Angiography is an imaging technique used on blood vessels. A contrast material is routinely injected via an intraluminally placed catheter. This imaging technique is slightly invasive. There are less invasive ways to visualize blood vessels in the allied health field, but this is one method that is used.
A diagnostic percutaneous anteriography uses the Sledinger technique of vascular catheterization. This technique requires a hollow core needle to be placed into either a femoral or brachial artery. A guidewire is then inserted through the needle and into the artery. Usually sonographic or fluoroscopic guidance is used to ensure that the guidewire is positioned correctly. Once the wire is in place, the needle is removed and exchanged for a vascular catheter or vascular introducing sheath. Different sized catheters can be used for different sized arteries and blood vessels.
Once the catheter is in position the guidewire is removed and a contrast agent is injected into the catheter. Images are taken before the injection and while the contrast agent flow through the lumen of the blood vessel that is producing the arteriogram. When the procedure is completed the catheter is removed and manual compressions or a percutaneous closure device can be used to ensure that hemostasis is obtained at the injection site. It will usually take anywhere from 2 to 6 hours for a patient to recover from this procedure.
Noninvasive angiographies are beginning to replace the conventional invasive technique. The noninvasive technique is more commonly used except where intervention is expected or there are indefinite results from other examinations. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are the two noninvasive techniques that are being more widely used. Both are effective at evaluating aortic, visceral, renal, and peripheral arterial disease.
The first step in the administration of medication to a patient is the assessment of the patient. Although the drug prescriber should have assessed the patient initially before prescribing a medication, whatever was prescribed should be assessed again because a patient’s condition can change at any time. Should any changes take place that make the administering of a prescribed medication a bad idea then the a nurse, or nurse practitioner should be aware of these changes and make an important decision concerning the patient’s health and needs. Assessing the patient prior to administering any medications can also provide valuable information when comparing the patient’s reaction to the medication after it is administered.
There are two assessments that should be made when medications are administered. The first assessment is called a general assessment and should be done after any medication is administered. The second assessment is for only specific types of medications. Here are specific questions that should be answered during a general assessment.
-Is the therapeutic action of the drug appropriate for the patient?
Although the patient has been evaluated by the physician, the nurse is responsible for verifying that the drug is also proper for the patient before it is administered. This can be done by reviewing the patient’s diagnosis and checking to see that the medication is recommended for that diagnosis in the drug manual. If a drug is prescribed that is not recommended for a particular diagnosis than the nurse should contact the prescriber. It is important to remember that some drugs are prescribed for their secondary therapeutic effect.
-Is the route proper for the patient?
The route in which a drug is administered can vary depending on the drug. The prescriber may specify a route that is not appropriate for the patient’s current condition. The nurse should ensure that the route used for administering is appropriate for the patient. If there are any concerns about a prescribed route the nurse should contact the prescriber and obtain an order to use an alternate route that is more appropriate for the patient’s condition.
Blood is five times thicker than water and contains a mixture of fluid and cells. Slightly salty and alkaline, blood has a pH of about 7.4 making is neutral. In the body, the portion of blood that is liquid is called plasma. The portion of the blood that makes up the cellular components is called the formed elements. On average, an adult is approximately 55% plasma and 45% formed elements. As a phlebotomist, blood composition is pertinent to understand.
Blood plasma is normally a clear, pale yellow fluid that is made up primarily of water. Only 10 percent of blood plasma is made of other dissolved substances such as gases like oxygen, carbon dioxide and nitrogen. Other dissolved substances in blood include minerals such as sodium, potassium, calcium, and magnesium. Sodium is important for maintaining the proper fluid balance, pH, calcium and potassium levels necessary for the heart to work properly. Potassium helps to maintain normal muscle activity and helps to conduct nerve impulses. Calcium is used by the body to form bones and teeth. It is also an important mineral for nerve conduction, and muscle contraction. Calcium is also important in the blood clotting process.
Plasma also contains nutrients that help to supply the body with energy that is needed to function. There are important nutrients like carbohydrates and lipids in blood plasma. Protein is also found in blood plasma and is used to regulate osmotic pressure. Other proteins, like antibodies are important in fighting against infection and fibrinogen is used in the clotting process.
Waste products are often found in plasma also. Urea, creatinine an uric acid are all waste products of metabolism that are commonly found in plasma.
There are several different types of additives that can be used in blood collection tubes by a phlebotomy technician. Each additive has a specific function. The type of additive that is used depends on the test that has been ordered. Generally, it is not advised to substitute additives or combine different additives.
Additives come in several different forms. They can be liquid, spray dried, and powdered. A tube with a powdered additive should be tapped prior to use so that the powder can settle to the bottom of the tube. Once collection is complete, an additive tube must be inverted 3 to 8 times in order to thoroughly mix the additive with the specimen.
