Laboratory #1 Bleeding Time

Laboratory #1 Bleeding Time Skills= 4 Points Objectives:

The student will be able to: 1. Appropriately prepare patient prior to performance of the bleeding time procedure. 2. Ask the patient prior to performance of the procedure whether or not the patient has taken aspirin or any other blood thinner!. ". #erform the $urgicutt bleeding time procedure with 1%%& accuracy. '. $tate what is being tested for with the bleeding time test. (. $tate and compare the four types of bleeding time methods. ). List ( coagulation tests which may aid in the diagnosis of coagulopathies. *. +escribe the course of action which should be taken when the bleeding time e,ceeds 1( minutes. -. $tate the sources of error which may occur in the performance of the bleeding time test and indicate how this would affect the test results .falsely increase or decrease/.

Materials:
1. 2. ". '. (. ). *. Blood pressure cuff $terile0 disposable blood lancet0 capable of a puncture ( mm wide and 1 mm deep $topwatch 1hatman 2o. 1 circular filter paper Alcohol pads 3lo4es Butterfly bandage

e!erences:
1. 2. ". '. 1#owers0 Lawrence 1.0 +iagnostic 5ematology0 pp. '*"6'*)0 '-). Brown0 B. A.0 5ematology: #rinciples and #rocedures0 (th edition0 7hapter (. 84y0 A. 7.0 0 2elson0 +.0 9 Beecher0 3.0 :. Lab. 7linical ;edicine0 2)0 1-120 1<'<. ;c=en>ie0 $hirlyn B.0 7linical Laboratory 5ematology0 pp. *-(6*-).
#age 1 of 11

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Laboratory #1 Bleeding Time

Princi&le:
The bleeding time test is a useful tool to test for platelet plug formation and capillary integrity. ?ccasionally0 the bleeding time test will be ordered on a patient scheduled for surgery. The bleeding time is dependent upon the efficiency of tissue fluid in accelerating the coagulation process0 on capillary function and the number of blood platelets present and their ability to form a platelet plug. #rolonged bleeding times are generally found when the platelet count is below (%0%%%@AL0 and when there is platelet dysfunction. 1hen a patient is suspected of ha4ing a bleeding disorder0 se4eral tests are performed to screen defect.s/ of primary hemostasis. These tests include the bleeding time0 prothrombin time0 acti4ated partial thromboplastin time0 platelet count0 fibrinogen0 and B+#. 7oagulopathies or problems with hemostasis0 such as thrombocytopenia0 Cualitati4e platelet defects0 4ascular abnormalities and 4on 1illebrandDs disease can be diagnosed with coagulation tests. Bour procedures are currently in use for determining the bleeding time: the +uke method0 the 84y ;ethod0 the ;ielke ;ethod and the $implate or $urgicutt ;ethod. '(ke Met)od 1. A standardi>ed puncture of the ear lobe is made0 and the length of time reCuired for bleeding to cease while the blood is being blotted e4ery "% seconds is recorded. 2. A lancet is used to make the puncture. ". 2o repeat testing is allowed due to space. '. 7auses apprehension in the patient. (. This test method is the easiest to perform0 but is the least standardi>ed and has the worst precision and accuracy. *vy Met)od 1. A blood pressure cuff is used to maintain constant pressure within the capillaries to help standardi>e the procedure. The cuff is inflated to '% mm 5g on the upper arm to control capillary tone and to impro4e the sensiti4ity and reproducibility. 2. The forearm is the bleeding time site used. ". A sterile0 disposable blood lancet is used and the length of time reCuired for bleeding to cease is recorded. '. The greatest source of 4ariation in this test is largely due to difficulty in performing a standardi>ed puncture. This usually leads to erroneously low results. Mielke Met)od
#age # of 11

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Laboratory #1 Bleeding Time

1. ;odification of the 84y ;ethod. 2. A Bard6#arker or similar disposable blade is used0 along with a rectangular polystyrene or plastic template that contains a standardi>ed slit. The blade is placed in a special handle containing a gauge in order to standardi>e the depth of the incision. ". The same procedure as described for the $urgicutt method is employed. '. Ad4antages of this method include: a. That the surgical incision more closely appro,imates the patientDs hemostatic response to surgery0 when compared to the puncture in the 84y ;ethod. b. The depth of the incision can be controlled. (. +isad4antages of this method include: a. 7ost6 scalpel and template reCuired sterili>ation after each use. b. #atient apprehension0 due to unconcealed scalpel. c. $mall scars might form. Sim&late+S(rgic(tt Met)od: Pre!erred Met)od 1. ;odification of the 84y ;ethod. 2. The first bleeding time de4ice introduced was the $implate. The $implate de4ice has a trigger and spring method for the blade. The blade has a depth of 1.% mm and a width of (.% mm. Another brand name is the $urgicutt. ". Ad4antages of this method include: a. 8nstrument is a sterile0 standardi>ed0 easy to use de4ice that makes a uniform incision. b. 8nstrument is a spring acti4ated surgical steel blade which is housed in a plastic unit. This eliminates 4ariability of blade incision. c. This method is the most standardi>ed method of all the bleeding time procedures. d. 8ne,pensi4e '. +isad4antages of this method include: a. $light scarring can occur so patient should be informed. 1Pre&aration o! t)e Patient
#age , of 11

