

Table 9: Red blood cell compatibility

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PROJECT 13 DONATING BLOOD FOR THE BLOOD BANK


Become a blood donor (if you arent a donor already)!

INFORMATION
Study 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 2010 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!

STEP 2
Select the vein Select a large, rm vein, preferably in the cubital fossa, from an area free from skin lesions or scars. Apply a tourniquet or blood pressure cu inated to 4060 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 3
Disinfect 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 (recommendedtakes 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 proceduretakes 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 eective 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.

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

COLLECTING BLOOD
For 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 donors information.

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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 specic 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 o at the end of the procedure (as described in step 6 below) rather than recapped. Ask the donor to open and close their st slowly every 10-12 seconds during collection. Remove the tourniquet when the blood ow is established or after 2 minutes, whichever comes rst.

AFTER A BLOOD DONATION


Donor 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. Oer the donor some refreshments. IMPORTANT NOTE! If you are not already one consider becoming a regular blood donor.

STEP 5
Monitor 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 ow 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.

POINTS OF INTEREST
Current 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]

STEP 6
Remove the needle and collect samples Cut o the needle using a sterile pair of scissors. Collect blood samples for laboratory testing.

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CASE STUDY 4: DESPITE ALL THE TRAINING AND THE NECESSARY CARE, ACCIDENTS DO HAPPEN

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 Michelles index finger. The

required protocol is followed and the patient is asked for permission to draw more blood sampleswith the necessary explanations and relevant forms to be filled out. Eventually, later in the day, the patients blood results arrive. Michelle is summoned to the Infection Control Officers 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 phlebotomists spine as she realizes that it is long, long overdue. Three months later, after a slow decline in health and

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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 dont allow for any exceptions. Ensure that your Hepatitis B inoculations are up to date.

CENTRAL VENOUS LINE


A central venous catheter (central venous line) is a catheter placed into the internal jugular vein or the subclavian vein or, less commonly, the axillary vein or femoral vein.

Figure 39b: An introducer and a central venous catheter

Figure 38: Central Venous Line Insertion

Depending on its use, the catheter is monoluminal, biluminal, or triluminal, dependent on the actual number of lumens (1, 2 and 3 respectively).

Figure 39c: Placing a central venous catheter under sterile conditions

Figure 39a: Examples of a central venous catheters

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 uid 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 uids Determining the mixed venous oxygen saturation Dialysis Need for intravenous therapy when peripheral venous access is impossible

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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

ARTERIAL CATHETERIZATION
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. RISKS INCLUDE Pain: Discomfort can result from the needle stick and placement of the catheter at the time it is inserted. Consider inltrating 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 ow and, very rarely, may cause the loss of a hand or a leg. This complication can be minimized by regularly checking the ow 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.

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

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CORONARY ARTERIOGRAPHY
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.

VIDEO

INTERVENTIONAL RADIOLOGY
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.

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KIDNEY DIALYSIS
Conventional chronic hemodialysis is usually done three times per week for about 3-4 hours per dialysis treatment, during which the patients 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 patients bloodstream through another tube connected to a second needle or port. During the treatment, the patients 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 nondominant 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.

Figure 41a: Placement of In and Out lines for renal dialysis

Figure 41b: An AV fistula for renal dialysis

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KIDNEY DIALYSIS
A port is most commonly inserted as a day surgery procedure in a hospital or clinic by a surgeon or an interventional radiologist under conscious sedation. Implantable ports are often used to give chemotherapy treatment and/or other medicines to cancer patients. Chemotherapy is relatively toxic to normal cells and can damage skin and muscle tissue, as well as small veins.

Figure 42a: A diagram of a venous access port

Figure 42b: A clinical example of a venous access port

A PORT MAY SERVE THE FOLLOWING PURPOSES:


For the delivery of TPN (Total Parenteral Nutrition) 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.

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PARENTERAL NUTRITION (TPN)


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]

ANESTHESIA
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.

