c3-PATIENT INTERVIEW.docx

PATIENT INTERVIEW ================= Patient adherence ----------------- Some tests have specific pre-collection requirements (fasting, medication administration, avoiding specific foods or beverages, specific time of blood collection). Depending on the work setting, you might be able to explain th...

PATIENT INTERVIEW ================= Patient adherence ----------------- Some tests have specific pre-collection requirements (fasting, medication administration, avoiding specific foods or beverages, specific time of blood collection). Depending on the work setting, you might be able to explain these testing requirements to the patient. Some patients arrive at the laboratory with instructions from the provider. It is important to know which tests have requirements so you can discuss this with the patient. You might encounter patients who arrive for blood collection without adhering to the testing requirements. If this happens, consult with the provider. If the test needs to be rescheduled, be sensitive if the patient becomes upset or angry. Use good communication skills to de-escalate the situation. Review the testing requirements and directions, making sure to use terms the patient understands. Encourage the patient to ask questions. Having the patient repeat the directions helps verify understanding. The following are the most common pretesting preparations: - **Fasting:** Some tests require that the patient fast before a test. Often, the patient may not eat or drink anything other than water for 8 to 12 hr. prior to blood collection. Unless the patient\'s condition or procedure expressly prohibits it, encourage the patient to drink water to facilitate hydration, which helps with finding viable venipuncture sites. Some tests allow the patient to drink black coffee or tea. - **Medication:** Some tests determine the effectiveness of a medication. Patients should take the medication at a predetermined time or write down what time they take the medication. Patients then have specific times for the collection of blood or urine. Providers decisions regarding treatment and care often rely on the accuracy of the timing. So when performing a venipuncture for these tests, it is important to collect the specimen at the correct time. - **Basal state:** This is based on the patient lifestyle and overall condition. Specimens are typically collected first thing in the morning, after refraining from eating or exercising for 12 hr. This preparation is necessary when the provider wants to establish reference ranges. Exercise and food can affect test results. Be sure to determine what a fasting basal state means for each patient and adjust the time of collection appropriately. For example, if the patient works a night shift, ((first thing in the morning\" is when the patient leaves work, which would not be the ideal time to do a collection that requires a basal state. Clarification of the patient\'s lifestyle or work habits is needed to appropriately schedule appointments. Before performing a venipuncture, determine whether the patient has adhered to the requirements for the test. Question patients using terminology they understand. For example, you might say, "Have you had anything to eat or drink?\" Some patients do not fully understand the term fasting but might respond "yes\" because they think the phlebotomist is seeking a positive answer. The patient should provide an exact time any medication (legal, illegal, over-the-counter, or prescription) was last taken. Some patients do not know what the basal state is, so questions such as, "What time did you wake up?\" or "When did you last have anything to eat or drink?\" or "Did you exercise today?\" help confirm basal state status. Accurate test results depend on the patient adhering to essential pretesting requirements. Patient interview ----------------- After determining that the patient has met pretesting requirements, you are ready to proceed with the patient interview. Ask questions to prevent or manage any predictable complications during the collection process. A major consideration is whether the patient has allergies to any of the supplies or equipment to be used. Because allergies to latex and adhesives are common, some facilities only use hypoallergenic tapes and adhesives. However, some syringes, tourniquets, and gloves still contain latex. If your facility uses these products, ask patients if they have a latex allergy. Many patients offer this information if they know they have reactions to particular substances, but others might be anxious or forget to mention the allergy. Another factor is whether the patient has ever felt faint or fainted during a blood collection. Some people are susceptible to syncopal reactions at the sight of blood. Patients who are fasting are also prone to low blood sugar levels, which can lead to fainting. Reclining chairs or examination tables can be used when performing the procedure instead of the routine phlebotomy chair. The locking arm on the venipuncture chair also offers some fall prevention. Nausea and vomiting are also potential reactions to procedures. Have facial tissues, washcloths, wipes, and a trash receptacle available at all times for patient use and a biohazard container available for disposal of potentially biohazardous substances. Asking questions related to these areas means you can be proactive toward many situations. It can be helpful to engage the patient in conversation throughout the procedure. This can offer enough distraction to prevent fainting or other complications. If the patient does feel faint, stop the procedure. Have the patient lower their head and take deep breaths. Loosen any tight clothing around the neck and apply a cold compress on the forehead or the back of the neck. Allow plenty of time for recovery before allowing the patient to stand. Observe the patient for at least 15 minutes following the episode. Make sure to complete the necessary documentation of the incident. Patients who lose consciousness and do not respond