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  1. Oct 10, '06 by Jo Dirt
    I was sent out to get a PT with INR on a patient whose previous level was way off (blood was like syrup coming out). So the doctor put her on 9 mg coumadin for 3 days then 5 mg daily after that.

    So the woman is hard to stick, anyway. I start with a 23 gauge butterfly needle and she has some veins on her hand and I attempt to use those, but her veins are tough and you can literally see them roll as you try to push in them, but I get a return but it is very slow to come out and the vein blows. After that, I finally find a vein on the arm and using a 21 gauge I get return from that but the blood comes so slow and halfway down the tube it just stops. To the private duty nurse and me it looks like her blood is so thick it won't do anything. The nurse tells me she isn't suprised because the patient will hardly bleed enough to get a blood sample for the glucose monitor.

    So I call the nurse at the doctor's office and explain what happened. She was very rude and said "I don't believe that!"
    Then I told her the patient had an issue with this before and the doctor put her on 9 mg's coumadin for 3 days and then 5 mg daily. She said she didn't believe that, either. I told her I had the order in front of me and she put it on hold. Then she comes back and says to bring her in the office and they will do it there.

    The nurse takes her to the doc's office. I call the residence about 15 minutes ago to see what happened, and the nurse tells me, well, they weren't very happy with us. They didn't draw her blood but they did a finger stick with this big lancet and got her PT that way but I don't think they got an INR, but her PT was 2.2 and they left her on 5 mg's of coumadin.

    I did not know they could check her PT with a finger stick. Anytime I have brought that blue topped tube to a lab they said it is very important I fill it to the top.

    Someone please explain what happened. What's this fingerstick deal? I feel like a real idiot. Why do blood draws for PT in the first place if all it takes is a fingerstick?

  2. 15 Comments so far...

  3. Oct 10, '06 by jmgrn65
    2.2 is the number of an INR not a PT, and sometimes if the milk the finger enough they can do a fingerstick, and use a peds tube.
  4. Oct 10, '06 by ukstudent
    Your not an idiot. You can not get correct results from a finger stick. The office nurse was the idiot.
  5. Oct 10, '06 by SouthernLPN2RN
    We did fingerstick PT/INR's routinely in the office. She shouldn't have been ugly with you about anything though. ((((Hugs))))
    ETA: I do recall having to use the tube if we sent the specimen to the hospital. I truly don't know why they need so much blood.
  6. Oct 10, '06 by steelcityrn
    at 2.2 she should not have had thick blood. It sounds like keeping her on 5 mg would be correct, but to recheck in at least a week. I am now using a protime monitor in the homes, on those pt's the physician ok's to use. Its so convenient to have a result during your visit, call it in and get further orders.
  7. Oct 10, '06 by ukstudent
    Sorry, it seems I was wrong. Our lab however will only use the 3ml blue tube, no microcontainers. Also if we use a butterfly we even have to waste the first 3 ml's of blood and use the 2nd 3ml's of blood. I have no idea how you would be able to get the correct flow of blood from a fingerstick.
  8. Oct 10, '06 by Jo Dirt
    Quote from steelcityrn
    at 2.2 she should not have had thick blood. It sounds like keeping her on 5 mg would be correct, but to recheck in at least a week. I am now using a protime monitor in the homes, on those pt's the physician ok's to use. Its so convenient to have a result during your visit, call it in and get further orders.
    I can't explain it, but two of us saw it ourselves. The blood just stopped about halfway down the tube and when we tried to milk it you could see where it was clotting!
    I just don't understand what was going on.

    Next time can I arrange to get a fingerstick instead of try to draw the blood? I had to stick her about 5 times (though I have seen them come back from the hospitals with bruises up and down both arms from unsuccessful VP's)

    Maybe I can use a peds tube and do the fingerstick using the same kind of lancet they used? The private duty nurse says she hardly bleeds enough to get a glucose reading with the regular lancets.
  9. Oct 10, '06 by SWRN84
    We use INRatio fingerstick machines for most of our patients in home health. We started using them a few months ago. Prior to that, though, I have occasionally had a patient where the blood would not entirely fill the tube to the line it was supposed to. In that case, the lab told us we could use pediatric blue top tubes for those INR's. Do you have access to a fingerstick protime machine in your agency? If so, I would definitely get an okay from the physician to go ahead and do it that way. It would save you a lot of hassle and the pt a lot of sticks. So far we have had very few problems with inaccurate results. The physicians we work with have basically said use one or the other...either fingerstick or venipuncture...but do not alternate between the two.
  10. Oct 11, '06 by augigi
    We get a lot of our VAD patients who live away from the hospital to use a "point of care" INR monitor called the Accuchek. It works just like a boold glucose monitor with fingersticks, and patient controlled coumadin (via algorithm) has actually been shown in research to result in better INR control. I've never heard of a hospital using one though - quite expensive.

    http://www.accu-chek.com/index.html
  11. Oct 11, '06 by ICRN2008
    FYI in general, the point-of-care tests tend to be less accurate and precise than traditional laboratory methods for obtaining a PT/INR. If you ever receive a high or unusual result with a POC meter, it should be confirmed with a venipuncture sample.

    Another FYI, there is no such thing as "thick" blood that clots too easily. Blood viscosity is entirely different from the amount and acitivity of the clotting factors.

    The nurse at the doctor's office should not have been rude to you. Some people are just really difficult sticks.