Anticoagulants are substances that do not allow blood to coagulate and form clots. This is often accomplished by either binding to or precipitating calcium in the blood so that is it unavailable in the coagulation process, or thrombin can be inhibited from forming. Whole blood specimens should be collected in tubes that contain an anticoagulant additive. Blood specimens should be gently mixed to prevent hemolysis.
Antiglycolytic agents are substances that are added to prevent glycolysis. When glycolysis occurs, glucose or blood sugar is metabolized. An antiglycolytic agent is used to stop the metabolization of glucose. If glycolysis is not prevented the blood sugar level will decrease at a rate of 10 mg/dL per hour.
Sodium fluoride is the most commonly used antiglycolytic agent. It is able to preserve the glucose in blood for 3 days and is also effective at inhibiting bacterial growth. Sodium fluoride tubes have gray stoppers and require eight inversions in order to mix the specimen thoroughly.
Clot activators are used to enhance coagulation and contain substances that provide more surface area for platelet activation. Silica is a glass and celite is a type of clay that is often used as clot activators. Silica particles cause the blood to clot within 15 to 30 minutes. Tubes that contain clot activators should be inverted five times for complete clotting to occur.
There are very few patients that enjoy receiving medications via injection. This route of administering medication is feared by many patients both young and old so as an allied health professional, it is important to be sensitive to this fear. Some patients are especially uncomfortable around needles. Whenever you have to administer a medication to a patient via an injection it is best to follow some simple guidelines that can help to reduce patient discomfort.
-Relax. Even though it won’t be easy for many patients, it is important that the patient relaxes when receiving a shot. Tense muscles are difficult penetrate and will cause the injection to hurt more than it would normally if the patient’s muscles were relaxed.
-Replace. If the medication was irritating to the patient, replace the needle after you use it to withdraw the medication from the vial. This will prevent the medication from having unnecessary contact with the patient.
-Position. Have the patient lay flat on the abdomen if you are injecting any medication in the dorsogluteal site. If you are injecting anything in the ventrogluteal site, have the patient lay on his or her side with knees flexed.
-Avoid hard tissues. Do not inject anything into an area that is sensitive or that has hardened tissues. Injecting into these areas will cause extreme pain.
-Compress. Do not forget to compress the skin at the injection site.
-Be patient. To prevent the antiseptic from sticking to the needle during the injection be sure to give the antiseptic time to dry before injecting any medication into an area.
-Dart. To reduce pain when the needle punctures the skin, dart the needle.
-Slow in/ quick out. Slowly inject the medication into the skin. Once the wheal has formed, quickly pull the needle out in a straight line.
-Ask the patient to cough. If you inject the medication when the patient coughs there is less chance that the patient will notice any pain. Have the patient cough on the count of three and inject the medication.
There are two different ways that media inoculations can occur. One way is to collect the blood specimen directly into the bottle. The other way is to collect the specimen in a syringe and then transfer in into the media bottle after the collection is complete.
Direct inoculation methods will use a butterfly syringe and special holder to collect the blood specimen directly into the blood culture media. To collect blood in this manner the special holder should be connected to the Luer connector of the butterfly collection set. The aerobic vial should be filled first. To avoid backflow from occuring, keep the culture bottle or tube lower than the collection site. Also, keep the culture media from contacting the stopper or needle during the collection process. Each container should be mixed well after it is full and the needle is removed from the holder. Once all of the containers are filled and there are no more tests to be done, remove the needle from the patient’s arm and activate the needle safety device. Be sure to keep firm pressure on the venipuncture site for several minutes.
Syringe inoculation will require that the blood be transferred to bottles after the collection process is complete. A special safety transfer device must be used to transfer the blood from the syringe to the bottles. This device is mandated by OSHA regulations. Once the draw is complete, the needle safety device should be activated once the needle is removed from the vein. The safety transfer device can now be attached to the syringe. The culture bottle should be pushed into the device until the needle inside the device penetrates the bottle stopper. The blood in the syringe will automatically be extracted by the vacuum created in the container. The plunger can be used to control the amount of blood that is extracted into the container. The plunger should never be used to force blood into the vial because the specimen may hemolyze.
Use extreme caution if you do not have a blood transfer device available for use with syringe inoculations. To reduce the likelihood of injuries to the phlebotomist, do not change needles prior to transfusion and do not hold the culture bottle in your hand during the inoculation process.
A glucose tolerance test (GTT) is often requested to determine if a patient has carbohydrate metabolism problems. Because glucose is the body’s major carbohydrate source of energy, a glucose tolerance test will show how well the body is able to metabolize glucose. The GTT is also called the oral glucose test for major blood glucose disorders such as increased hyperglycemia and decreased hypoglycemia. The GTT is able to evaluate the insulin levels that are regulated by the pancreas when a specific measurement of glucose is introduced into the body. The glucose levels are recorded on blood specimens that are collected at specific intervals. Insulin levels can also be measured if necessary. Generally, a GTT is 1 hour for gestational diabetes and 3 hours for all other glucose evaluations. Very rarely is it necessary for a test to go longer than 6 hours. The results of the test are plotted on a graph and create what is known as a GTT curve.
