CDC 4N051_M07_Transcript Vital Signs and Monitoring

Lesson 4 of 10 Lesson 4- Measure and Record Parameters After completing this lesson, the student will be able to measure and record parameters in accordance with prescribed guidance and publications. Perform Orthostatic Vital Signs Blood pressure will fall in relation to the patient’s position. It w...

Lesson 4 of 10 Lesson 4- Measure and Record Parameters After completing this lesson, the student will be able to measure and record parameters in accordance with prescribed guidance and publications. Perform Orthostatic Vital Signs Blood pressure will fall in relation to the patient’s position. It will change from when the patient is lying, sitting, or standing. The normal difference in systolic pressure tends to be no greater than 15 mmHg lower than it was in a reclining position. The diastolic pressure may fall 10 mmHg from the lying position. This change is not noticeable in most individuals. Internal receptors make rapid adjustments to compensate for the changes in blood volume distribution. For some individuals, the pressure may drop more rapidly. This is known as postural hypotension or orthostatic hypotension. This could be a result of several factors such as circulatory problems, dehydration, or medication effects. When the provider suspects the patient has a low blood volume or possible dehydration, he or she may ask for orthostatic vital signs to be taken. Orthostatic vital signs are done by taking the blood pressure and pulse with the patient in the lying, sitting, and standing positions (in this order), and waiting three minutes between the positions. Signs and symptoms to immediately report to the nurse or provider are: decrease in blood pressure, significant increase in pulse rate, fainting, blurred vision, and/or lightheadedness. Treatment for postural/orthostatic hypotension may include intravenous therapy or blood transfusion therapy. 1. Place patient in supine position A. Record patient’s pulse. B. Record patient’s blood pressure. C. Record patient’s position. D. Wait 3 minutes. 2. Place patient in sitting position A. Record patient’s pulse. B. Record patient’s blood pressure. C. Record patient’s position. D. Wait 3 minutes. 3. Place patient in standing position A. Record patient’s pulse. B. Record patient’s blood pressure. C. Record patient’s position. 4. Present patient’s orthostatic vital signs to the  provider. Ensure the patients legs remain uncrossed for each position. C O NT I NU E Neurologic Checks There will be times when you have to perform a neurologic exam in the field, clinic, or inpatient unit. Neurological checks are commonly performed on any patient who has had a head injury, a neurological problem such as a seizure, or complains of neurological symptoms such as weakness, numbness, or tingling in a particular area of the body. The following steps are completed: 1 Identify the patient’s mental orientation to person, place, and time. This is generally completed by asking the patient to state his or her full name; the month, day or year; name the current President or a relevant question the patient should be able to answer. Keep the patient’s age in mind when doing this. A 3 year old probably won’t be able to tell you who the president is but can probably point to or name an appropriate toy or parent. 2 Check the pupils and determine if they are of equal size. This should be done with lights dimmed to allow the pupils to dilate. It is easier to identify difference in pupil size if they are dilated instead of pinpointed. Measuring the size will help to identify an increase in intracranial pressure which, when extreme, will cause one or both pupils to dilate. 3 Check pupil response to light by using a pen light and slowly bring the light from the lateral side of the head and shine it in one eye. The lights dimmed here as well. Quickly remove the light and repeat the action on the other eye. You should see the pupil constrict quickly when the light is shined in the eye, and then it should return to its former size when the light is removed. 4 Using the same procedure as above, shine the light in one eye and watch the other eye. You should see pupillary reaction and consensual reflex. This means that both eyes’ neurological functions are working together and can be seen when both pupils react and become smaller when light stimulates either eye (one eye at a time). Let the pupil return to its former size and repeat the process with the other eye. It should only take a few seconds for the pupil to return to its former size. Both pupils should react quickly and simultaneously regardless of which eye the light is shined into. Sluggish or unequal responses should be reported to the provider immediately, as this may be an indication of rising intracranial pressure. 5 Check extraocular movements strength of the eye muscles by having the patient follow an object or your finger as you move your hand from side to side, up and down, and diagonally. Watch to see if the patient’s eyes move together with smooth movements. Report lack of synchronous movement or nystagmus (jerking or bouncing movement of the eye). 6 Ensure the patient can follow simple commands, such as touching his or her nose with the left index finger or rotating his or her foot counterclockwise. The ability to appropriately follow commands lets you know that the patient’s cognition and motor pathways are intact. 7 Test upper and lower extremity strength by performing the following movements. Have the patient squeeze your fingers (index and middle fingers) with both hands (ensure you have your fingers crossed or it may hurt!). Push his or her feet against your hands. With his or her arms straight in front, have the patient push down on your hands and then resist as you push down on his or her forearms. Weakness may signal a brain or spinal cord injury. 8 For an unconscious patient, you may need to use painful stimuli in order to identify their cognitive state. Press on the area near the base of a fingernail with a hard object and observe whether the patient withdraws from the stimulus or displays flexion or extension posture. You may also apply pressure with two fingers in a grasp position on the patient’s trapezius muscle and look for the same patient responses previously mentioned. Additionally, The Glasgow Coma Scale is a great tool to rank their condition. 9 Report and document all findings. Describe and report any abnormal findings. Pupil gauge (mm) C O NT I NU E Perform Pulse Oximetry/Oxygen Saturation Pulse Oximetry/Oxygen Saturation - A noninvasive method commonly used today to rapidly determine pulse and oxygen profusion is the pulse oximetry/oxygen saturation device. This is another method used to monitor the function of the respiratory system. The oximetry machine measures the amount of arterial blood that is saturated with oxygen in the body by measuring the percentage of hemoglobin (blood) that is bound with oxygen. A sensor or probe is attached to the patient in an area where the red light and infrared on the sensor can reach a capillary bed. Oxyhemoglobin will absorb more infrared than red light, and a microprocessor will use this information to compute an oxygen concentration value. This value can then be read on the monitor screen. The sensor can be placed in areas such as a fingertip, earlobe, toe, or even the bridge of the nose. Depending on the type of pulse oximetry you are using, you may need to turn the unit on or it may start as soon as you place it on the patient. Because ulcers can develop from consistent use, turn the sensor every two hours. Always make sure that you check the patient when you are taking any reading from a monitor. Some people with chronic lung disease have adapted to pulse oxygen concentrations that would have most of us gasping for breath. Report any readings below 95% or observation of a patient who appears to be in any respiratory or circulatory distress immediately. A clinical emergency is identified when an oxygen saturation level is less than 90%. C O NT I NU E Performing Intake and Output R E C O R DI N G I N TA K E I N T R AV E N O US F L UI D R E C O R DI N G O UT PUT Any liquid must be recorded in the patient's chart under the intake category. The correct measurement for liquids is milliliters. Many healthcare facilities will list dietary amounts for certain dishes that may not