Phlebotomy

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Phlebotomy

• Mr. Abdulaziz.M.
• Biochemistry Department
• Laboratory Lessons

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Objectives

• Theory and practice of phlebotomy
• How to interact professionally with patients
• Occupational health hazards and appropriate
  precautions
• Related anatomy and physiology
• Phlebotomy equipment and supplies
• Phlebotomy procedures
• Complications of venipuncture and how to handle
  them.

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Theory and Practice of Phlebotomy
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What is phlebotomy

• The term phlebotomy refers to the ancient
  practice of bloodletting
• Now the term phlebotomy is used for the
  withdrawal of blood from a vein, artery, or the
  capillary bed for lab analysis or blood
  transfusion.

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Who is a phlebotomist

• Collects blood and other specimens
• Prepares specimens for testing
• Interacts with patients health care
  professionals
• plays a vital role in any health care system

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Who is a phlebotomist

• Other medical professionals, including doctors,
  nurses, technologists, and medical assistants
  must also be trained to collect blood specimens.

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Laboratory work flow cycle
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Laboratory Workflow Cycle
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Laboratory Workflow Cycle
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Laboratory Workflow Cycle
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Professionalism
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Professionalism
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Confidentiality

• All employees are responsible for maintaining
  confidentiality of medical information

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Attitude

• Tone of voice and facial expression will
  determine how patients respond to you.
• Always be polite, friendly, calm, and
  considerate.

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Appearance

• Your personal appearance will also affect the
  impression you make.
• Comply with your facilitys dress code and
  personal appearance policies.

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Safety
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Blood-Borne Pathogens

• Infectious micro-organisms which live in the
  bloodstream.
• You can be exposed to bloodborne pathogens if you
  are injured with a contaminated needle.
• You can also be exposed if your mucous membranes,
  including eyes, mouth, or the inside of your nose
  come into contact with contaminated body fluids.

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Blood-Borne Pathogens
Diagram of Hepatitis C Virus
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• Occupational Health and Safety Administration of
  the federal government has mandated bloodborne
  pathogen training for all workers who are at risk
  of exposure.

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OSHA Training

• Standard Precautions
• Personal Protective Equipment
• Hand Washing
• Hazardous waste disposal
• Needle sticks and prevention act

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Standard Precautions
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Standard Precautions

• Standard Precautions means treating all body
  fluids and substances as if they were infectious.
  

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Standard Precautions

• Potentially infectious body fluids include
  Blood, Semen, Vaginal Secretion, Peritoneal,
  pericardial and pleural fluids, and Saliva
• Sweat and tears are not generally considered
  infectious.

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Personal Protective Equipment
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Personal Protective Equipment

• lab coat
• Gloves
• Face masks ( certain types of isolation)

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Hand Washing

• Hand washing is the single most important
  infection control measure.
• Wash hands thoroughly before, after, and between
  all patient contacts.
• Be sure to turn off faucets using a paper towel
  to avoid contamination.

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Hand washing

• Remove rings
• Stand by the sink but do not touch it
• Apply soap and rub hands together
• Both sides of the hand, between fingers, around
  knuckles, under fingernails
• Rinse hands in a downward motion
• Dry hands with a clean paper towel
• Turn off water with another paper towel

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Hand Washing
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Hazardous waste disposal

• All needles other sharps must be disposed of in
  approved sharps disposal containers.
• Other contaminated waste must be discarded in an
  appropriate biohazard bag or waste receptacle.

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Needlestick
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Needle sticks and prevention act

• Safety Devices should always be encouraged

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Anatomy Physiology
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Anatomy Physiology

• Anatomy is the branch of science concerned with
  the study of the structure of the body.
• Physiology is the branch of science concerned
  with the study of the function of the body.

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Anatomy Physiology

• The cardiovascular system consists of the Heart,
  and Blood Vessels.
• Its main function is circulate oxygenated blood
  from the lungs to various organs, and return
  blood depleted of oxygen to the lungs, where it
  is reoxygenated.

