Patient Preparation and Specimen Collection
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PATIENT PREPARATION BEFORE DIAGNOSTIC AND LABORATORY PROCEDURES
Successful encounters with patients begin with a professional, respectful, and compassionate approach. Positive communications should begin by addressing the patient using proper titles such as Ms., Mrs., or Mr.; the use of inappropriate terms of endearment is a common patient complaint. First names may be used with the permission of the patient. Health-care providers should also always introduce and identify themselves to the patient before explaining the upcoming procedure, when and where the procedure will take place, and the expected duration of the scheduled procedure.
The first step in any laboratory or diagnostic procedure is patient preparation or patient teaching before the performance of the procedure. This pretesting explanation to the patient or caregiver follows essentially the same pattern for all sites and types of studies and includes the following:
- Statement of the purpose of the study. The level of detail provided to patients about the test purpose depends on numerous factors and should be individualized appropriately in each particular setting.
- Description of the procedure, including site and method. It is a good idea to explain to the patient that you will be wearing gloves throughout the procedure. The explanation should help the patient understand that the use of gloves is standard practice established for his or her protection as well as yours. Many institutions require hand washing at the beginning and end of each specimen collection encounter and between each patient.
- Description of the sensations, including discomfort and pain, that the patient may experience during the specimen collection procedure. Address concerns about pain related to the procedure and suggest breathing or visualization techniques to promote relaxation. For pediatric patients, a doll may be used to “show” the procedure. Where appropriate, the use of sedative or anesthetizing agents may assist in allaying anxiety the patient may experience related to anticipation of pain associated with the procedure. Sensitivity to cultural and social issues, as well as concern for modesty, is important in providing psychological support.
- Instruction regarding pretesting preparations related to diet, liquids, medications, and activity as well as any restrictions regarding diet, liquids, medications, activity, known allergies, therapies, or other procedures that might affect test results. Some procedures may require informed, written consent. Consent must be obtained prior to the procedure or administration of any medications ( Figure 1). To increase patient compliance, the instructions should include an explanation of why strict adherence to the instructions is required.
- Recognition of anxiety related to test results. Provide a compassionate, reassuring environment. Be prepared to educate the patient regarding access to the appropriate counseling services. Encourage the patient to ask questions and verbalize his or her concerns.
Specific collection techniques and patient preparation vary by site, study required, and level of invasiveness. These techniques are described in the individual monographs.
- It is essential that the patient be positively and properly identified before providing care, treatment, or services. Specimens should always be labeled with two patient specific identifiers (e.g., the patient’s name, date of birth, medical record number, or some other unique identifier), date collected, time collected, and initials of the person collecting the sample.
- Orders should be completed accurately and submitted per laboratory policy.