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PROJECT 14 INFILTRATING A WOUND WITH LOCAL ANESTHETIC BEFORE SUTURING


Two methods of infiltrating a wound with a local anesthetic solution before debridement and suturing

VIDEO
INFORMATION
Most 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-eective 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 Considerations Clean the Wound Equipment (Set Up) Repair the Wound Assess the Results and Anticipate Complications Tetanus Immunization Status Educate the Patient Regarding Wound Care

REQUIREMENTS
You will need: The Venipuncture Trainer Gloves 5ml syringe 20G needle Clean work surface cover IV uid bag Alcohol hand rub A suitable volunteer (as usual)

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METHOD 1 FOLLOW THESE STEPS AS IF IN A REAL-LIFE CLINICAL SITUATION:


STEP 1
Remember the basics: take a medical history, prepare your hands hygienically, and don clean gloves.

STEP 9
Repeat the same procedure on the other side of the laceration.

STEP 10
Wait 2-3 minutes; test the eectiveness 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 dierent suturing techniques? Get your very own Apprentice Doctor How to Suture Wounds Course and Kit

STEP 2
Withdraw some of the uid from one of the IV uid bags from the out port. This will be used as a fake local anesthetic solution.

STEP 3
Draw a 5 cm (2 inch) line on the Venipuncture Trainer to represent the laceration.

STEP 11
Lift 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!

STEP 4
Insert the needle into the tissue, about 5 mm (1/4 inch) away from the laceration, beside one end of the laceration.

STEP 5
Deposit a drop or two of local anesthetic and wait for 3040 seconds. Advance the needle parallel to the long axis of the laceration to the other end of the laceration or to the length of the needle.

STEP 6
Aspirate to ensure that you are not in a blood vessel, to avoid accidentally injecting the local anesthetic solution intravenously.

STEP 7
Inject the local anesthetic solution continuously just below the skin as you withdraw the needle. Note the skin rising as you deposit the local anesthetic uid. With a real patient you will see blanching (the tissue will become whiter).

STEP 8
If the laceration is longer than the needle, repeat the same procedure along the next section of skin next to the laceration but ensure that you enter the skin in already locally anesthetized skin.

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METHOD 2
For this method, use a thin 27G needle. A short dental syringe and needle will work just ne.

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 signicantly 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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POINTS OF INTEREST
Local and general adverse effects and complications include: 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]

LOCAL ADVERSE EFFECTS


The 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 EFFECTS


Central 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 system Complications related to the conductive system of the heart include heart palpitations (innocent and usually due to the vasoconstrictors effects), arrhythmias, and a complete heart block (extremely rare but potentially fatal if not treated promptly) Allergic reactions An 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.

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.

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General anesthesia Prerequisite 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 pumps External infusion pumps are medical devices that deliver fluids, including nutrients and medications (such as anesthetic agents, antibiotics, chemotherapy drugs, and pain relievers) into a patients 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.

NEW DEVELOPMENTS
Scientists and bioengineers are developing amazing new technologies. Here are a few examples: Microprobes for continuous monitoring Instead 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 injections In future, people who have a fear of needles one may barely perceive receiving a needleless injectionat 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]

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SHORT NOTES ON OTHER BODILY SECRETIONS


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.

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.

SPUTUM
Sputum 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).

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SWEAT
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 NOTES ON OTHER BODILY EXCRETIONS


URINE
Urine 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 specic microbes involved in urinary tract infections.

FECES
A 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 nding the cause of symptoms aecting the digestive tract, including prolonged diarrhea, bloody diarrhea, increased atulence, 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!

URINALYSIS
The 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, specically taking the midstream urine. A urine sample for the lab is collected in a standard lab collection container (100-150 ml required).