There are different doses of glucose and different timing intervals that can be done for various tests. However, it is important that the method for blood collection is the same for all specimen collections. For example, if the first specimen was collected by venipuncture than all subsequent collection should be acquired in the same manner.
The patient should be prepared for taking a GTT. It is important that the patient eat balanced meals that contain approximately 150 grams of carbohydrates per meal for 3 days prior to the test. The patient must also be advised to fast between 12 and 16 hours before the test. The patient can drink water anytime during the fast or test but no other beverages or food can be consumed during this time. The patient is also not permitted to smoke or chew gum during the fast or test because these actions stimulate the digestion and can cause inaccurate results. To ensure compliance with these guidelines, a health-care provider should discuss verbally the requirements and also provide the patient with a written copy of the instructions to refer to, if necessary.
The drug vancomycin is a bactericidal agent that is commonly used to fight infections that occur in the bone and joints as well as bacterial septicemia that is caused by Staphyloccocus. This drug is used to treat methicillin-resistant strains of Staphyloccocus that cause endocarditis. Patients who are more likely to have endocarditis are usually prescribed vancomycin by a pharmacy technician early in hope of preventing any infection.
This drug is also used to treat Clostridium difficile and staphyloccoccal enterocolitis. It can be administered orally or parenterally, however, a parenteral vancomycin should not be used to treat antibiotic-associated pseudomenbranous colitis, unless careful consideration is made otherwise.
As with any other type of antibiotic, before vancomycin is administered, the patient should be assessed to ensure that there he does not have an antibiotic associated allergies. If the patient has hearing loss, kidney problems or any inflammatory intestinal problems, special consideration should be given. Patients with hearing loss are rarely prescribed vancomycin. Patients with kidney problems should be given a lower dose of vancomycin and patients with inflammatory intestinal problems should be carefully monitored when given vancomycin due to the increased risk they have for toxicity. Every patient who is prescribed vancomycin should have adequate renal function.
Certain medications interact adversely vancomycin. Drug-drug interaction can occur when Vancomycin is administered with the following drugs:
Patients who are given vancomycin should have their kidneys monitored. Kidney problems have been associated with this drug. Also, patients who take vancomycin have been found to have an increased histamine release that may cause injury if the vancomycin is administered to rapidly. There could also be impaired tissue integrity and a loss of hearing or an increase of ringing in the ears.
The blood bank has many different types of blood specimens that must be labeled to correctly identify the types of blood products that they are. This is important because only certain blood products can be transfused safely into patients. Blood specimens should always be carefully collected and labeled so that future blood transfusions are safely done. There are specific procedures that can help to ensure the correct processing of all blood specimens.
Blood specimens are required to be collected in plain red stopper tubes or lavender or pink top EDTA tubes. Once the blood is collected, the specimens must labeled with the patient identification. Any specimens that are mislabeled, incomplete, inaccurately or unlabeled will not be tested. Any identification errors require that the specimen be re-collected. These types of errors can delay a patient’s treatment. Errors can be dangerous and even fatal if undetected. Blood banks usually require the following information to be labeled on all of their specimens:
-Patient’s full name, including middle initial
-Patient’s hospital identification number or social security number for outpatients
-Patient’s birth date
-Date and time of collection
There are several different blood bank identification systems that can be used. ID bracelets are commonly attached to the patient’s wrist and used to identify the blood specimen to the patient. The patient’s identity is confirmed and written on the bracelet, that also has a special and unique ID number. A carbon copy of the information is retained on the bracelet and the original copy can be removed and attached to the blood sample. This helps to identify the correct specimen to the right patient. There are certain protocols that each blood bank may require in addition to this specific protocol.
Blood donors are often recruited for transfusion purposes. There are specific guidelines that blood banks must follow when collecting blood from donors. These guidelines are put into place to ensure quality and standardization. All blood banks are regulated by the United States Food and Drug Administration because blood products are classified as being pharmaceutical.
Blood donors must be at least 17 years old. Most donors are not older than 66 years old unless the blood bank physician approves. Donors must meet specific weight requirements. They must be at least 110 lbs. Minors who would like to donate blood must have written permission from their parents. Every potential blood donor must undergo a brief physical examination and complete medical history. This is important to determine the patient’s health. This information is collected each time a person donates blood no matter of frequently. Any information disclosed by the donor should be kept in strict confidence. Every donor is required to provide written permission for the blood bank to use any blood that is collected.
There are certain collection principles that should be followed when collection blood from a donor.
-Donor blood should be collected from the large antecubital vein.
-The collection unit should be sterile, in a closed system that contains a bag connected to a length of tubing with a sterile 16 to 18 gauge needle.
-The bag should be placed lower than the patient’s arm.
-Each donor unit usually contains about 450 mL of blood when full.
-Only one needle puncture can be used to fill a unit.
-Partially filled units are not acceptable. If a unit is partially filled the procedure must be repeated with an entirely new unit.