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Anatomy Physiology
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Blood Collection sites
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Anatomy Physiology
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Anatomy Physiology
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Blood Components
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Blood Components

• Circulating whole blood is a mixture of
• Plasma (which contains fluid, proteins, and
  lipids), and
• Formed elements, consisting of red cells, white
  cells, and platelets.

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Whole Blood
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Plasma
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Plasma
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Blood cells
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Blood Clot

• When a blood sample is left standing without
  anticoagulant, it forms a coagulum or blood clot.
  
• The clot contains coagulation proteins,
  platelets, and entrapped red and white blood
  cells.

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Serum

• Serum contains all the same substances as plasma,
  except for the coagulation proteins, which are
  left behind in the blood clot.

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Equipment
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Trays

• Trays should be sanitized daily using appropriate
  disinfectant
• Kept Organized and well-stocked.

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Blood Collection tubes

• glass or plastic tube with a rubber stopper.
• It has a vacuum so that blood will flow into the
  tube.
• anticoagulants and/or other chemical additives.

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Blood collection tubes

• Rubber stoppers of blood collection tubes are
  color coded.
• Each type of stopper indicates a different
  additive or a different tube type.

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LAVENDER

• EDTA to prevent clotting
• hematology studies.
• Should be completely filled
• Must be inverted after filling

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LIGHT BLUE

• sodium citrate.
• coagulation (clotting) studies.
• must be completely filled
• must be inverted immediately after filling

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GREEN

• sodium or lithium heparin
• for tests requiring whole blood or plasma such as
  ammonia

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RED

• No additives
• Blood bank tests, toxicology, serology
• Must not be inverted after filing

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GRAY

• Inhibitor for glycolysis anticoagulant
• Sodium Fluride potassium oxalate.
• glucose levels.

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YELLOW

• Acid citrate dextrose
• Inactivates complements
• DNA studies, paternity testing

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ROYAL BLUE

• heparin or Na EDTA anticoagulants
• Tube is designed to contain no contaminating
  metals
• Trace element and toxicology studies

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Blood Culture Bottles

• Different blood culture bottles are used for
  aerobic, anaerobic, and pediatric collections.

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Blood collection tubes Safety

• The rubber stopper is positioned inside the
  plastic shield

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Sizes

• Adult3 - 10 ml
• Pediatric 2 - 4 ml.
• Tubes for fingersticks or heelsticks ½ or less

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Expiration Dates
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Holders

• A plastic holder must be used with the evacuated
  tube system.

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Needle holders with built-in protection devices
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Syringes
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Syringes with built-in safety devices
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Needles
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Needles

• Different sizes.
• size gauge.
• The larger the needle, the smaller the gauge
  number.
• 21 or 22 gauge needle is mostly used.

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Needle Components
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Single Draw Needle

• Single draw needles are of the type that fit on a
  syringe, and can be used only to fill the syringe
  to which they are connected.

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Multiple Draw Needle

• Used with vacuum collection tubes.
• They have a retractable sheath over the portion
  of the needle that penetrates the blood tube.

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Needles with built-in safety devices

• An internal blunt needle that is activated with
  forward pressure on the final blood tube prior to
  withdrawal of the needle from the vein.

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Butterfly Needle

• Winged infusion set
• Difficult venipunctures including pediatric draws
• with a syringe or a holder and vacuum collection
  tube system.
• 21, 23, or 25 gauge.

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Butterflies with built-in safety features

• number-one cause of needlestick injuries, so
  proper use of their safety devices is critical.

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Butterflies with built-in safety features
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Lancets

• Lancets are used for difficult venipunctures,
  including pediatric draws.

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Tourniquets

• Vein easier to SEE, FEEL, and PUNCTURE

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Sterilization
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Bandaging Material
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Gloves

• Gloves must be worn for all procedures requiring
  vascular access.
• Non-powdered latex gloves are most commonly used

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Sharp Disposal Container
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Marking Pen
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Collecting Blood
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Greeting

• Always greet patient in a professional, friendly
  manner.
• A good initial impression will earn the patients
  trust, and make it easier and more pleasant to
  draw a good specimen.
• Knock on the patients door before entering.
• Identify yourself by name and department.
• Explain the reason for your presence.