have labeling provided. R E C O R DI N G I N TA K E I N T R AV E N O US F L UI D R E C O R DI N G O UT PUT Any fluid that is given to the patient is also recorded as fluid intake. During shift change over, ensure to discuss if any IV fluids are currently being infused and how much has been infused. Another bag of fluid may be needed during the shift which will require you to include the amount infused from the previous bag. For example, if at shift change 400 mL was left in the old bag and during the course of the shift 200 mL was infused from the new bag. Then a total amount that was infused during the work shift was 600 mL. Keep in mind, this is only for fluids that are infused intravenously, any type of blood productions will be documented in a different category. R E C O R DI N G I N TA K E I N T R AV E N O US F L UI D R E C O R DI N G O UT PUT Urine is considered fluid output which is recorded. To measure urine, pour fluid into a measuring container, place on a flat surface and read at eye level. For patients that have a urine bag, empty prior to being full or at least once per shift. If a patient is ambulatory, inform them about saving the urine by providing a collection container. All amounts will be documented in the output section. Other types of output – Drainage from other sources such as chest tubes, wounds or nasogastric tubes are also considered output, which will need to be recorded as well. If the patient is sweating profusely, make a note in the output record. If a patient is experiencing diarrhea, the liquid stool can be measured in a process similar to measuring urine. Emesis will be measured the same way. Monitoring and documenting intake’s and output’s is the responsibility of the aerospace medical technician and the registered nurse, you do not need a doctor’s order to initiate the process.  Daily Totals – The daily average adult will have a urine output of 1000 mL to 1500 mL, however, if the urine output is less than 720 mL in 24 hours or less than 30 mL per hour either the charge nurse or provider should be notified. (Williams, P.A., 2017) Multiple Choice A clinical emergency is identified when an oxygen saturation level is less than _____%. 70% 80% 90% 100% SUBMIT Complete the content above before moving on. Body Weight and Abdominal Circumference For an accurate body weight measurement, the individual must be weighed on scales that are calibrated properly. The frequency for calibration varies, depending on the manufacturer’s recommendations and current Air Force guidance. The individual’s weight is determined with his or her shoes off and dressed in any standard duty uniform. Have the individual remove all contents from pockets and any extraneous equipment or outer clothing. When reading the measurement, stand either directly in front of or behind the scale. Reading the scale from either side rather than straight on reduces accuracy. Subtract three pounds for clothing and record the result to the nearest quarter pound. As you know, many medications are calculated and administered based on the patient’s weight in kilograms (kg); therefore, you must be able to convert pounds to kilograms. When converting pounds to kilograms, remember, 1 kg = 2.2 lbs. When measuring the abdominal circumference during a physical exam, medical providers will utilize a body mass index to determine if the patient is at risk. A body mass index (BMI) is based off the individual’s height and weight. However, at times, a waist circumference can be used as another determining factor calculating risk. For example if a woman’s waist is greater than 35 inches and a man’s waist is greater than 40, they are at greater risk for disease. C O NT I NU E Perform Spirometry/Pulmonary Function Testing Spirometry is accomplished when required as part of an occupational physical examination or whenever clinically indicated and requested by a health care provider. It is most useful for evaluating losses in respiratory function and following the course of certain respiratory diseases. Although spirometry cannot provide a specific diagnosis, it can distinguish between obstructive pulmonary disease involving increased airway resistance (such as chronic bronchitis or asthma) and restrictive disorders involving a decrease in total lung capacity due to structural or functional changes in the lungs such as tuberculosis or polio). To help you understand the calculations of spirometry, you will first study the respiratory volume of the lungs, followed by an explanation of the procedures for calculating the PFT and, finally, the actual testing procedures. From studying anatomy and physiology in this course, you should already have a fairly good idea of what the respiratory organs are and how they function. In this section you will learn how to identify abnormalities in the respiratory system using spirometry. First, take a look at the principles behind spirometry by studying the volume of air that circulates through the respiratory system. This will help you understand exactly what you should be looking for during spirometry. Respiratory Volumes and Capacities The amount of air that travels in and out of the lungs varies substantially depending on the conditions of inspiration and expiration. Consequently, several different respiratory volumes can be described. Specific combinations of these respiratory volumes, called respiratory capacities, are measured to gain information about a person’s respiratory status. The volumes are measured with a device called a spirometer. R E SPI R AT O R Y V O L UME S R E SPI R AT O R Y C A PA C I T I E S DE A D SPA C E The respiratory, or lung volumes include tidal reserve, inspiratory reserve, expiratory reserve, and residual volumes. During normal quiet breathing, about 500 ml of air moves into and out of the lungs with each breath. This respiratory volume is referred to as the tidal volume (TV). The amount of air that can be inspired forcibly beyond the tidal volume (about 3,100 ml) is called the inspiratory reserve volume (IRV). The expiratory reserve volume (ERV) is the amount of air, normally 1,200 ml, which can be evacuated from the lungs after a tidal expiration. Even after the most strenuous expiration, about 1,200 ml of air still remains in the lungs; this is the residual volume (RV). Residual volume air helps to maintain alveolar patency and prevent lung collapse. R E SPI R AT O R Y V O L UME S R E SPI R AT O R Y C A PA C I T I E S DE A D SPA C E The respiratory capacities include inspiration capacity, functional residual capacity, vital capacity, and total lung capacity. As noted in the following paragraphs, the respiratory capacities always consist of two or more lung volumes—inspiratory and vital capacities. Inspiratory Capacity - Inspiratory capacity (IC) is the total amount of air that can be inspired after a tidal expiration; thus, it is the sum of the tidal and inspiratory reserve volumes. Functional Residual Capacity - Functional residual capacity (FRC) is the combined residual and expiratory reserve volumes and represents the amount of air remaining in the lungs after a tidal expiration. Vital Capacity - Vital capacity (VC) is the total amount of exchangeable air. It represents the sum of the tidal, inspiratory reserve, and the expiratory reserve volumes. In healthy young males, the VC is approximately 4,800 ml. Total Lung Capacity - Total lung capacity (TLC) is the sum of all lung volumes and is normally around 6,000 ml in males. Average lung volumes and capacities (with the possible exception of vital volume) tend to be slightly less in women than in men because of their smaller size. Total lung capacity (TLC) is the sum of all air in the lungs after maximal inhalation. R E SPI R AT O R Y V O L UME S R E SPI R AT O R Y C A PA C I T I E S DE A D SPA C E Some of the inspired air fills the conducting respiratory passageways and never contributes to gas exchange in the alveoli. The volume of these conduits (area in and around the nose, pharynx, larynx, trachea, and bronchial tree), which make up the anatomical dead space, typically amounts to about 150 ml. A general rule of thumb is that the anatomical dead space volume in milliliters in a healthy young adult is equal to the person’s weight in pounds. With a tidal volume of 500 ml, only 350 ml of this is involved in alveolar ventilation. The remaining 150 ml of the tidal breath is in the