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SHORT NOTES ON OTHER BODILY FLUIDS


Cerebrospinal fluid (CSF) is a clear, colorless bodily uid 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 uid and to detect the levels of biochemical constituents like protein and glucose. These parameters alone may be extremely benecial in the diagnosis of subarachnoid hemorrhage and central nervous system infections such as encephalitis and meningitis. Microbiological CSF culture examination may yield the specic 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 uid. It is not found in blood, mucus, or tears, thus making it a specic marker of cerebrospinal uid and the detection of leakage like CSF rhinorrhea. Diagnosis of the cause is usually done with blood tests, an ultrasound scan of the abdomen, and direct removal of the uid 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 prole, liver enzymes, and coagulation prole. Most experts recommend a diagnostic paracentesis be performed; the uid 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 uid from the blood or lymphatic vessels into the surrounding tissues or into a body cavity. PLEURAL EFFUSION is excess uid accumulating between the two pleural layers that surround the lungs. Pleural uid 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 uid 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 dierential 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 specic immunoglobulins

Figure 44: Cerebrospinal fluid fills the ventricles and surrounds the brain and spinal cord.

ASCITES is an accumulation of uid 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.

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JOINT EFFUSION is the presence of increased intraarticular uid, a fairly common nding in the inamed knee joint, but any joint may be aected. It may happen as a result of trauma, inammation, hematologic conditions or infections.

EXUDATES AND TRANSUDATES


AN EXUDATE is any uid that lters from the circulatory system into lesions or areas of inammation. It is rich in the protein and cellular elements that ooze out of blood vessels due to inammation 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 uid that passed through a membrane due to increased pressure in the veins and capillaries forcing the uid through the vessel walls. This process lters 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 inammation. There is an important distinction between transudates and exudates. Exudates have a higher protein content and thus a higher specic gravity, while transudates have a lower protein content and thus a lower specic gravity.

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 uctuation 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 insucient 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!

PUS
Pus is a viscous, yellowish-white uid 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 uctuation and determine the point of maximum uctuation.

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 ow 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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CASE STUDY 5: A ROUTINE VENIPUNCTURE CASE

Judy has always had a problem with dicult 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 Judys 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 diculty 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 eorts of competent medical professionals, Judy drifts deeper into the coma. Two days later, the consulting neurosurgeon declares her brain dead. The autopsy ndings 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

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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 patients 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.

VASOVAGAL RESPONSE AND VASOVAGAL SYNCOPE


A vasovagal attack is a disorder that causes a rapid drop in blood pressure and heart rate, resulting in decreased blood ow 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 o 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 specic 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.
Figure 45: Various patient positions

Not drive home (and not drive at all) on the day blood is drawn.

The emergency treatment to simply restore the patients blood ow to the brain is to reposition the body. Use one of the following positions:

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ALLERGIC RESPONSES
A number of different allergic reactions may be encountered during routine venipuncture procedures, including the following:

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.

CONTACT DERMATITIS
This 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.

ANAPHYLAXIS (ANAPHYLACTIC SHOCK)


Anaphylaxis is a life threatening allergic reaction that is rapid in onset.

Figure 46: Anaphylactic shock diagram

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CAUSES
Any medication may potentially trigger anaphylaxis. Other causes include severe latex allergy and food allergens. If not qualied to treat the emergencycall for assistance! Administration of epinephrine (adrenalin) is the rst line of treatment, with antihistamines and steroids often used as an adjunctive treatment. Nebulized salbutamol may be eective 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 insucient 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.

DIAGNOSIS
Anaphylaxis 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 pressure d. Gastrointestinal symptoms

TREATMENT
Anaphylaxis is a medical emergency that may require resuscitation measures such as airway management, supplemental oxygen, large volumes of intravenous fluids, and close monitoring.

NEEDLE PENETRATION THROUGH THE VEIN


Withdraw the needle somewhat, re-angulate the needle a bit more supercially, 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).

HEMATOMA
If a hematoma forms under the skin adjacent to the puncture site release the tourniquet immediately and apply rm pressure while withdrawing the needle. Move to another site. Older patients are prone towards forming hematomas. Considerations for preventing a hematoma: Use the major supercial 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.

