Chapter 5: 

Special Collections, non-blood samples and Point-of Care Testing

PEDIATRIC PATIENTS:

Collecting blood from pediatric patients presents technical challenges. Because greater technical expertise is required to perform phlebotomy on children than on adults, you should master your collection methods on adult patients first. Similarly, you should master collection in older children before moving on to young children and infants.



SUPPLIES:

When performing venipuncture on children, use butterfly needles and smaller tubes to prevent iatrogenic anemia.


Take along a selection of rewards, such as stickers or small toys. Keep a stock of cartoon bandages as well. 


Remember not to use these on infants younger than 2 years due to the danger of adhesive allergies.



ANESTHETICS:

Topical anesthetic cream may be useful for venipuncture procedures in pediatric patients. The most commonly used agent is EMLA (eutectic mixture of local anesthetics).


It must be applied 60 minutes before the draw, however, which means that the site must be chosen at that time. It is possible to numb more than one area if it is not practical to choose the site ahead of time.

GERIATRIC PATIENTS

With the aging of the population, many of your patients are likely to be geriatric patients.  As with infants, collection from geriatric patients presents both physical and psychologic challenges. 



PHYSICAL CHANGES:

As people age, their bodies undergo a number of changes that may have an impact on the safety and effectiveness of normal collection procedures. 


Skin changes are among the most important. The skin becomes less elastic, and the layers of skin become thinner. Bruising is more likely, and it takes longer to replace cells, so longer healing times are needed. 



Applying the Tourniquet:

If you are performing venipuncture, you can apply the tourniquet over clothing, a washcloth or paper towels to limit bruising. 


Do not apply the tourniquet as tightly as you would normally, because veins in geriatric patients collapse more easily, and release the tourniquet immediately after inserting the needle.

To secure arm and comfort, you can place the arm on a phlebotomy wedge

SPECIAL EQUIPMENT USED IN THE INTENSIVE CARE UNIT AND EMERGENCY ROOM


Patients in the ICU are likely to have some type of vascular access device or line in place that may affect your collection.  


A vascular access device (VAD) is a tube that is inserted into either a vein or an artery and is used to administer fluids, medications or draw blood.


Blood collection from a VAD is done only by trained personnel on the physician's order, not by a phlebotomist.  



TYPES OF VASCULAR ACCESS DEVICES: 


A central venous catheter (CVC), also called a central venous line is the most common type of  VAD. 


A peripherally inserted central catheter (PICC) is inserted into a central vein, usually from the antecubital area. 


As stated earlier, only specially trained personnel can draw blood from a PICC Line, and a phlebotomist must never draw blood from these devices.

Arterial Punctures

Arterial Punctures are used in diagnosis & management of respiratory disorders


Personnel Who Perform Arterial Puncture


•    Nurse

•    Medical Technologist & technicians 

•    Respiratory Therapist

•    Emergency medical technicians 




Non-blood Specimens 



Non-blood Specimens should be labeled with same ID information as blood specimens


Labeling should include type & source of specimen 

Label should be applied to container, not lid, as lid is removed for testing

All body substances are potentially infectious

Standard precautions must be observed in handling them 



Urine 

Most frequently analyzed non-blood body fluid

Readily available, easy to collect & inexpensive to test. 


Its analysis can aid in:

Monitoring wellness, Diagnosis & treatment of urinary tract infections and determining effectiveness or complications of therapy 


Accurate results depend on:

Collection method

Container used 

Specimen transportation & handling 



Routine Urinalysis  (UA)

It is the most commonly requested urine test. It screens for urinary & systemic disorders



Culture & Sensitivity 

Ordered for patients with symptoms of urinary tract infection. Requires clean-catch collection in sterile container


1) Place measure portion of urine on special nutrient medium that encourages growth of microorganisms 

2) Incubate for 18 to 24 hrs

3) Identify any microorganisms that grow

4) If microorganism is identified, sensitivity test is performed to determine which antibiotics will be effective 



Urine drug screening performed to detect:

Illicit use of recreational drugs

Use of anabolic steroids to enhance performance in sports

Unwarranted use of prescription drugs

Tests are performed in groups based on drug classifications



Urine pregnancy testing

Tests for HCG, a hormone appearing in urine after conception

First morning specimen is preferred due to higher concentration 



Types of Urine Specimens 

Random: collected at any time

First morning/8-hour: collected on waking after 8hrs sleep 

Glucose Tolerance test (GTT)


Urine Collection Methods 

1) Regular Voided: patient voids into clean container

2) Mainstream: Patient voids into toilet first, then container

3) Midstream clean catch: requires cleaning of genital area before collection 

4) Catheterized: sterile catheter inserted through urethra into bladder

5) Suprapubic aspiration: Collected by inserting needle directly into bladder 6) Pediatric: collected in plastic bag, for children not potty trained




Nasopharyngeal Secretions 

From nasal cavity and pharynx

Cultured to detect presence of micro-organsims causing:

Diphtheria

Pertussis (whooping cough)

Covid-19


Collected using sterile Dacron or cotton tipped flexible wire swab. Swab is inserted into nose & passed into nasopharynx. It is rotated, removed, placed in sterile container, labeled, sent to lab



Sputum 

Mucous or phlegm ejected from trachea, bronchi and lungs and is collected for diagnosis or monitoring of lower respiratory tract infectious (tuberculosis).


First morning specimens are preferred (larger volume). 


Patient takes 3 or 4 deep breaths and then coughs forcefully, expelling sputum into container



Buccal (cheek) Swabs

Less invasive, painless alternative to blood collection for obtaining cells for DNA analysis


Phlebotomist gently massages mouth on inside of cheek with swab and DNA is extracted from cells on swab




Feces(stool)

Useful in evaluation of gastrointestinal disorders.

Stool specimens can be evaluated for presence of intestinal parasites & their eggs, Checked for presence of pathogenic bacteria & viruses and tested for presence of occult blood using guaiac test




Throat swabs

Collected to aid in diagnosis of strep infections. Nurses collect form inpatients, phlebotomists from outpatients


Collected with a sterile polyester-tipped swab in covered transport tube containing transport medium






.