anatomical dead space. If some of the alveoli cease to act in gas exchange (due to alveolar collapse or obstruction, for example) the alveolar dead space is added to the anatomical dead space, and the sum of the non-useful volumes is referred to as total dead space. Calculating the Pulmonary Function Test Since spirometry illustrates the various respiratory volumes and capacities, examiners can readily identify potential disease processes. For example, increases in TLC, FRC, and RV could occur as a result of hyperinflation of the lungs in obstructive disease, whereas VC, TLC, FRC, and RV are reduced in restrictive diseases that limit lung expansion. Much more information can be obtained about a patient’s ventilation status when the rate of air movement in and out of the lungs is assessed. The two primary tests measured in the physical exam arena are the forced vital capacity (FVC) and forced expiratory volume (FEV). The measured values are then compared against predicted normals based on the individual’s sex, height, and age. FVC measures the amount of air expelled when a patient takes a deep breath and then forcefully exhales maximally and as rapidly as possible. FEV determines the amount of air expelled during specific time intervals of the FVC test; for example, the volume exhaled during the first second is forced expiratory volume at one second (FEV1). Those with healthy lungs can exhale about 80 percent of the FVC within one second. Those with obstructive pulmonary disease have a low FEV1, while restrictive disease produces a low FVC. According to AF standards, abnormal functions are present when the FEV1 or FVC is less than 80 percent of the predicted or the FEV1/FVC percent is less than 70 percent. The examinee must make a full inspiration before the forced expiration, put forth a maximal effort, and continue expiration for at least five seconds or until an obvious plateau in the volume-time curve has occurred for the tracing to be acceptable. Have the examinee make two practice attempts before three further tracings are recorded and assessed for acceptability. In assessing for acceptability, reject any attempts marred by coughing, or if the variation between the two largest FVCs of the three satisfactory tracings exceeds 10 percent. Annotate the results on the Air Force Form 1226, Pulmonary Function Studies. Testing Procedures There are various spirometers available, but each must meet the general guidelines outlined in DAFMAN 48–123, Medical Examinations and Standards, to constitute an acceptable spirometer. However, the procedures for accomplishing the test are basically the same. The procedure must be explained to the examinee in simple terms. A statement that the examinees will be tested on “how hard and how fast they can breathe” may not be physiologically precise, but it may be the only explanation necessary. The procedure should be described on how deep a breath to take and how hard and fast to exhale. Meanwhile the proctor should also demonstrate the instructions. Before administering the test, find out if your patient has smoked, eaten, or has recently had a respiratory tract infection. At least one hour must have passed since the examinee has either smoked or administered a bronchodilator and at least two hours since his or her last meal. If the examinee is acutely ill or has experienced an upper or lower respiratory tract infection during the previous three weeks, postpone the test. To properly accomplish this test, instruct the examinee to do the following tasks: 1 Remove any constrictive clothing or dentures and stand in front of the spirometer. 2 Place a nose clip on his or her nose, keeping it firmly there (this is very important). 3 Take the deepest possible inspiration from a normal breathing pattern to close his or her mouth firmly around the mouthpiece (i.e., maintain an air-tight seal around the mouthpiece) and blow into the apparatus as hard, fast, and completely as possible. Predicted Values To determine predicted values, use the formulas in DAFMAN 48–123. There you will notice four spirometric standards: one for Caucasian females, one for Caucasian males, one for females of other races, and one for males of other races. Make sure you are using the correct one! After ensuring you are about to use the correct nomogram, align a straight edge across the two known factors of height and age. The points where the straight edge crosses FEV1 and FVC will give you the predicted normals for each category. It must be pointed out that the FVC and FEV1 of nonCaucasians is about 15 percent lower than in Caucasians of the same age and height; differences in the FEV1/FVC percent are not significant.  Make allowances for these ethnic differences during evaluations to avoid serious errors in interpretation. In non-Caucasians, multiply the predicted FEV1 and FVC for any given person by 0.85 to adjust for this 15 percent difference. You do not have to make this adjustment or correction for the FEV1/FVC calculation. Once you have determined the predicted value, record it on AF Form 1226. Multiple Choice The volumes are measured with a device called a __________. pulmonary spirometer forced vital capacity forced expiratory spirometer SUBMIT Complete the content above before moving on. Perform 12-lead Electrocardiogram (ECG) You should be familiar with the anatomy of the cardiovascular system from the previous study where you learned how the electrical impulses stimulate the heart. Now you will review the electrophysiology briefly, and learn about the tracing and how to prepare your patient for his or her electrocardiogram. The crescent-shaped sinoatrial (SA) node, a small cell mass with an enormous job, is also known as the pacemaker. The SA node initiates the stimulation of the heart muscle to contract with electrical stimulation. Located in the right atrial wall, just inferior to the entrance of the superior vena cava, the SA node typically depolarizes spontaneously at the rate of 70–80 times every minute. However, its inherent rate - in the absence of hormonal and neural factors - is around 100 times per minute. Because no other region of the conduction system or the myocardium has a faster depolarization rate, the SA sets the pace for the heart as a whole, determines its characteristic and sinus rhythms, and determines our heart rate. The cells in the heart are negatively charged, or polarized, in the resting state. When the heart muscle is stimulated electrically by the SA node, both atria contract (depolarization). Think of this depolarization as an advancing wave of positive charges. The stimulating progressive wave continues until it reaches the atrioventricular (AV) node located in the inferior portion of the interatrial septum immediately above the tricuspid valve in approximately 0.04 seconds. The impulse is delayed momentarily (for about 0.1 seconds) at the AV node, allowing the atria to respond and complete their contraction. At this time the cells in the atria regain their negative charge, or repolarize. The electrical impulse passes from the AV node down the AV bundle (Bundle of His) to the left and right bundle branches, and then to the Purkinje fibers, which complete the pathway through the interventricular septum and penetrate into the heart apex and turn superiorly into the ventricular walls. The cells within will become charged positively (i.e., depolarized) once stimulated, causing simultaneous contraction of the ventricles. Because the left ventricle is much larger than the right, the Purkinje network is more elaborate in that side of the heart. Electrophysiology of the Heart The electrical currents generated and transmitted through the Once the patient has been prepared properly, you are ready to run the ECG. heart also spread throughout the body and can be monitored Ask the patient to lie still and breathe normally until the end of the with an instrument called an electrocardiograph. The graphic procedure. Ask the patient to withhold speaking or crossing the legs or arms recording of electrical changes during heart activity is called an until the test is finished. (Speaking or crossing the legs or arms may cause electrocardiogram, or simply an ECG or EKG. Twelve standard artifact or an improper reading). leads are used to record an ECG. Three of these are bipolar leads that measure the voltage difference between the arms, or an arm