Procedure: Blood Sampling: Venipuncture - PCM level

[Plabforum]

Who you are:
You are FY2 in A&E department

Who the patient is:
Adam Elkady, 26-year-old male has taken some paracetamol tablets

Other information:
Your consultant has asked you to take a blood sample from the patient to test for the level of paracetamol in her blood.

What you must do
Take focused history, do the relevant procedure, and manage the patient accordingly

History Taking:

• Confirm the patient’s identity
• Start the station well (I can see from my notes that you are here as you have taken some PCM tablets)
• IPS:
  – Pick up on non-verbal cues (if the patient is looking at the ground or avoiding eye contact)
  – Build Rapport. Show sympathy and empathy. Remember to be extra-sensitive since this is a suicidal patient.
  – Reassure by giving confidentiality
• Why? & Why?
  – My consultant has asked me to take a blood sample from you to test for the level of PCM in your blood
• Focused History: What, how many, when, with what (do not ask why, this is not a psychiatry station)
• Red flags - vomiting, drowsiness, jaundice
• MMA
  – Medical Conditions (specify any bleeding disorder, Liver or kidney conditions)
  – Medications (specify any blood thinner)

Patient preparation:

• Patient:
  – Benefit ( I would like to take a blood sample from you in order to check the level of paracetamol in your blood.
  – Risk: It should not be painful, but if you feel uncomfortable at any time let me know.
  – Explain: explain exactly what you are going to do: (I will be inserting a thin needle into one of the blood vessels (veins/ arteries) of your (forearm/ wrist).
  – It will feel like a sharp scratch, but I will be as quick and gentle as possible
• Doctor:
  – Position : Can you please straighten your elbow/ wrist for me.
  – Exposure: Can you please roll up your sleeves for me.
  – Please be observant. (Notice whether the patient has short sleeves, or has rolled up the sleeves already, and comment on it accordingly).
• Both:
  – Privacy: I will ensure your privacy.
  – Chaperon: Blood procedures do not require a chaperone.
  – Consent: Do I have your consent to proceed.
  – Ask about any arm soreness and any arm preference.
  – Do not forget to inform the patient that if you fail, you may need to repeat the procedure.

Procedure

1. Collect.
2. Open (everything you are going to use before going to the manikin).
3. Start the procedure.

• Collect your equipment:
  – Gloves.
  – Tourniquet , Yellow tube is the first choice for toxicology, Second choice is the red tube.
  – 1 Alcohol swab
  – Vacutainer and needle
  – Blood Tube
  – Cotton piece
• Prepare your equipment in your clean area, then put them on your tray:
  – Partially open the alcohol swab
  – Remove the grey (white) cap from the needle and discard it. Then attach the needle to the vacutainer.
  – Loosen up the other cap (The green cap) slightly and keep it aside ready for the procedure.
• Gloves: Assume you are wearing gloves
• Feel the vein
• Tourniquet (Tie the tourniquet above the cubital fossa)
• Clean Prick Collect
  – Clean the area with one single stroke
  – Remove the green cap to reveal the needle, and discard the cap. Then warn the patient and prick with the bevel pointing up.
  – Keep the needle fixed and secure all the time.
  – Loosen the tourniquet as soon as you see the flashback.
  – Once in the vein, while holding the vacutainer holder firm and still with your left hand, attach the vacutainer and let it fill.
  – Once blood is collected, turn the tubes upside down and swill it around a bit to ensure full mixing.
• Cotton and Label
  – Withdraw the needle carefully. Once the needle is out, press the cotton down on the puncture site.
  – Dispose the needle attached to the vacutainer holder into the sharps bin.
  – Verbalise labelling the sample with the patient’s details and verbalise sending it to the lab.

Management

• Sit down and discuss with the patient the management details:
• Keep in the observation unit
  – You will be given a plasma PCM concentration (a value that will require action)
• Treatment
  – Interpret the results of the PCM concentration on the PCM chart
  – If above the t.t line: N-acetyl cysteine- takes about 21 hours
  – After medical fitness, refer to Psychiatry colleagues for support, relief of stress and improving mood

Safety net

• About the procedure itself (any bleeding, swelling or soreness) .
• About the patient’s general condition (Tummy pain, vomiting, confusion, drowsiness, yellowish discolouration…) .