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Laboratory #1 Bleeding Time

After proper greeting and identification of the patient0 e,plain that a Ebleeding timeE has been ordered by his@her doctor. This test is used to see how long it will take for the patient to stop bleeding and a clot to form after a puncture is made in the forearm. Fnless the patient is an infant0 outline to the patient how the test will be done. G,plain that the test will take appro,imately 1% to 2% minutes to complete. Let the patient know that he may e,perience some discomfort from the incision and the cuff of the sphygmomanometer. After e,plaining the procedure to the patient0 stop and ask if they ha4e any additional Cuestions. The technician may respond to any Cuestions the patient has concerning the procedure O-L.. 8f the patient inCuires about the significance of the test relati4e to his@her condition0 he@she should be referred to the physician who ordered the test. The patientHs physician can interpret test results within the conte,t of each patientHs condition. 8t is critical that you ask the patient whether or not they ha4e taken aspirin0 aspirin containing compounds .many o4er the counter medications contain aspirin/ or blood thinners such as heparin or coumadin recently. These drugs will cause a falsely abnormal bleeding time and t)e test s)o(ld not be done.

1Overvie/ o! Proced(re $elect a site on the patientDs forearm appro,imately three fingers widths below the bend in the elbow that is free of 4isible subcutaneous 4eins. A4oid surface 4eins0 scars0 bruises and edematous areas. Apply the blood pressure cuff and inflate to '% mm 5g. #erform the incision after the cuff has been in place "%6)% seconds. Apply the bleeding time de4ice to the arm in a hori>ontal position0 do 2?T apply undue pressure as this will falsely increase the depth of the incision. $tart the stop watch as soon as the incision is made. The blood is wicked onto the filter paper at "% second inter4als taking great care that the wound is 2?T directly touched with the filter paper. ?nce blood no longer stains the filter paper the timing is stopped. The bleeding time is reported out to the nearest "% seconds. Proced(re: 1. 3reet and identify the patient. 2. G,plain the procedure to the patient. ". ?btain a history about aspirin or aspirin containing compounds taken within last * 6 1% days. '. $elect a site on the patientHs forearm appro,imately three fingers widths below the bend in the elbow that is free of 4isible subcutaneous 4eins. (. 7leanse the outer surface of the patientHs forearm by mo4ing the alcohol pad in concentric circles from the incision site outwardI allow to air dry. ). #lace a blood pressure cuff on the patientHs arm abo4e the elbow. Turn the knob on the bulb of the sphygmomanometer until it stops. $Cuee>e the bulb to inflate the sphygmomanometer. 8nflate the cuff and maintain pressure at '% mm 5g. *. Jemo4e the $urgicutt de4ice from the blister pack0 being careful not to contaminate or touch the blade6slot surface. Jemo4e the safety clip. 8. +epress the trigger! on the bleeding time de4ice. The puncture must be performed within "% to )% seconds of inflation of the blood pressure cuff.
#age 4 of 11

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Laboratory #1 Bleeding Time

$imultaneously start the stopwatch.

<. After "% seconds ha4e passed blot .do not wipe/ the blood with the filter paper. T)e !ilter

paper must not touch the wound on the arm. Blot the site at regular thirty second inter4als. Jotate the filter paper after each "% seconds. 1%. 1hen bleeding ceases and blood no longer is drawn to the filter paper0 stop the watch and release the blood pressure cuff by turning the knob ne,t to the bulb in the opposite direction used to inflate the cuff. Jemo4e the blood pressure cuff. 11. Jecord the bleeding time. Bleeding time is determined to the nearest ,0 seconds1 12. 8f bleeding continues for more than 1( minutes0 the procedure should be discontinued0 and pressure applied to the wound sites. The bleeding time should be repeated on the other arm. 8f bleeding has again not ceased within 1( minutes0 the results are reported as greater than 1( minutes. 1". After ensuring that the bleeding has stopped0 carefully bandage the site. 1'. Appropriately discard all used materials and wash hands. -ormal 2al(es 1.% K <.% minutes 3(ality 4ontrol Luality control is accomplished through the standardi>ation of the procedure. The wound should be a standard length and depth and a constant pressure of '% mm5g should be maintained throughout the procedure. 1So(rces o! 5rror+Tro(bles)ooting 1. 8f the patient has taken aspirin or aspirin6containing compounds * to 1% days prior to the procedure0 the bleeding time may be prolonged. The technician must determine the patientHs history concerning aspirin ingestion to ensure Cuality results. Aspirin blocks the formation of thrombo,ane and prostacyclin in both platelets and endothelial cells. This results in abnormal aggregation of the platelets. +amage from aspirin effects the platelets for its entire life span. Jesults may be affected by an improperly performed puncture. A puncture that is too shallow0 too deep0 or in an inappropriate location will ad4ersely affect test results. The alcohol must be completely dried before making the puncture. 8f residual alcohol is on a puncture site0 the bleeding time will be erroneously prolonged. 8f the technician does not initiate timing of the procedure simultaneously with the puncture0 the results will be ad4ersely affected. 8f the technician allows the filter paper to touch the wound0 the platelet clot may be dislodged0 causing falsely ele4ated results.
#age 6 of 11

2. ". '. (.