and a leg, and nine are unipolar leads. Together the 12 leads provide a fairly comprehensive picture of the electrical activity of the heart. Although it’s referred to as the 12 lead placement, an ECG only uses ten electrodes for reading. Some electrodes form a pair, which provides this tool with two leads. The electrodes are selfsticking pads containing a conducting gel at their centers. On the other side, the electrodes snap onto the ECG’s or heart monitor’s connected cables. The ECG shows a glimpse of the electrical activity taking place inside the heart and does this from a particular angle. Therefore, the ten electrodes in the 12 lead ECG give 12 perspectives of the heart’s electrical activity at a given time, using various angles. A typical ECG consists of a series of three distinguishable waves called deflection waves. The first wave, the small P wave, lasting about 0.08 seconds, results from movement of the Be sure to tell the patient when you are done running the test so he or she will feel free to talk or ask questions. It is normally a good idea to have a provider look at the ECG tracking before you remove all the equipment in the possible event it needs to be repeated. By measuring the various waves, complexes, interval, and electrical voltage, a trained person can determine the rate, rhythm, and axis of the heart, along with any evidence of myocardial hypertrophy or infarction. These determinations, along with other portions of the cardiovascular examinations (blood pressure and auscultation, for example), will give an overall picture of the person’s cardiovascular status. However, although the ECG presents an accurate picture of the electrical activity of the heart, it should not be used as a final determining factor as to a person’s cardiovascular status. Rather, it is used as a starting point for further evaluation and testing if any abnormalities are discovered. Whenever you accomplish an ECG on rated personnel, send an original copy to the United States Air Force (USAF) Central Electrocardiographic Library. (This holds true for any cardiac study done on a rated flyer.) depolarization wave from the SA node through the atria. Approximately 0.1 seconds after the P wave begins, the atria contract. What is the difference between an ECG and EKG? There is no difference; both refer to the same procedure, however one is in English (electrocardiogram – ECG) and the other is based on the German spelling (elektrokardiogramm – EKG). Chest Lead Placement Limb Lead Placement Options Below are the steps to follow when performing an ECG. 1 Prepare the chest and place electrodes in the correct sequence. 2 Connect wires (leads) from the machine to the electrodes. 3 Ask patient to hold still and maintain normal breathing; press the run button. 4 Allow enough paper to run through the machine to allow the patient's tracing to be torn off cleanly. 5 Verify that ECG tracing has no artifact (electrical interference). 6 If tracing is not clear, troubleshoot IAW the manual. 7 Retake the ECG tracing. 8 Turn off the machine. Remove lead wires from the electrodes. 9 9 10 Stabilize the skin, and gently remove electrodes from the patient's skin. 11 Verify all electrodes have been removed. 12 Allow patient to redress, assist if necessary. 13 Route ECG for interpretation. When sending ECGs to the library, remember to comply with the following rules: Complete the patient identification area on the tracing. Affix the tracing firmly to a properly completed optional form (OF) 520, Medical Record- Electrocardiograph Record cover sheet. Send only original tracings. Duplicated copies are unacceptable, as they cannot be placed on microfilm for future reference. Multiple Choice A typical ECG consists of a series of _________ distinguishable waves called deflection waves. three four five six SUBMIT Complete the content above before moving on. Perform Visual Acuity Test Visual acuity is defined as the eyes’ ability to distinguish an object’s shape and details. One of the basic functions of medical technicians is to measure patients’ visual acuity. You must perform this task with a high degree of accuracy and professionalism. Accurate measurements are extremely important for proper patient treatment, medical, and legal reasons. You hear some people’s vision is 20/20 or 20/40. What does all this mean and why do some people see better than others? Why do people need glasses or contacts? When should visual acuities be checked? Let’s find out! It is assessed by the smallest identifiable object seen at a specified distance (usually 20 feet for distance acuity and 16 inches for near acuity). Think of it as a measure of the resolving power of the visual system. It is the ability of the visual system to receive light from images and transmit light to the retina where it is converted to an electrochemical message, transmitted through the visual pathway, and then interpreted by the brain as a visual image. Visual acuity is often confused with visual efficiency. Visual efficiency refers not necessarily to how well one sees but rather how comfortably one sees. Many patients may be able to see the 20/20 line of your eye chart but are reluctant to read it because they may not be seeing it with a great deal of visual efficiency. Some even refuse to read the actual line on the eye chart they can see, figuring if they see too well, nothing will be done about their visual complaint. It may be wise to encourage your patients to read the smallest line they can, even if it is not as comfortable and clear as they would like. Reassure them the provider will still work on helping them achieve better visual efficiency, even if their visual acuity doesn’t seem to indicate a problem. There are refractive errors not necessarily diminishing visual acuity but affecting the patient’s visual comfort. Many factors influence visual acuity. Primary factors are the region of the retina stimulated, illumination, spectral quality of light, contrast, pupil size, time of exposure, patient’s age, condition of the ocular media, presence of ametropias, and individual variations. Region of the Retina Stimulated – The fovea centralis is the area where best vision (under photopic conditions) occurs. The fovea contains only cones, which produce the clearest images. Visual acuity progressively decreases the farther an image strikes the retina from the fovea. This is because the concentration of cones is greatest in the fovea and decreases toward the retina’s periphery. Illumination – Good illumination (photopic) conditions allow the visual system to use the cones in the fovea to process light stimuli. Dim light (mesopic) conditions force people to use a mixture of rods and cones to see adequately. This causes a loss of clarity, as rods do not provide images as sharp as cones. When illumination is very poor (scotopic), the visual system becomes almost completely dependent on the rods for any vision. Rods, while very good at picking up visual images under low light conditions, do not produce very sharp and clear vision. Under scotopic conditions, vision is best when images are placed just outside the fovea. This allows a mixture of rods and cones to process what visual images can be seen. (It’s interesting to note the greatest number of rods per area of retina exists just outside of the fovea.) For example, a very dim star in the night sky may only be seen when you look slightly away from it. This allows the rods to pick up its image. If you look straight at it, it disappears, as the cones are not sensitive enough to process the minute amount of light coming from the galaxy far, far away. Spectral Quality of the Light – The spectral quality of light refers to its color or wavelength. The eye can generally see wavelengths between 400 and 750 nanometers (nm). White light contains all the colors of the rainbow. Some lights are white but have a reddish or bluish tinge to them. Look at the fluorescent lights in your building and you may notice this. Some of the lights will look different from others. The clarity of vision can change due to variations in the spectral quality of the light being seen. Some light has more blue in it; some has more red and so on. This variation, though subtle, does have an effect on visual acuity and efficiency. Some people are sensitive to fluorescent lighting but do fine under incandescent lighting. This is most