right away require emergency intervention from a rapid response team. Choosing the correct location is an important component of the procedure. If a patient has had a mastectomy, applying a tourniquet to the arm on the side of the surgery could affect the lymph nodes on that side, causing swelling, injury, or infection. If the patient has had mastectomies on both sides, you might have to use a vein on the back of the hand or on the wrist. Tourniquets and manipulation of the arm can also damage or dislodge a central venous access port (a device for receiving fluids or medications into a large vein) or an arteriovenous fistula or shunt (an access point a surgeon creates so that a patient can receive hemodialysis treatments). In inpatient settings, one arm might have an intravenous infusion. Other limitations include an arm cast, scarring, burns, or thrombosed veins. Thrombosed veins feel like a rope cord upon palpation, roll easily, and are not advisable to use for venipuncture. Ask the patient which arm they prefer you use. Some patients prefer a venipuncture in their nondominant arm; others might say that previous blood collections have been unsuccessful in one arm and suggest using the other. Always ask these questions to maximize safety and minimize injury. Obtaining information on current medications alert you to additional concerns that might require specific precautions. Many medications-both over-the-counter and prescription-can lead to complications. You are not expected to have a thorough knowledge of all of them, but an understanding of common medications and classification is needed. For example, a patient taking an anticoagulant is likely to require additional precautions to prevent excessive bleeding. Medications also can affect test results. For example, acetaminophen can falsely elevate levels of liver enzymes, and some blood pressure medications can affect glucose, sodium, and potassium levels. Generally, providers interpret the results accordingly. Other factors that can affect testing include alcohol use, cigarette smoking, and exercise. Alcohol can affect coagulation activation and platelet reactivity, especially in patients who have diabetes mellitus. If you suspect that the patient is intoxicated, note this in the medical record so the provider can consider it when interpreting the test results. Patients who have been fasting might not realize that sugar in chewing gum could affect test results. Smoking elevates several coagulation factors, and vigorous exercise causes coagulation activation. If you think the patient has recently exercised, the patient should rest for 15 to 30 minutes before blood collection. Document these factors for the provider to review. Patient education ----------------- Patient education is straightforward and easy to integrate into the procedure. Tell the patient what is going to happen and why. This helps lessen patient anxiety. Reviewing the specific order and tests being conducted with the patient ensures accuracy in interpreting the order or requisition form. Further conversations regarding complications depend on patient risk factors. Patients having their first venipuncture can experience additional nervousness. Explain the procedure using terminology the patient can understand and answer questions before beginning the procedure to minimize these reactions. If a patient has never had a venipuncture, explain the procedure by doing the following: - Discuss the steps of the procedure: examining and preparing the site, positioning the tourniquet, inserting the needle, filling the blood tubes, and applying a bandage to the venipuncture site after obtaining the blood and removing the needle. - Inform the patient that they will feel a slight bit of pain, like a pinprick, when the needle is inserted and possibly while the tubes fill. Never promise that the procedure will not hurt; pain is a subjective experience, and patients have varying levels of pain tolerance. - Tell the patient to say something immediately if they have severe pain or feel sick. - Explain the complications of venipuncture (hematoma, infection, prolonged bleeding, serious pain) and what to do if they occur. Be careful not to give too much information. Most of these complications are relatively rare, and there is no need to frighten patients with specifics. Although uncommon, there are complications you must recognize and respond to appropriately. Possible complications include the following: - **Excessive bleeding or bruising:** A little bleeding after venipuncture is common. Always apply pressure to the venipuncture site or have the patient do so until there is no evidence of additional bleeding. A little bruising is also normal. A bruise that expands to approximately the size of a 2 x 2 gauze pad indicates continued bleeding under the skin. If that same gauze becomes soaked with blood, the bleeding is excessive and warrants medical attention. Apply pressure and ice until the patient receives further evaluation by the provider. - **Severe pain or lack of sensation:** The patient should be evaluated further for severe pain, numbness, or tingling in the venipuncture arm after the procedure. This can indicate nerve damage from the procedure. If the patient feels an electric-like shock or pain radiating down the arm and into the hand during the procedure, remove the tourniquet, remove the needle, and apply pressure to the site. Ice can also be used, depending on facility policy. The risk of nerve involvement is increased when drawing from the basilic vein because it lies close to the median nerve. - **Infection:** If the area around the venipuncture site becomes red, swollen, and painful, the patient might have an infection. Hematomas can also evolve into infections. Infections do not occur immediately after the procedure. Alert patients to these signs and to contact their provider if they appear. Give patients time to ask questions at the end of the procedure. Advise patients to seek medical advice if any unusual symptoms occur following venipuncture.