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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 sucient. 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 diuse ecchymosis.
Figure 47: Extensive ecchymosis in an elderly patient

NEEDLE/ CANNULA IN THE TISSUE


If performing phlebotomy and you land up in the tissue surrounding the vein, you have one of the following choices: Go a bit deeper, if you are right above the vein. Go laterally towards the vein, if you are on the side of a vein. If you saw a flashback of blood and it disappears, you may have to withdraw the needle a bit as you may have gone right through the vein. If no luck, move to another site or ask a more experienced colleague to assist.

TISSUE INFILTRATION (EXTRAVASATION)


If the needle lands up in the tissue during IV infusion 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 patients 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.

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CANNULA/ CATHETER BLOCKED (OCCLUDED)


Use appropriately fibrinolytic (thrombolytic) agents, (e.g., Cathflo) to dissolve small clots as per physicians orders. Adhere to the appropriate flushing procedure for any needleless connector system. Flush the catheter immediately after a bolus of medication has been infused.

Inspect the tissue surrounding the IV site. Did the cannula slip out and is it infiltrating the tissue?
Figure 48: A blocked peripheral IV cannula

Prevention is better than cure! Keep the IV uid running; dont close the infusion for long periods of time. Dont let it run dry. The IV uid bag must be at least 1 meter (3 feet) above the patient for gravity to overcome the venous pressure and guarantee a positive ow of IV uid. Dont allow the IV uid bag to be at the level of the patient, or worse, lower than the patient, for any signicant time. Use appropriately anticoagulant preparations to prevent blood clots from forming as per physicians orders.

Check the IV bag and line. Is the IV bag empty? Inspect the tubing and cannula for kinks. If you cant 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]

CATHETER-RELATED INFECTIONS
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. [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.

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INTRA-ARTERIAL POSITION OF NEEDLE/ CANNULA DURING PHLEBOTOMY


If you are drawing blood and you suspect an intraarterial position: If you havent 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).

INADVERTENT INTRA-ARTERIAL INJECTION OF MEDICATIONINSTEAD OF INTRAVENOUS INJECTION


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 havent 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 intraarterial 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.

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CLINICAL DIFFERENTIATION BETWEEN ARTERIES AND VEINS


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 uids 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 rm pressure as instructed above.

SUPERFICIAL PHLEBITIS
Superficial phlebitis, also called supercial 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 dierentiated 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 veins 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 supercial veins on the skin, showing as a red line as the inammation follows the path of the supercial 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 inammation 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 aected limb and apply an anti-inammatory cream or gel to the area. In addition, anti-inammatory medication and analgesics can be used when necessary.

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SEPTIC THROMBUS
If a thrombus becomes septic, or invaded by pathogenic bacteria, the patient will become febrile with all the local and systemic signs and symptoms of infection (raised white blood cell count, etc.). In severe cases, septic shock may ensue. Treat empirically with relevant antibiotic therapy and supportive treatment. Blood cultures may be required.

DEEP VEIN THROMBOSIS (DVT)


It is not recommended to use veins, for either 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.

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EMBOLISM
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.

AIR 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 circulation With air embolism, prevention is better than cure!

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NEEDLESTICK INJURIES
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 patients 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 countrys 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 hospitals Infection Control Officer and follow the appropriate directives as soon as possible. Initiate the correct antiretroviral medication if applicable.

VIDEO

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LOCAL TISSUE DAMAGE


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. 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.

NERVE DAMAGE
The two nerves with the highest risk of being injured during a venipuncture procedure are the radial and median nerves. Permanent nerve damage is a dicult complication for the patient to come to grips with and carries a high medicolegal risk.

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 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

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.

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ASSESSMENT MODULE
(Available online) [CLICK HERE] The evaluation module consists of two sections: Section 1. Short multiple choice questions (20 marks) Section2. A selection of one practical project performed by the student and assessed by a designated evaluator (20 marks)

CONGRATULATIONS AND FINAL REMINDERS


Congratulations you have completed The Apprentice 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 sta 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 didnt, inform us as well. [CLICK HERE] to access The Apprentice Doctor Venipuncture Course and Kit evaluation questionnaire. Thank you for your time!