likely related to their sensitivity to changes in the spectral quality of the light. Contrast – A black letter on a white background is easier to see than a black letter on a gray background. Assuming the same intensity of illumination, visual acuity decreases as contrast decreases. Ever try to read an orange sign with yellow letters on it? It’s tough because the contrast is poor. The two colors are close to each other on the visible spectrum. Now imagine an orange sign with violet letters. The contrast is much better as they are on opposite ends of the visible spectrum, so reading the sign is much easier. Pupil Size – The eye produces aberrations similar to those found in spectacle lenses. Aberrations is the deviation of light rays through lenses, causing images of objects to be blurred. When the pupils are dilated (large), the divergent peripheral light rays previously blocked by the iris are now entering the eye and creating a focusing dilemma for the optics of the eye. A blurred image triggers the brain to signal the eyes to accommodate (focus). One effect of the accommodative response is for the pupils to constrict. The constricted pupils only allow light rays going relatively straight to enter the eye. This reduces the number of deviant light rays striking the retina to improve visual acuity. When you perform the pinhole test, you are using this principle. The pupil’s main job is to regulate the amount of light entering the eye. If it allows too much light in, the photoreceptors (rods and cones) are washed out by light and a poor image is sent to the visual cortex of the brain. If the pupil is too small and not enough light gets in, the cones in the fovea are not adequately stimulated, and the visual cortex must rely on stimulus sent by the less precise rods, again reducing visual acuity. Time of Exposure – If a person is given a long time to analyze an object, more details are assessed as more rods and cones are stimulated. The result is usually good visual acuity. If the time of exposure is short, there is less information being sent to the brain for analysis. The result is generally poor visual acuity. Condition of the Ocular Media – Any abnormality of the ocular media (cornea, aqueous humor, crystalline lens, or vitreous humor) tends to reduce visual acuity. Corneal scars, cells, and flares in the aqueous, cataracts, and neo-vascularization in the vitreous are a few examples of the many conditions degrading one’s ocular media. Age – When you were born, your vision was around the 20/400 level. Your visual acuity progressively improves as you develop. As you continue to age, time and ultraviolet (UV) light take its toll on the cornea, crystalline lens, and retina, causing your visual acuity to diminish. Typically, healthy eyes and good vision are between the ages of 19 and 40. Presence of Ametropias (correctable refractive errors) – Any refractive condition preventing light rays from focusing clearly on the fovea reduces visual acuity. Ametropia is a refractive error (e.g., hyperopia, myopia, and astigmatism). If these refractive errors are not corrected, visual acuity decreases or, at a minimum, visual efficiency suffers. Individual Variations – People are different. Some people have better vision than others for a variety of reasons (e.g., genetics, visual stimulus experienced as a child, personality type, etc.). Not all people see the same even with all other factors being equal. This is due to individual variations. There are many factors involved with the physiology of visual acuity. One of the main factors is ametropias, or refractive problems, of the eyes. Refractive Status of the Eye A ME T R O PI A E MME T R O PI A Ametropias are refractive conditions that are correctable and prevents the eye’s ability to focus light rays on the retina for a clear image, reducing visual acuity. Examples are hyperopia, myopia, and astigmatism. If these refractive errors are not corrected, visual acuity decreases or, at a minimum, visual efficiency suffers. Normally these errors could be corrected by glasses or contact lenses. If they cannot be corrected, the patient may be experiencing blindness. A person with good vision and no refractive error is considered to be an emmetrope or have emmetropia. A ME T R O PI A E MME T R O PI A Emmetropia is a refractive condition in which no refractive error is present and the eye is able to focus light rays on the retina for a clear and crisp image. Distant images are focused sharply on the retina without the need for accommodation or corrective lenses. This is the desired state. The emmetrope may need to accommodate to see near objects. This is normal as it does not cause undue eyestrain. Remember it this way: winning an Emmy is good, so being an emmetropic is good. Testing Visual Acuity Begin by using a Snellen eye chart. Perform during a physical exam and/or perform when there’s an issue with vision. Testing may be done without glasses, followed by testing with (based on provider’s orders). 1 Patient should be placed 20 feet from the Snellen chart. Accuracy of the test is reliant on maintaining the correct distance from the chart. 2 Patients with corrective lenses should keep them on (except reading glasses). Test each eye individually. Cover one eye with an eye shield or an opaque card. 3 Instruct patient to read the smallest line of print possible, reading from left to right. Record the fraction at the end of the last line. Record number of letters missed. Record whether corrective lenses were worn (i.e. 20/50 -2 with contact lenses). 4 Test and record the other eye’s visual acuity. Conduct the test with both eyes uncovered; record the score. 5 If patient cannot read any of the lines even with glasses, position them closer to the chart. The score will be altered to correlate with how far the patient is from the chart. Document results of the tests. Multiple Choice How far away should a patient stand from the Snellen Chart? 5 feet 10 feet 15 feet 20 feet SUBMIT E ND O F L E S S O N Lesson 5 of 10 Lesson 5- Speciman Collection After completing this lesson, the student will be able to assist with specimen collection in accordance with prescribed guidance and publications. Specimen Collection: Cerebrospinal Fluid (CSF) This lesson covers an important task you will perform as an aerospace medical service journeyman—the collection of specimens. No matter whether you work in an inpatient unit, the emergency room, or an outpatient clinic, accurate performance of this task is a must. You are probably sitting there saying, “Another repeated topic from tech school.” That’s true, but the importance of these tasks bears repeating. In this lesson, you will learn several types of collection and the specifics associated with each one. As mentioned in the previous lesson, special tests and procedures can help diagnose and treat medical problems. We will continue on with lumbar puncture. Lumbar puncture, also referred to as a spinal tap or spinal puncture, is the insertion of a needle into the subarachnoid space, usually between the third and fourth lumbar vertebrae. This procedure is performed to aspirate cerebrospinal fluid (CSF). It provides important information about intracranial pressure and the composition of the CSF to aid in the evaluation of some underlying condition. Lumbar punctures are widely used in the diagnosis of bacterial and viral infections, such as spinal meningitis. It is also used in the evaluation of seizure disorders. Keep in mind, the provider will do the procedure. You are responsible for preparing the room and the patient, and assisting the provider with collection and labeling of specimen tubes. Ensure each collection tube is sealed and labeled with the correct information. The procedural steps are below: 1 Take baseline vital signs before the procedure. 2 Obtain equipment needed. 3 Open sterile supplies as requested. 4 Position and drape the patient. 5 Assist the provider.  