WPCs @=׉"N"N* %P6kI $=V+6qc셯3LSA7l9:fLhPt)l@U7H&"HIdjɗ>Q{tyS8rze!UO160Pu4cA:;,T6u_R"囮qEiMa)Glo&9([ [)Vu"# H5;2LI<ɸJiܷF\KuW{䐬5ۮgiUmfj!iVy^EM߯}G)yj# ƠQyů]j%\sO칱@ z^bPo[C=p_V6S%(-yeZMg.e8R*>F7IUu2ydU6x %4 nD 04 % U:- g w} 4 ^   m # NUN 1 1u`. 0yc 0wf 72 0PE+f- 0PfaK C B++ AH 0P D+7 0Kb<\  `(Roman 10cpiX'  Lab #7: Bleeding Timelab7&sq  0 .   3|x<\  `(Roman 10cpiXx\  @ X@( U$  ,@AZ"Arial Regular  rt;>q{3? HaURICOH Aficio SP 4210N PCL 5e,,,,0(9 Z6Times New Roman Regular 6(CEKQW]cioAutoList11.a.1.1.1.1.1.1.3#37=CIQYag1.a.i.(1)(a)(i)1)a) $      (;3$2#  0  .3  0  (O;$0  2#  a  .3  0` (#(#i) )   _99A\) xddE9Wf!A X Exercise8:BleedingTime((3$ U!    \ *   _    89  ((3$ U!   TABLE ALevel 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5d dc_ba I&mage <=8C HKKKK((3$ U!   'dxd( $ Figure  1  Level 1Level 2Level 3Level 4Level 5 U!   _XXY XA XXX <XXA  _8A XXdd8EXERCISE8:BLEEDINGTIME#XA X <# X  (     0      8      @ XjGXXXA Textbook:0  Chapter14PointofCareCollections(8thedition)~&%% Skills:0 ( 0(%(%20pointsV%%  (     0      8   Objectives:0  .%%  (#33"3"  32#  1  .3  0 (   Properlypreparepatientpriortoperformanceofthebleedingtimeprocedure.3݌ (%(% Ќ  "3"  32#  2  .3  0 (   Ascertainpriortoperformanceoftheprocedurewhetherornotthepatienthastakenaspirinoranyother   "bloodthinners".34݌  (%(% Ќ  "3"  3_2#  3  .3  0 (   Stateandcomparethefourtypesofbleedingtimemethods.3_݌ (%(% Ќ  "3"  3b2#  4  .3  0 (   Define coagulopathy,"reproducibility"and sensitivity.3b݌ r (%(% Ќ  "3"  3r2#  5  .3  0 (   List5coagulationtestswhichmayaidinthediagnosisofcoagulopathies.3r݌ ^ (%(% Ќ  "3"  3 2#  6  .3  0 (   Listthe3factorsthedurationofthebleedingtimeisdependenton.3 ݌J (%(% Ќ  "3"  3 2#  7  .3  0 (   Describetheinterviewprocessforpreparingthepatientforthebleedingtime.3 ݌6 (%(% Ќ  "3"  3 2#  8  .3  0 (   Describethecourseofactionwhichshouldbetakenwhenthebleedingtimeexceeds15minutes.3 ݌z"(%(% Ќ  "3"  3 2#  9  .3  0 (   CorrectlyperformtheModifiedIvyBleedingtimeprocedurewith100%accuracy.3 ݌f(%(% Ќ  "3 "  3 2#  10  .3  0 (   StatethesourcesoferrorwhichmayoccurintheperformanceoftheBleedingTimetestandindicatehow R thiswouldaffectthetestresults,_ie_,falselyincreaseordecreasethetest.3 ݌>(%(% Ќ  XXjGDiscussion#XjGX#   The bleedingtimetest isausefultoofortestingplateletplugformationinthecapillaries.Itisgenerallyused  inconjunctionwithothercoagulationtestssuchastheprothrombintime,activatedpartialthromboplastintime,  plateletcount,fibrinogenandfibrindegradationproducts(_FDP_)toaidinthediagnosisofpatientssuspectedof  havingableedingdisorder.Coagulopathies(problemsinhemostasis)suchasthrombocytopenia,qualitative p