EPILOGUE
In essence, the simple technique of venipuncture is a minor surgical procedure and all the rules common to surgery apply. On occasion, simple procedures may become complicated due to various reasons. The most serious complication following a simple venipuncture procedure is deathusually as a complication of a complication. Be alert and minimize the risks to your patients for developing complications and your risk regarding medicolegal consequences.

REFERENCES
1. Mario Saia,et al. Needlestick Injuries: Incidence and Cost in the United States, United Kingdom, Germany, France, Italy, and Spain. Biomedicine International 2010; 1: 41-49. 2. Preventing Needle-stick Injuries in Health Care Settings. CDC Publication 1999. 3. Sharps Injuries: Assessing the burden of disease from sharps injuries to health care workers at national and local levels. WHO Publication 2005. 4. WHO Guidelines on Hand Hygiene in Health Care. WHO Publication 2009. 5. Kouji Yamada et al. Cubital Fossa Venipuncture Sites Based on Anatomical Variations and Relationships of Cutaneous Veins and Nerves. Clinical Anatomy. 2008 21: 307313. 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): 22162217.

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7. WHO guidelines on drawing blood: best practices in phlebotomy. WHO Publication 2010. 8. Mller JC, Reiss I, Schaible T. Vascular access in neonates and infantsindications, routes, techniques and devices, complications. Intensive Care World. 1995 Jun; 12(2):48-53 9. Laura L et al. Difficult Venous Access in Children: Taking Control. JOURNAL OF EMERGENCY NURSING September 2009; 35:5 10. Beal MW, Hughes D. Vascular access: Theory and techniques in the small animal emergency patient. Clin Tech Small Anim Pract. 2000 May; 15(2): 101-9. 11. Rob White. Vascular access techniques in the dog and cat. In Practice 2002; 24: 174-192. 12. Guidelines for the Prevention of Intravascular Catheter-Related Infections. CDC Publication 2011.

CREDITS
Facilities for videos and photography: Rhesa Van Der Merwe: Hospital Manager, Union and Clinton Hospitals Hans Van De Zee: Specialist Veterinary Surgeon, Valley Farm Animal Hospital in Pretoria Our gratitude to all the skillful veterinary practitioners and sta 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 Andor Package, 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: Giz.lubbe@gmail.com Patient models: Anton Scheepers Elna Van Der Hever Jacquiline Sumerville Rgardt Scheepers Ruan Klut Stfan Scheepers Production: Open Window School of Visual Communication Hub Arthur Twigge (Coordinator) Chase Jordan Coetzee (Assistant videographer) Dagan Read (Software development and nal 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.com Male: Craig Gildner Voice123.com Stories (narration): Dave Pettitt Voice123.com

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ATTENTION ALL FUTURE DOCTORS IN HIGH SCHOOL!


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Get insight into the methods doctors use to make an accurate diagnosis. Understand the human body from a doctors 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.