NOTE: Flight surgeon will likely ground aircrew or special operational members requiring a lumbar puncture for diagnosis, from flying or operational duty for 24 hours or until a diagnosis is made. C O NT I NU E Specimen Collection: Cytology As a medical technician, specimen collection is one of many important tasks you will perform. Accurate performance of this task is a must no matter where you work (inpatient unit, outpatient unit, or emergency room). In this lesson, you will learn several types of collection and the specifics associated with each one. Specimen collection can help diagnose and treat medical problems by performing special tests and procedures. In this section, we will discuss the special tests and procedures you will be involved in, starting with cytology. Cytology is the study of cells. A variety of procedures can be used to obtain tissue for a cytological examination. Venipuncture, bone marrow aspiration, urine catheters, and lumbar puncture are just a few of the types of procedures used. The samples are viewed under a microscope, normally to confirm a diagnosis. Studies of the tissues are performed to detect carcinogenic, metabolic, vascular, and other changes. Always remember to use standard precautions and aseptic technique to guard against infection or contamination of the specimen. Your involvement will be to assist in the preparation, procedure and post care of the patient. There are basic procedural steps that apply to all specimen collection procedures, before, during, and after. However, some collection procedures will have more specific steps and you will learn about those specific procedures below under each different collection or test. Perform all tasks according to unit protocol/policy. Review steps beforehand. Ask clarifying questions. Verify doctor’s order, gather equipment and supplies, perform hand hygiene. Use standard precautions and aseptic techniques. Verify the procedure you’re about to perform. Don the appropriate PPE. Before the Procedure During the Procedure Ensure you have the right equipment and supplies. Dispose of sharp instruments and needles appropriately IAW policy. Setunit up all equipment and supplies in the patient’s room. Perform hand hygiene. Greet the patient; introduce yourself. Verify that you have the correct patient by using two Remove PPE. Throw away used supplies. Remove protective equipment and discard or store appropriately. Perform hand hygiene immediately. Restore the unit. After the Procedure Gather used equipment; dispose of, clean, or store items back in their proper location. Ensure patient is clean, dry, and comfortable. Ensure call light and personal items are within reach, lower bed to its lowest level. Remove soiled linens. Remove unsightly, odorous, or potentially infectious trash from the room C O NT I NU E Collect and Label: Emesis A patient’s emesis is collected to determine the presence of blood or in the case of poisoning, to determine what had been consumed. An emesis basin is usually the easiest container to use. After collecting the specimen, be sure to label it correctly. Information required on the label includes the type of specimen, date and time, patient’s name, DoD ID number, patient registration number (for inpatient) and ordering physician’s name. An Emesis basin  NOTE: Label all specimens in this manner. Procedural Steps 1. Adhere to the rules for medical asepsis. 2. Follow standard precautions, as well as bloodborne pathogen standards. 3. Ensure you have the correct container for the specimen. 4. Ensure you use a clean container for each specimen – evaluate the insides for loose dirt, debris, etc. Do not touch inside of the lid and/or inside of the container itself. Attempt to discard foreign debris from the inside lid/container without human touch. 5. Verify that you have the correct patient. Use two approved patient identifiers (i.e. full name and DoD ID number). Match patient info with patient identification bracelet, specimen label, etc. 6. Label the specimen container at the patient’s bedside – do not leave the room until all specimens are correctly labeled. 7. Collect the specimen at the correct time. 8. Secure the specimen container lid tightly. 9. Place the specimen into an approved (and labeled) biohazard bag. Ensure the bag is sealed. 10. Doff gloves before leaving the patient’s room. 11. Carry the specimen (labeled and bagged) to lab or designated location. 12. Perform hand hygiene. C O NT I NU E Collect and Label: Urine Urine Sample Urine samples can be used to complete various tests. One of these tests is a sugar and acetone test. This is done to detect the presence of sugar or acetone bodies (glucose) in the urine. The method used is determined by each facility and universal precautions are implemented. Urine can be collected using several devices such as a urinal, collection bottle, commode hat, bed pan, fracture pan, and more. Once you obtain the sample from the patient, transfer the required amount of urine to a urine specimen container, then take the sample to the utility room (or designated location). Most facilities use a test strip method to examine the urine. You simply dip the test strip into the urine and wait a specific amount of time for the results. Check your unit’s policy for the method used in your facility. Before conducting any urine test, consider the following information: What test has been ordered What equipment do you need When to test urine Instructions for the test ordered What observations to document and/or report The time of collection Test results Any problems with collection Color, clarity, and odor of specimen Blood in the urine Particles in the urine Any patient complaints, such as pain, burning, difficulty voiding, etc. How to report test results and when What patient concerns to report immediately UR I N E SPE C I ME N C O L L E C T I O N T E ST I N G UR I N E - R E A GE N T ST R I PS ST R A I N E D SPE C I ME N First, gather all supplies and equipment and perform hand hygiene. Verify correct identification of the patient and label the specimen container at the patient’s bedside. Finally, don gloves. Instruct the patient to void into a clean bedpan, urinal, collection bottle, or other device. Ensure privacy for the patient. Explain to the female patient how to hold the urine cup so that it surrounds the urethra. Explain to both men and women patients that only 1.5 inches of urine is necessary. Transfer the urine into a proper specimen container by pouring about 120 mL into the container. Send to the lab within 5-10 minutes. UR I N E SPE C I ME N C O L L E C T I O N T E ST I N G UR I N E - R E A GE N T ST R I PS 1. Gather all supplies and equipment. A. Check the expiration date on the bottle. If expired, do not use. B. Check the color of the strips. If discolored, do not use. C. Do not touch the test area on the strips. D. Follow the manufacturer’s label to ensure accuracy. 2. Perform hand hygiene. 3. Verify correct identification of the patient. 4. Don gloves. 5. Gather equipment for the urine specimen. 6. Ensure privacy for the patient. 7. Collect the urine specimen. 8. Remove a strip from the reagent bottle and immediately secure the lid. 9. Dip the strip test area into the urine. 10. After the correct amount of time has passed, remove the strip. See manufacturer’s label. 11. Remove excess urine from the strip by tapping it gently against the urine container. 12. Wait the necessary amount of time, per the manufacturer’s guidance. 13. Compare the strip with the color chart on the bottle. 14. Doff gloves. Perform hand hygiene. 15. Document and/or report test results and any other significant observations. ST R A I N E D SPE C I ME N UR I N E SPE C I ME N C O L L E C T I O N T E ST I N G UR I N E - R E A GE N T ST R I PS 1. Gather all supplies and equipment. 2. Perform hand hygiene. 3. Verify correct identification of the patient. 4. Don gloves. 5. Gather urine strainer for the urine specimen. 6. Strain urine over toilet bowl. 7. If stone is found, save and send to the lab for analysis. 8. Doff gloves. Perform hand hygiene.  Urine left standing for 15 minutes or more will not provide an accurate test result. ST R A I N E D SPE C I ME N Multiple Choice Which test is used if a patient has been poisoned and you need to find out what the poison is. Emesis Urine Cytology Lumbar Puncture SUBMIT Complete the content above before moving on. Collect and Label Sputum Patient must cough to collect the sputum. Sputum collection is a special test that is helpful in diagnosing medical problems. Sputum specimens are examined for numerous types of microorganisms. In fact, the causative agents for many pulmonary disorders are often discovered in a microscopic examination of the sputum. Tuberculosis is frequently discovered in this manner. For this reason, it is a valuable diagnostic aid to the provider. When you are collecting the specimen, remember, the causative agent may be in it; therefore, you must exercise caution when collecting it. Be sure to follow universal precautions to decrease the chance of spreading the disease to yourself, other patients, and coworkers. Handle the specimen carefully, touch only the outside of the container, close the container tightly to prevent spillage and further contamination, and be sure to wash your hands after you have handled it.  