plateletdefects,vascularabnormalities,andvonWillebrand'sdiseasemaybediagnosedwithcoagulationtests. \ Thetestisperformedbymakingaminorstandardizedincisionineithertheforearmandrecordingthelengthof 4 timerequiredforbleedingtocease.Thedurationofbleedingfromapuncturedcapillarydependsuponthe x  followingfactors:quantityofplatelets,qualityofplateletsandtheabilityofthebloodvesselwalltoconstrict. d   DukeMethod  <   Therehavebeenmanymethodsusedtomeasurethebleedingtime,datingbackto1910when Duke originally "" describedamethodinwhichalancetwasusedtomakepuncturewoundsintheearlobe.Thistestwasdifficult # # tostandardize,didnotallowspaceforrepeattestingandoftencausedundueapprehensioninthepatient. #!$  IvyMethod  %p#& In1941,Ivyetalintroducedthefirstmajorinnovationsforstandardizingthebleedingtimetest.Ivychosethe 'H%( forearmasthebleedingtimesite,andheappliedabloodpressurecuffinflatedto40mmHgontheupperarm (4&) tocontrolcapillarytoneandtoimproveboththesensitivityandreproducibility.The sensitivity ofatestrefers x) '* toitsabilitytodetectborderlineabnormalities.Themoresensitiveatestis,themorelikelyitistodetectsmall d* (+ deviationsfromthenormal.The reproducibility ofatestreferstothereproducibilityofthetestresultswhen2 P+(, personsperformingthesameprocedureunderidenticalcircumstancesarriveatidenticalresults.Thismethod <,)- wasalsodifficulttoreproduceduetoseveralvariables(_ie_,depthofpuncture,lengthofpuncture). (-*.  .+/ Ї _Mielke_ԀMethod  X The _Mielke_ԀMethod isamodificationoftheIvymethod.InthisprocedureaBardParkerorsimilardisposable 0 bladeisemployed,alongwitharectangularpolystyreneorplastictemplatethatcontainsastandardizedslit.The   bladeisplacedinaspecialhandlecontainingagaugeinordertostandardizethedepthoftheincision.Thesame   procedureasdescribefortheIvybleedingtimeisemployed.Theadvantagesofthetemplate/scalpelincluded  thefollowing:the"surgical"incisionmorecloselyapproximatedthepatient'shemostaticresponsetosurgery,  whencomparedtothepuncturewoundmadeintheIvyprocedure;thelargesurfaceareaofthetemplate x minimizedskindisplacement;andthedepthoftheincisioncouldbecontrolled.Thisprocedurewasnotwidely  d usedbecausethescalpelandtemplaterequiredsterilizationaftereachuse.Inaddition,theunconcealedscalpel  P  causedpatientapprehension,whichwasunpleasantforboththepatientandthepersonperformingtheprocedure.  <  Thephlebotomistalsoneededtoinformthepatientthatsmallscarsmaybecausedbythismethod.  (   CommercialBleedingTimeDevices  X  In1978,ableedingtimedevicewasmadecommerciallyavailable.Thefirstbleedingtimedeviceintroduced 0  wasthe _Simplate_ .Anotherpopularbrandiscalled _Surgicutt_ .Thesearesterilestandardized,easytouse,  disposableinstrumentsthatmakesauniform,surgicalincision.Theinstrumentisaspringactivatedsurgicalsteel   bladehousedinaselfcontainingplasticunitfromwhichthebladeprotractsandretractsautomatically,  eliminatingthevariableofbladeincision.Hereagain,somepatientsmayreceiveslightscarringattheincision  siteandshouldbesoinformedpriortoperformingthisprocedure.Thesedevicesmakestandardizedincisions x andarealsosterile,disposable,andrelativelyinexpensive.Thisisthemoststandardizedmethodofallofthe d bleedingtimeproceduresandisthemethodofchoice. P  PreparationofthePatient (  Afterpropergreetingandidentificationoftheexplainthata"bleedingtime"hasbeenorderedbyhis/herdoctor X andisatesttoseehowlongitwilltakeforthepatienttostopbleedingandaclottoformafterapunctureismade D intheforearm.Unlessthepatientisaninfant,outlinetothepatienthowthetestwillbedone.Explainthatthe 0 testwilltakeapproximately10to20minutestocomplete.Letthepatientknowthathemayexperiencesome  discomfortfromtheincisionandthecuffofthesphygmomanometer.Afterexplainingtheproceduretothe  patientstopandaskiftheyhaveanyadditionalquestions.Thephlebotomistmayrespondtoanyquestionsthe  patienthasconcerningtheprocedure ONLY .Ifthepatientinquiresaboutthesignificanceofthetestrelativeto   his/hercondition,he/sheshouldbereferredtothephysicianwhoorderedthetest.Thepatient'sphysiciancan  x! interprettestresultswithinthecontextofeachpatient'scondition. !d" Itiscriticalthatyouaskthepatientwhetherornottheyhavetakenaspirin,aspirincontainingcompounds(many #^ andmaintainpressureat40mmHg.*J(%(% 7.0 ( Holdingtheskintight,anddepressthe triggeronthebleedingtimedevice. Thepuncturemustbe " performedwithin30to60secondsofinflationofthebloodpressurecuff. Simultaneouslystartthe  stopwatch.(%(% 8.0 ( After30secondshavepassedblot(do not wipe)thebloodwiththefilterpaper. Thefilterpapermust   nottouchthewoundonthearm. Blotthesiteatregularthirtysecondintervals.Rotatethefilterpaper  ! aftereach30seconds.!"(%(% 9.0 ( Whenbleedingceases,stopthewatchandreleasethebloodpressurecuffbyturningtheknobnexttothe j#!$ bulbintheoppositedirectionusedtoinflatethecuff.Removethebloodpressurecuff.V$v"%(%(% 10.0 ( Recordthebleedingtime..&N$'(%(% 11.0 ( IMPORTANT: Ifbleedingcontinuesformorethan15minutes,theprocedureshouldbediscontinued, (&&) andpressureappliedtothewoundsites.Thebleedingtimeshouldberepeatedontheotherarm.If ('* bleedinghasagainnotceasedwithin15minutes,theresultsarereportedasgreaterthan15minutes.)(+(%(% 12.0 ( Afterensuringthatthebleedinghasstopped,carefullybandagethesite.