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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 couldnt 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 denitions 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 immunodeciency 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 inammatory 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 Deciency Syndrome, caused by human immunodeciency 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. Allens test (Modified Allens test) Allens test is used to test blood supply to the hand, specically, 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 persons 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 anity for a specic antigen. Anticoagulant A natural or synthetic agent that prevents the formation of blood clots. Antifibrinolytics Used to inhibit brinolysis (the process of dissolving a blood clot). Antigen A substance that is capable of producing a specic immune response with a specic 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 uid 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 reux 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 bodys pH buering system (maintaining acid-base homeostasis). Bleeding time A test that measures the time it takes for small blood vessels to close o and stop bleeding. Blind stick Performing a venipuncture with no apparently visible or palpable vein. Blood The uid 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 dierent 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 specic antigen manifesting on specic 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, proteincontaining uid 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 uids 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 ospring. 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 ow 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 exible tube for insertion into a duct, vein, or cavity in order to drain away uid 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 ow 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 o 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, exible 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 uids, 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 uid is a clear, colorless bodily uid 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 specic and toxic eect 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 eective 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 uid 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 Inammation 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 nd 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 uids 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 specic 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 supercial 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 brin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by brinolysis. Dead space (residual volume) The residual volume withheld in an IV device. Refers to the amount of uid 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 brin. Dehydration The lack of water in the body resulting from inadequate intake of uids or excessive loss of water and electrolytes through sweating, vomiting, or diarrhea. Dermatitis Inammation 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 dierent 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 uid 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 inated. 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 uids, often recognized by the leakage of blood and bodily uids, usually resulting in death. Ecchymosis A diuse collection of blood outside the blood vessels within the tissue. Edema The swelling of soft tissues as a result of excess uid accumulation. EDTA (Ethylenediaminetetraacetate) A calcium chelating (binding) agent that is used as an anticoagulant for laboratory blood specimens. Effluent An outow, usually of uid. Effusion The oozing of uids from blood or lymph vessels into body cavities or tissues as a result of inammation. Electrolytes Ions in cells, blood, or other bodily uids 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 inuencing the distribution of disease and their causes in a dened 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 bodys 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 uid from a vessel into surrounding tissue as a result of injury, burns, or inammation. 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 uid rich in protein and cellular elements that oozes out of blood vessels due to inammation 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 bodys 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 brin formation that hangs o the tip of the catheter like a tail. Fibrinogen The protein from which brin is formed. Fibrinolytic (Thrombolytic) Fibrinolytic or thrombolytic drugs are used to dissolve (lyse) blood clots (thrombi). Finger prick See nger stick. Finger stick A procedure in which a nger 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 buttery 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 ow rate decrease. General anesthesia A medically induced coma and loss of protective reexes 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 infants 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 uid 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 dierence in their rates of diusion 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 uid delivery. Hepatitis Inammation 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 uids. Hepatitis C Inammation 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 Immunodeciency Virus known to be responsible for producing Acquired Immunodeciency 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 uids. 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 bodys plasma. Hypodermic needle A needle that attaches to a syringe for the purpose of injections or withdrawal of uids 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 bodys 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 diusely into tissue. Infusate IV solution to be administered. Infusion pumps A programmable medical device used for infusing controlled amounts of uid or medication into a patients 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 uid within the cells. Intradermal injections An injection of medication into the skins 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 uids 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 uid 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 uid 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 articial replacement for lost kidney function in people with renal failure. Lactated Ringers (LR) See Ringers Lactate Laminar flow hood Safety cabinets with air ow 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) Emulsied 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 tting and a female luer tting. The female tting screws into threads in the sleeve on the male tting. 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 uids.

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Lymphedema A type of swelling that occurs in lymphatic tissue when excess uid 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 bodys 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 lter 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 buttery and Vacutainer holder to allow for the withdrawal of multiple tubes of blood during a venipuncture. Mural Thrombosis A brin 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 ne 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 ow of intravenous uid 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 Scientic 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 lm of paran 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 childrens 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 Inamed, 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 eective clinical practice. Intended to be followed by all clinical personnel and set as a benchmark for what and when specic 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 uid bag. Pulse points Specic areas or points on the human body where an arterial pulse or throb can be palpated on mild digital (ngertip) pressure.

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Pus The yellowish or greenish uid that forms at sites of infection, consisting of dead white blood cells, dead tissue, bacteria, and blood serum. QNS Quantity Not Sucient Radiography 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 aects 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 uid 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 specic type of human blood group responsible for hemolytic disease of the newborn. Ringers 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 ushAntibioticSaline ushHeparin. 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 inammation 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 uid. 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 bers and associated connective tissue cells beneath a mucous membrane. Superficial Relating to, aecting, 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 hearts function, blood ow, 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 uid (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 uid does not normally collect in larger amounts, or where any signicant uid collection is physiologically nonfunctional (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 brin 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 uid seeping into the surrounding tissue instead of owing 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 uids 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 ow 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 uid that passes through a membrane, ltering out most of the protein and cellular elements, thus yielding a watery solution. Transudates A uid 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 specic 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 ow 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 ow. 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 dicult venous access. Y Site Injection port that branches o primary lines. Used for piggybacking medications into primary set.

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