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Laboratory #1 Bleeding Time

<.

8f the stopwatch has not been appropriately calibrated0 it may keep incorrect time. $topwatches should be calibrated on a regular basis as a part of the Cuality assurance program.

1%. The direction of the incision should be consistent. A hori>ontal incision gi4es a longer bleeding time than a 4ertical incision. 11. The bleeding time is prolonged in thrombocytopenia0 hereditary and acCuired platelet dysfunctions0 4on 1illebrandHs disease0 afibrinogenemia0 se4ere hypofibrinogenemia0 and some 4ascular bleeding disorders. 12. 7ertain drugs like #la4i, and Ticlid0 which are platelet inhibitors can falsely prolong the bleeding time.

-OT5: 8f bleeding continues for more than 1( minutes0 the procedure should be discontinued0 and pressure applied to the wound sites. The bleeding time should be repeated on the other arm. 8f bleeding has again not ceased within 1( minutes0 the results are reported as greater than 1( minutes.

#age 7 of 11

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Laboratory #1 Bleeding Time

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Laboratory # 1: Tem&late Bleeding Time e&ort Skills=4 &oints

Must include appropriate units. Patient -ame Patient *' es(lt 8it)in e!erence ange9

#age $ of 11

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Laboratory #1 Bleeding Time

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Laboratory #1 : Bleeding Time St(dy 3(estions Points= 1616

1. 1hat is the bleeding time useful forN .1 pt/

2. 1A. List four .'/ types of bleeding times that can be performed. .2 pts/

B. 1hich is the easiest to perform but gi4es the least accurate resultsN .%.( pts/

7. 1hich is the method of choiceN .%.( pts/

". 1hat other coagulation tests are used in conOunction with the bleeding time to diagnose bleeding disordersN .2.( pts/

'. List two conditions in which the bleeding time could be prolonged. .1 pt/

#age : of 11

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Laboratory #1 Bleeding Time

(.

A.

1hy is a blood pressure cuff used in the 84y bleeding timeN .1 pt/

B.

1hat pressure should the cuff be kept atN .1 pt/

7.

5ow often should the puncture site be blottedN .1 pt/

). 1hat is the normal range for 84y bleeding timesN .1 pt/

*. $tate the course of action which should be taken when the bleeding time e,ceeds 1( minutes. .1 pt/

-. List three sources of error in the bleeding time procedure. ." pts/

#age ; of 11

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Bleeding time is a crude test of hemostasis. It indicates how well platelets interact with blood vessel walls to form blood clots. Bleeding time is used most often to detect qualitative defects of platelets. The bleeding time test is usually used on patients who have a history of prolonged bleeding after cuts, or who have a family history of bleeding disorders. There are several methods to perform the bleeding time test:

Laboratory #1 Bleeding Time

Ivy method: is the traditional format for this test. In the Ivy method, a blood pressure cuff is placed on the upper arm and inflated. A lancet or scalpel blade is used to make a stab wound on the underside of the forearm. The time from when the stab wound is made until all bleeding has stopped is measured and is called the bleeding time. very !" seconds, filter paper or a paper towel is used to draw off the blood. The test is finished when bleeding has stopped completely. Template method: a template is placed over the area to be stabbed and two incisions are made in the forearm using the template as a location guide. Duke method: a nick is made in an ear lobe or a fingertip is pricked to cause bleeding.

A normal bleeding time for the Ivy method is less than five minutes from the time of the stab until all bleeding from the wound stops. #ome te$ts e$tend the normal range to eight minutes. %ormal values for the template method range up to eight minutes, while for the modified template methods, up to &" minutes is considered normal. %ormal for the 'uke method is three minutes.

#age 10 of 11

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Laboratory #1 Bleeding Time

There are several methods to perform the bleeding time test:

I vy method: is the traditional format for this test. In the Ivy method, a blood pressure cuff is placed on the upper arm and inflated. A lancet or scalpel blade is used to make a stab wound on the underside of the forearm. The time from when the stab wound is made until all bleeding has stopped is measured and is called the bleeding time. very !" seconds, filter paper or a paper towel is used to draw off the blood. The test is finished when bleeding has stopped completely. Template method: a template is placed over the area to be stabbed and two incisions are made in the forearm using the template as a location guide. Duke method: a nick is made in an ear lobe or a fingertip is pricked to cause bleeding.

#age 11 of 11

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