If the laboratory wants to grow the causative organism in a culture, the specimen must be collected in a sterile container and handled with a sterile technique; otherwise, you will contaminate the specimen. Normally, the specimen is collected in a wide-mouthed bottle or sputum cup. It should be as free of saliva as possible and obtained by a deep cough. For best results, have the patients rinse their mouth with hot water before they attempt to cough up the specimen. This rinse gets rid of excess saliva. Stay with the patients while they are coughing. Try to get at least a teaspoonful of sputum for the examination. Prepare the appropriate laboratory form indicating the examination requested and take it to the laboratory immediately. If there is any delay, place the specimen in a refrigerator, but not in one used for food. Before conducting any sputum test, consider the following information: When to collect the specimen. The right amount needed, which is usually 1-2 teaspoons. Can the patient hold the sputum container. I MPO R TA N T O B SE R VAT I O N S SPUT UM C O L L E C T I O N What observations to document and/or report: 1. The time of collection 2. The amount collected 3. How easy it was for the patient to expectorate the sputum 4. Sputum color 5. Sputum odor 6. Sputum consistency 7. Whether there was blood in the sputum or not 8. If patient could not expectorate 9. How to report observations and when 10. What patient concerns to report immediately I MPO R TA N T O B SE R VAT I O N S SPUT UM C O L L E C T I O N 1. Gather all supplies and equipment. A. Sputum specimen container and lid B. Specimen label C. Biohazard bag 2. Perform hand hygiene. 3. Verify correct identification of the patient. 4. Label the specimen container at the patient’s bedside. 5. Don gloves; collect tissues. 6. Ensure privacy for the patient. 7. Instruct patient to rinse their mouth out with water. 8. Instruct patient to hold the specimen container, careful that only the outside is touched. 9. Instruct patient to cover their mouth and nose with tissues while coughing. 10. Instruct patient to take 2-3 deep breaths and cough up the sputum. Repeat this action until approximately one teaspoon of sputum is in the cup (or the desired amount per the provider). 11. Instruct patient to spit directly into the specimen container, careful that sputum not touch the outside of the container. 12. Tightly secure the lid on the specimen container. 13. Place container in the biohazard bag. 14. Doff gloves before leaving the room; perform hand hygiene. 15. Take specimen to the lab. 16. Document and/or report any significant observations. C O NT I NU E Stool Stool Samples Stool samples are obtained for many reasons (i.e., occult blood, parasites, fat, and other abnormalities). To obtain a stool sample, give the patient a commode hat to defecate into. Once they have defecated, using gloves and a wooden tongue blade, place two tablespoons of feces into the specimen container. The specimen must be taken to the laboratory while it is warm.  Urine must NOT be included in the stool sample. Patients should use one device for voiding and another device for a bowel movement. Additionally, some stool tests require a warm sample. This means the specimen must be taken to the laboratory immediately following collection. Before collecting a stool sample, consider the following information: When to collect the sample What equipment is needed, to include any special measures Collection Procedures 1. Confirm doctor’s orders; verify the specific culture. 2. Gather all supplies and equipment. 3. Verify correct identification of the patient. 4. Ensure you have adequate lighting. 5. Explain to the patient everything you are about to do. 6. Label the culture tube in front of the patient. A. Label should have the correct patient info B. Label should specify date, time, type of specimen culture, and location of the wound. 7. Perform hand hygiene; don gloves. 8. Remove wound dressing by folding the soiled sides together; discard. 9. Clean the area around the wound edges by using an antiseptic swab. 10. Doff gloves and discard. 11. Open sterile gloves, as well as dressing supplies. 12. Don gloves. A. Remove sterile swab from the culture tube and insert the tip into the wound wherever there’s drainage. B. Rotate swab gently. C. Transfer the swab from the wound to the culture tube, careful not to touch any other surface. 13. Using a sterile technique, redress the wound with the sterile dressing supplies. 14. Squeeze the ampule in the bottom of the tube, which will release the preservative. 15. Insert the swab into the solution and wet it thoroughly. 16. Doff gloves and perform hand hygiene. 17. Place tube in a biohazard bag and take to lab. 18. Document and/or report observations and any other significant patient concerns. Multiple Choice If you have a patient that you suspect of having a pulmonary disorder, which test should be ordered that you could help you diagnose the patient. Drainage Stool Sputum Urine SUBMIT Complete the content above before moving on. Perform and Label: Venipuncture As an aerospace medical service journeyman, there may be many occasions to perform a venipuncture. If you work the evening or night shift, either you or the nurse may be responsible for drawing all admission lab work. To perform venipuncture, gather all equipment you will need, including: a needle (20 gauge or larger), syringe (size depends on amount of blood needed), antiseptic, 2x2 gauze sponges, vacutainer and vacutainer needle (if using vacutainer system), test tubes (with proper color for tests ordered by the physician), tourniquet, and nonsterile gloves. Your unit may have a venipuncture tray that includes the equipment you will need. Watch the video below to learn how to perform a safe and effective blood draw. Safe and Effective Blood Draw Video Transcript.pdf 163.7 KB  As previously discussed in the lesson on IV therapy, determine the site to use by applying the tourniquet above the elbow. The tourniquet will distend the veins and allow you to visualize and palpate the vein. (NOTE: The tourniquet should not stop the arterial flow of blood; and the radial pulse should still be palpable.) Remove the tourniquet. Next, cleanse the area with an antiseptic solution and allow the area to dry. Reapply the tourniquet and put on gloves. Insert the needle, bevel up into the vein. Obtain the blood sample, remove the tourniquet, and apply a gauze sponge over the site and withdraw the needle. Have the patient maintain pressure over the site for two to three minutes. Using local policies, transfer the blood into a test tube, ensure proper labeling, and send it to the laboratory. C O NT I NU E Perform and Label: Throat Swab If you have ever been to a doctor for a sore throat, you will probably remember one of the first things the technician did was to stick a cottontipped applicator into your mouth. You probably did not care much for the procedure, in fact, you most likely gagged. However, it was done for a reason. Since the mouth is the portal of entry for many organisms, the taking of a throat culture may reveal the type of “bug” giving you the sore throat. When physicians know the organism, they can effectively treat the sore throat. Collections of throat secretions are taken to determine the presence of diseaseproducing organisms. Collect the specimen with a sterile, cotton-tipped applicator from a sterile test tube. The cotton-tipped applicator is placed in the affected area of the mouth or throat. Carry out the procedure using aseptic technique. After the throat is swabbed, replace the cotton-tipped applicator in the test tube, properly identify the specimen with the patient’s social security number, and carry it to the laboratory. The results of the culture take two to three days. The rapid strep test (there are several different types used) can produce results within minutes to hours. It can only detect the presence of “Group A” strep, the one most likely to cause serious throat infections; it does not detect other kinds of strep or other bacteria. Supplies Needed: Tongue blade Culture tube Biohazard bag Patient label Gloves Pen light Watch the video below to learn how to properly perform a throat swab. How to Collect a Throat Swab Specimen Video Transcript.pdf 131.3 KB C O NT I NU E Strain Urine for Calculi C O L L E C T I N G A N D T E ST I N G UR I N E ST R A I N E D SPE C I ME N For some patients, you may strain the urine for calculi. As you learned previously, another term for stones is calculi. These stones may develop anywhere in the urinary tract system. If the physician thinks a patient may have a stone, he or she orders straining of all of the patient’s urine. Most facilities have paper funnels with fine mesh gauze in the end, called a strainer. As you strain the urine, look for stones. If you find a stone, save it, place in a sterile urine cup, apply correct labeling, notify the nurse and send it to the laboratory for analysis. C O L L E C T I N G A N D T E ST I N G UR I N E 1. Gather all supplies and equipment. 