+)-(%(%  13.0 ( Appropriatelydiscardallusedmaterialsandwashhands. -+/(%(%    X   '7  XXjG X  EXERCISE8:TheBleedingTime#   XaE#   XjGX &%XXjGNameofPhlebotomist____________________________0  0%%0@%%Date___________,L@%@% NameofPatient________________________________   INSTRUCTIONS :Placeacheckintheappropriatecolumnbasedonthefollowing#XjGX%&F#  XXjG0 ( A0(%(%Performedh%% 0 ( B0(%(%NeedsImprovement* J%% 0 ( C0(%(%NotPerformed#XjGXG#  %% *\ddd Xdd Xdd X%%,dd ,,dd ,,dd ,dd +  4$    4XXjGA A$,! 2 "$ AB A$,! 2 "$ AC A$,! 2 "$ ASkill @6& 2 "  $ @#XjGXI#&%XXjG @4  @4 'h  ' 'h  ' 'h  '! ! (#33 "3"  3L2#  1  .3  0    Washesorsanitizeshandsanddonsglovesbeforestartingtheprocedure. 3LL݌  ;1!h $$  ; '  ' '  ' '  '"3"  33N2#  2  .3  0    Roleplay:Approach,greetandidentifythepatient. 33N`N݌  ;1! $$  ; 'Hh  ' 'Hh  ' 'Hh  '"3"  3O2#  3  .3  0    Roleplay:Explainstheproceduretothepatient. 3OO݌  ;1!Hh $$  ; ' ' ' ' ' '"3"  3ZQ2#  4  .3  0    3ZQQ݌  Roleplay:Questionspatientconcerningmedicationstakenduringthepast7to10days.  "  @"  @"  @"  @"  @" ;1!$$  ; '(H ' '(H  ' '(H! '"3"  3ZS2#  5  .3  0    Selects,preparesandorganizesequipment 3ZSS݌  . ;1!(H"$$  ; '# ' '$ ' '% '"3"  3T2#  6  .3  0    Selectsanappropriatesiteforthebleedingtimetest. 3TU݌  ;1!&$$  ; '(' ' '(( ' '() ' "3"  3~V2#  7  .3  0    Positionsthebloodpressurecuffontheproperlocationofthearm. 3~VV݌  ;1!(*$$  ; 't+ ' 't, ' 't- '"3"  3X2#  8  .3  0    3XLX݌  Cleansestheincisionsite. ;1!t.$$  ; '/ ' '0 ' '1 '"3"  3Y2#  9  .3  0    Prepareslancet. 3YY݌  ;1!2$$  ; 'Tt3 ' 'Tt4 ' 'Tt5 '"3 "  3 [2#  10  .3  0    Inflatesthebloodpressurecuffto40mmHg. 3 [7[݌  ;1!Tt6$$  ; '7 ' '8 ' '9 ' "3 "  3\2#  11  .3  0    Makesincisionwithin3060secondsofinflatingthebloodpressurecuff,simultaneouslystarts : stopwatchortiming. 3\\݌  ;1!;$$  ; '(< ' '(= ' '(> '"3 "  3^2#  12  .3  0    Appropriatelywicksflowofbloodontofilterpaperfromincisionevery30seconds. 3^^݌  ;1!(?$$  ; 'x@ ' 'xA ' 'xB '"3 "  35`2#  13  .3  0    Observesforthecessationofbleedingandstopstimingwhenbleedinghasceased. 35`b`݌  ;1!xC$$  ; 'D ' 'E ' 'F '"3 "  3a2#  14  .3  0    Releasesgaugeonbloodpressurecuff,removesbloodpressurecuff. 3ab݌  ;1!G$$  ; 'X!xH ' 'X!xI ' 'X!xJ '"3"  3c2#  15  .3  0    CleansestheincisionsiteandappliesaBandAid. 3cc݌  ;1!X!xK$$  ; '" L ' '" M ' '" N '"3"  3e2#  16  .3  0    Recordstimeatthebottomofthisform 3eKe݌  ݀USINGAPPROPRIATEUNITS. ;1!" O$$  ; '8$X"P ' '8$X"Q ' '8$X"R '"3"  3f2#  17  .3  0    Disposesoflancetinsharpscontainer. 3ff݌  ;1!8$X"S$$  ; '%#T ' '%#U ' '%#V ' "3"  3Jh2#  18  .3  0    Disposesofotherusedmaterialsappropriately. 3Jhwh݌  ;1!%#W$$  ; ''4%X ' ''4%Y ' ''4%Z '"3"  3i2#  19  .3  0    Removesallequipment. 3ij݌  ;1!'4%[$$  ; '(&\ ' '(&] ' '(&^ '"3"  3Nk2#  20  .3  0    Removesgloves,washesorsanitizeshands. 