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Case Study #1
Huge quantities of blood are often collected from critically ill patients in the intensive care unit (ICU). Several studies have shown that iatrogenic blood loss due to laboratory testing can result in increased number of hospital deaths due to stress on the cardiovascular and respiratory systems. As an example, Anthony, and 80-year-old man with a massive heart attack, was admitted to the ER and then the ICU. The first laboratory tests were ordered in the ER for CK and Troponin T and other cardiac assays. Also, a CBC was ordered and coagulation tests. Over the next few days, Anthony developed complications, and as each specialist was consulted, more blood tests were ordered. Blood was collected with each order. After a week in the ICU, a STAT laboratory requisition for type and cross-match of two units of packed red cells was received in the laboratory. Anthony had developed iatrogenic anemia.
1. Which vacuum collection tube cannot be used to collect for the CK, Troponin T, and other cardiac assays since it contains fluoride, an additive that could destroy the analytes and thus interfere with their testing?
2. Which vacuum blood collection tubes should be used for collection of blood for the CBC and coagulation studies? What is important to remember about filling these tubes?
3. Which vacuum blood collection tube should be used for collecting the blood to go to the blood bank for type and cross match?
4. What is iatrogenic anemia, why did it develop, and how could it have been prevented in this patient?
Case Study #2
George, an experienced health care worker, was closing the clinic just as the last patient showed up to have her blood collected for some routine laboratory work. The patient apologized for being late and mentioned that she was diabetic and had to stop for an insulin injection prior to arriving. The health care worker proceeded to get the appropriate forms, requisitions, and supplies ready for the venipuncture procedure. The patient preparation and assessment, identification, and site selection process took place without incident, and all was going smoothly until the actual venipuncture occurred into the basilic vein area. Suddenly the patient screamed out in pain and could hardly sit still. George responded ‘I know it hurts a little, but if you just wait a few moments, I will be finished with the procedure shortly’.
1. What is the most likely cause of the patient’s pain? Hint: why is the basilic vein usually avoided?
2. What should George have done when the pain occurred? What should he do now?
Case Study #3
A 55-year-old woman came to have some routine blood tests performed by the skin puncture method. She told the health care worker that she had a mastectomy on her right side about 15 years ago.
1. Where should the health care worker perform the fingerstick? (be specific)
2. Why should the health care worker consider the information about the mastectomy important?
Case Study #4
A precocious 5-year-old patient was being seen in a pediatric clinic. The young girl was to have a blood specimen collected for hematology tests. The patient told the health care worker that she hated needles. The health care worker considered which type of blood collection method she should use for this patient.
1. What are the options for this patient?
2. What are the pros and cons for each possible method?
3. Which method would you choose and why?
Case Study #5
Ellen was collecting a blood specimen for a new patient. She performed the venipuncture procedure correctly and after completion of the procedure, she shook the tubes to mix the additives. She labeled them properly and delivered them to the laboratory. A few hours later, as Ellen was looking for test results on the specimen that she collected, she saw the comment that the specimen had been hemolyzed. She followed up to see if the patient had been punctured again for a second specimen. The health care worker assigned to the floor had performed the recollect and delivered the specimen to the laboratory.
1. What mistake did Ellen make after collecting the blood specimen?
2. How could this be prevented in the future?
3. What should the patient be told about the recollect?
Case Study #6
A 90-year-old former industrial worker who has lost 30 pounds over the past 4 years, resulting in a frail body, is having his blood collected in the nursing home where he now resides. His physician has ordered a potassium level, a hemoglobin level, and a PT/INR tests because the patient is on Coumadin.
1. What is the proper order of draw for the collection of blood for these assays?
2. What is the most appropriate blood collection equipment to use?
3. How should the patient be approached for the blood collection considering his age?
Case Study #7
A patient has been sent to the laboratory by his physician to have a three-hour glucose tolerance test performed. When he arrives at 10:30 am, the health care worker asks him if he has fasted overnight and been on the prescribed carbohydrate diet for the preceding days. The patient states that he has followed the one-day diet plan and has not eaten or had anything to drink since 9pm last night. He had only one cigarette this morning around 8:15 and a cup of black coffee, no sugar.
1. Did the patient follow the proper protocol for the diet plan preceding the glucose tolerance test? What is the protocol that should be followed for the diet plan preceding the glucose tolerance test?
2. The glucose tolerance test requires fasting overnight. Did the patient follow the fasting procedure properly? Explain
Case Study #8
A 50-year-old woman is scheduled to have a hysterectomy later in the week. She is at the hospital for preoperative laboratory work and a chest x-ray. The nurse and phlebotomist are both in the room with the patient. The nurse is conducting a nursing assessment and reveals to the patient that the chest x-ray is abnormal. At the same time, the phlebotomist is ready to collect a blood specimen. Both health care workers can use a computerized handheld data-entry system to access information and to enter information about the patient in an electronic format.
1. Is it okay for the phlebotomist to collect a blood specimen while the nurse is conducting a health assessment? Explain
2. Is this situation acceptable? If not, give some suggestions about how to improve it.
Case Study #9
A health care worker in the ambulatory outpatient clinic was checking in an elderly outpatient for blood collection who indicated that she has been on Coumadin (a blood thinner) therapy for the past seven months.
What precautions should the health care worker take for this patient when collecting her blood?
Case Study #10
Sharon had been on the job for only 8 months. She was a health care worker at a rural hospital in the southwest where she had been hired to do early morning blood collections and deliver specimens to the centralized laboratory. She was tired when she went to work one Friday morning. She drew blood from a frail middle-aged man, Mr Gilmore. She had trouble with the collection procedure in that she had to stick him twice before she acquired the blood specimen. Sharon was relieved when she finally finished the procedure. As she began to clean up and discard the used equipment, she noticed that the biohazard container was full. She decided, however, that it could probably hold the needles she had used on Mr. Gilmore. She used her finger to push the used needles and needle holders into the container and she felt a sharp puncture. She realized that she had stuck herself with a contaminated sharp object. She gathered the specimens she had drawn and quickly left. She immediately reported the injury to her supervisor.
1. Describe what Sharon did correctly and incorrectly.
Which procedures would need to be reviewed with Sharon