2. Perform hand hygiene. 3. Verify correct identification of the patient. 4. Don gloves. 5. Gather urine strainer for the urine specimen. 6. Strain urine over toilet bowl. 7. If stone is found, save and send to the lab for analysis. 8. Doff gloves and perform hand hygiene. ST R A I N E D SPE C I ME N C O NT I NU E Urine Reagent Stick There are several different tests that you may complete on urine samples. One of these tests is a sugar and acetone test (S&A). This is done to detect the presence of sugar or acetone bodies in the urine. The method used is determined by each facility. In most cases, you will obtain a urine specimen from the patient using a commode hat, while implementing universal precautions. Place the urine to be sampled in a urine specimen container and take the sample to the utility room. Most facilities use a test strip method; you simply dip the test strip into the urine and wait a specific amount of time for the results. Please check your unit operating instructions for the method used in your facility. Another test you may complete is a hematest. This is a test for occult blood in the urine. Once again, a urine sample is obtained. Then, using a test strip, place it into the urine and wait the amount of time specified in the test strip instructions for the results. C O L L E C T I N G A N D T E ST I N G UR I N E T E ST I N G UR I N E - R E A GE N T ST R I PS There are several different tests that you may complete on urine samples. One of these tests is a sugar and acetone test (S&A). This is done to detect the presence of sugar or acetone bodies in the urine. The method used is determined by each facility. In most cases, you will obtain a urine specimen from the patient using a commode hat, while implementing universal precautions. Place the urine to be sampled in a urine specimen container and take the sample to the utility room. Most facilities use a test strip method; you simply dip the test strip into the urine and wait a specific amount of time for the results. Please check your unit operating instructions for the method used in your facility. Another test you may complete is a hematest. This is a test for occult blood in the urine. Once again, a urine sample is obtained. Then, using a test strip, place it into the urine and wait the amount of time specified in the test strip instructions for the results. C O L L E C T I N G A N D T E ST I N G UR I N E 1. Gather all supplies and equipment. A. Check the expiration date on the bottle. If expired, do not use. B. Check the color of the strips. If discolored, do not use. C. Do not touch the test area on the strips. D. Follow the manufacturer’s label to ensure accuracy. 2. Perform hand hygiene. 3. Verify correct identification of the patient. 4. Don gloves. 5. Gather equipment for the urine specimen. T E ST I N G UR I N E - R E A GE N T ST R I PS 6. Ensure privacy for the patient. 7. Collect the urine specimen. 8. Remove a strip from the reagent bottle and immediately secure the lid. 9. Dip the strip test area into the urine. 10. After the correct amount of time has passed, remove the strip. See manufacturer’s label. 11. Remove excess urine from the strip by tapping it gently against the urine container. 12. Wait the necessary amount of time, per the manufacturer’s guidance. 13. Compare the strip with the color chart on the bottle. 14. Doff gloves. Perform hand hygiene. 15. Document and/or report test results and any other significant observations. C O NT I NU E Capillary Stick A skin puncture is performed when only a small amount of blood is needed to perform a test. Different sites can be used to obtain this sample (e.g., fingertips, earlobes, or heels of neonates). To perform a skin puncture, obtain the required equipment—lancet, pipette, slides, micro hematocrit tube, alcohol, sterile gauze sponges, or any other equipment needed for that particular test. Now you are ready to perform the test. Identify the patient, cleanse the selected site with alcohol, and then dry the site to prevent any alterations in test results from the alcohol. Apply gloves and press or squeeze above the site to allow the blood to infiltrate the area. To minimize pain, quickly prick the skin with your sterile lancet. Release the pressure and wipe off the first drop of blood. This first drop of blood contains epithelial cells, which can interfere with the test results. Obtain the sample needed, and then apply pressure over the site with a sterile gauze sponge until the bleeding stops. C O NT I NU E Using a Blood Glucose Meter A glucose meter is an instrument used by diabetics to quickly obtain blood glucose levels. Normal fasting blood glucose levels range from 70 to 115 mg/dl. Many facilities have several different types of glucose monitoring equipment; therefore, each of them will not be discussed in this text. Operating instructions are provided for each unit. Before operating the equipment you will need to read and become familiar with the instructions for each unit you are required to use. Also, your trainer will give you preoperational training before using the glucose meter on a patient.  It is imperative to read the manufacturer’s manual for the specific glucose testing device you have on-hand. This is the best way to ensure accurate test results; and the best way to prevent repeat testing on the patient. There are a variety of machines on the market, all with their own specifications. Make sure you know how to use what you have. Collection Procedures 1. Gather all supplies and equipment and verify correct identification of the patient. 2. Explain to the patient what you are about to do in plain language. Identify which finger you plan on using and instruct patient to hang their hand down. If hand is cold, instruct patient to warm it up with warm water or passively warm it using your own hands. 3. Perform hand hygiene and don gloves. 4. Cleanse the site with an alcohol swab – ensure finger does not touch anything else, to include other fingers. Allow alcohol to dry. 5. Turn on the glucose machine. Place lancet in the lancet holder and remove the needle cover. Cock the lancet device. 6. Cross-check the control number on the screen with the control number on the bottle of test strips – they should be the same. 7. Remove test strip from the bottle and insert the end (should have metal strips) into the machine. Place fingerstick device firmly against the skin and hit the release button. 8. If necessary, wipe away the first drop of blood with a gauze pad or cotton ball. You’ll need to have read the manufacturer’s manual prior to use. 9. Gently squeeze the finger, milking downward to the tip until an appropriate drop of blood has formed. Carefully place the drop of blood onto the test strip. 10. Apply pressure to the puncture site with a clean cotton ball or gauze pad; instruct patient to then hold it firmly in place. 11. Document the glucose reading on the machine. Turn off machine. Discard used supplies appropriately. Doff gloves and perform hand hygiene. Multiple Choice A _____________ is performed when only a small amount of blood is needed to perform a test. skin puncture skin prick finger puncture finger prick SUBMIT E ND O F L E S S O N