3Nk{k݌  ;1!(&_$$  ; ')(` ' ')(a ' ')(b ' "3"  3l2#  21  .3  0    Leavespatientcourteously. 3l m݌   C     1'%)(c$$   1#XjGX%&=K# "3"  3!n2#  22  .3  0 (   ResultofBleedingTime :______________________________3!nQn݌+*d(%(% Ќ   "3"  34o2#  23  .3  0 (   Bleedingtimeis(circleone) : NORMALABNORMALo 34odo݌-+f(%(% Ќ   X XXjGEXERCISE8:BLEEDINGTIME#XjGX  Xcp#    Name____________________________Date__________________  Points:24  ! ! (#33"3"  3q2#  1  .3  0 (   Whatisthebleedingtimeusefulfor(1points)?3q'r݌ (%(% Ќ   (  ( "3"  3s2#  2  .3  0 (   Whatothercoagulationtestsareused,inconjunctionwiththebleedingtime,todiagnosebleeding 6  disorders(2.5)?3s=s݌"(%(% Ќ  "3"  3et2#  3  .3  0 (   Briefly describethebleedingtimeprocedureasoutlinedintheprocedure.(2points)3ett݌(%(% Ќ  "3"  3u2#  4  .3  0 (   Statethethreefactorsthedurationofbleedingisdependenton(1.5points).3uu݌(%(% Ќ  ";"  ;v0 ( 2#  a  .3  0(%(%  ;vv݌ %% Ќ  ";"  ;w0 ( 2#  b  .3  0(%(%  ;ww݌ !%% Ќ  ";"  ;dx0 ( 2#  c  .3  0(%(%  ;dxx݌!"%% Ќ   (6(03"3"  3y26(  5  .3  0 (   Definethefollowingterms(1each):3yy݌b#!$(%(% Ќ  ";"  ;z0 ( 26(  a  .3  0(%(%  coagulopathy;zz݌:%Z#&%% Ќ   (     0   ";"  ;{0 ( 26(  b  .3  0(%(%  sensitivity;{|݌'&)%% Ќ  ";"  ;|0 ( 26(  c  .3  0(%(%  reproducibility;||݌+)-%% Ќ   (     0      r.,0 "3"  3~26(  6  .3  0 (   BrieflydescribetheDukebleedingtimemethodandstatethe_drawbacks_Ԁofthisprocedure(1.5points).3~;~݌(%(% Ќ  __"3"  326(  7  .3  0 (   ݀HowdidtheIvybleedingtimemethoddifferfromtheDukebleedingtimemethod(1points).3݌ 8 (%(% Ќ   (  TT%% TTTT TTTT TTTT TTTT TTTT_^-@~0 2E2!2!Tl_ TTTT %%TT7.0 ( Whatisthepurposeofusingthebloodpressurecuffduringthebleedingtimeprocedure(1.5points).Pp(%(% 8.0 ( BrieflydescribehowtheMielkebleedingtimemethoddiffersfromtheIvymethod(1points).(%(%  (   9.0 ( ListthreeadvantagesoftheMielkemethodovertheIvymethod(1.5points).$#&(%(%  (    10.0 ( StatewhytheMielkemethodwasnotwidelyused(1points). .@,0(%(% Ї ( 13.0 ( DiscusstheadvantageofusingadevicesuchasSimplateorSurgicuttinthebleedingtimeprocedure(1.5 h points).Tt(%(% 14.0 ( Whyisitimportanttofindoutwhetherthepatienthasbeentakingaspirinoraspirincontaining  compounds(1point).(%(% 15.0 ( Howshouldthephlebotomistpreparethepatientfortheprocedure(2points). (%(% __16.0 ( Whatisthecorrectresponsetogivetopatientswhoinquireaboutthesignificanceofthetestresult(1 8!X" points).$"D #(%(% 17.0 ( Statethenormalvaluesforthebleedingtime(1point).(&*(%(% 18.0 ( Statethecourseofactionwhichshouldbetakenwhenthebleedingtimeexceeds15minutes(1.5points).4-T+/(%(%   .@,0 Ї19.0 ( Listthreesourcesoferrorinthebleedingtimeprocedure(1.5points).|(%(% %   (     0      8      @