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Technical Tip

• The more relaxed and trusting your patient, the
  greater chance of a successful atraumatic
  venipuncture.

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Technical Tip

• Good verbal, listening, and nonverbal skills are
  very important for patient reassurance

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Patient Identification

• Make sure the name, medical record number, and
  date of birth on your order/requisition match
  those on the patients armband.
• Verify the patients identity by politely asking
  them to state their full name.

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Patient Identification

• Properly identifying patients and specimens is
  probably the single most critical part of your
  job.
• The consequences of misidentifying a specimen can
  be life threatening.

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Patient Identification

• Never rely on the patient name on the door or
  above the bed. Patients are frequently moved from
  room to room.

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Technical Tip

• A hospitalized patient must always be correctly
  identified by an ID band that is attached to the
  patient.

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Standard Precautions
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Wash hands
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Apply gloves
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Technical Tip

• Patients are often reassured that proper safety
  measures are being followed when gloves are put
  on in their presence.

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Position the Patient

• Comfortable position
• Turn the arm so that the wrist and palm face
  upward, and the antecubital area is accessible

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Technical Tip

• When supporting the patients arm, do not
  hyperextend the elbow. This may make vein
  palpation difficult.

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Applying the tourniquet

• Tie the tourniquet just above the elbow.
• The tourniquet should be tight enough to stop
  venous blood flow in the superficial arm veins.
• The tourniquet should be applied a maximum of 1
  2 minutes.

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Applying the tourniquet
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Applying the tourniquet
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• After applying the tourniquet, you may ask the
  patient to make a fist to further distend the arm
  veins.

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Technical Tip

• Patients often think they are helping by pumping
  their fists
• This is an acceptable practice when donating
  blood, but not in sample collection as this can
  lead to hemoconcentration

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Choose a site

• The median cubital vein
• If not accessible Cephalic vein, or the Basilic
  vein.
• If not accessible veins on the back of the
  hand.
• Use a much smaller needle for these hand veins.

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Technical Tip

• Using the nondominant hand routinely for
  palpation may be helpful when additional
  palpation is required immediately before
  performing the puncture.
• Often, a patient has veins that are more
  prominent in the dominant arm.

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draw from these areas
Never

• Scarred, abraded, or inflamed skin
• Arms containing IV catheters
• Edematous arms
• Occluded Veins
• Shunts

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Cleansing the site

• Isopropyl alcohol swab
• Outward expanding spiral starting with the actual
  venipuncture site.
• Allow the alcohol to dry-
• 1-disinfect the site
• 2-prevent a burning sensation

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Cleansing the site
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Technical Tip

• Patients are quick to complain about a painful
  venipuncture. The stinging sensation caused by
  undry alcohol is a frequent, yet easily avoided,
  cause of complaints.

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Attach needle to holder
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Place tube into holder
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Hold vein in place
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Insert needle
the needle bevel up
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Push tube into holder

• Gently push the tube onto the needle holder so
  that the catheter inside the needle holder
  penetrates the tube.
• Blood flow should be visible at this point.

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Technical Tip

• Allow tubes to fill until the vacuum is exhausted
  to ensure the correct blood to anticoagulant
  ratio.

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Blood wont flow

• If you do not see blood flow, the tip of the
  needle
• May not yet be within the vein.
• May have already passed through the vein.
• May have missed the vein entirely.
• May be pushed up against the inside wall of the
  vein.

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TROUBLESHOOTING
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Incomplete collection or no blood is obtained
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Incomplete collection or no blood is obtained

• Change the position of the needle. Move it
  forward (it may not be in the lumen)

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Incomplete collection or no blood is obtained

• or move it backward (it may have penetrated too
  far).

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Incomplete collection or no blood is obtained

• Adjust the angle (the bevel may be against the
  vein wall).

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Incomplete collection or no blood is obtained

• Loosen the tourniquet. It may be obstructing
  blood flow.
• Try another tube. There may be no vacuum in the
  one being used.
• Re-anchor the vein. Veins sometimes roll away
  from the point of the needle and puncture site.

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Other Problems

• A hematoma forms under the skin adjacent to the
  puncture site - release the tourniquet
  immediately and withdraw the needle. Apply firm
  pressure.

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Other Problems

• The blood is bright red (arterial) rather than
  venous. Apply firm pressure for more than 5
  minutes

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Multiple Tube Collection

• If you are drawing more than one tube
• Keep a firm grip in the needle holder while
  pressing down on the patients arm.
• Use your other arm to interchange tubes.

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Order Of Draw
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Order of draw
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Removing the Needle

• Gently release the tourniquet before the last
  tube of blood is filled
• Remove the last tube from the needle
• Withdraw the needle in a single quick movement

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Apply Pressure

• Quickly place clean gauze over the site, and
  apply pressure.
• You may ask the patient to continue applying
  pressure until bleeding stops.

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Apply Adhesive bandage
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Technical Tip

• The practice of quickly applying tape over the
  gauze without checking the puncture site
  frequently produces a hematoma

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Needle disposal

• Remove the needle from the holder if appropriate,
  and properly discard it in an approved sharps
  disposal container.
• Discard all waste and gloves in the appropriate
  biohazardous waste container.
• Wash hands.

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Specimen Labeling

• Label specimens at the bedside according to your
  institutions standard procedures, or apply
  preprinted labels.
• Proper labeling is the single most critical task
  you are asked to perform.

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Proper labeling generally includes

• Patients first and last name
• Hospital identification number
• Date time
• Phlebotomist initials
• Your institution may provide bar coded computer
  generated labels that contain this information.

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Summary Of Venipuncture Technique

• requisition form.
• Greet the patient.
• Identify the patient.
• Reassure the patient and explain the procedure.
• Prepare the patient.
• Select equipment and supplies.
• Wash hands and apply gloves.
• Apply the tourniquet.
• Select the venipuncture site.
• Release the tourniquet.
• Cleanse the site.
• Assemble equipment.

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Summary Of Venipuncture Technique

• Reapply the tourniquet.
• Confirm the venipuncture site.
• Examine the needle.
• Anchor the vein.
• Insert the needle.
• Push the evacuated tube completely into adapter.
• Gently invert the specimens, as they are
  collected.
• Remove the last tube from the adapter.
• Release the tourniquet.
• Place sterile gauze over the needle.
• Remove the needle, and apply pressure.
• Activate needle safety device.

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Summary Of Venipuncture Technique

• Dispose of the needle.
• Label the tubes.
• Examine the patients arm.
• Bandage the patients arm.
• Dispose of used supplies.
• Remove and dispose of gloves.
• Wash hands.
• Complete any required paperwork.
• Thank the patient.
• Deliver specimens to appropriate locations.

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Syringe Specimen Collection

• Small or delicate veins that might be collapsed
  by the vacuum of the evacuated tube system.
• May also be used to collect blood culture
  specimens.

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Finger stick-Specimen collection

• A safety Lancet, which controls the depth of
  incision
• Finger-sticks should not be performed on children
  under one year of age.

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Finger stick

• If possible, use the fourth (ring) finger or the
  middle finger.
• Many patients prefer that you use fingers on
  their nondominant hand.
• Choose a puncture site near the right or left
  edge of the finger tip.
• Clean the site as you would for routine
  venipuncture.

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Finger stick

• Select a safety lancet appropriate for the size
  of the patients finger.
• You may warm the finger prior to puncture to
  increase blood flow.
• Make the puncture perpendicular, rather than
  parallel, to the finger print.

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Finger stick

• Wipe away the first drop of blood using gauze to
  remove tissue fluid contamination.

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Finger stick

• Collect blood into an appropriate tube.
• Label specimens appropriately.
• Make sure bleeding has stopped. Apply an adhesive
  bandage if necessary.
• Discard sharps appropriately.

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Heel stick

• Veins of small children and infants are too small
  for venipuncture
• Butterfly needles may be used to collect venous
  blood in older children.

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Heel stick neonatal blood collection

• These devices are designed to control the depth
  of incision, since going too deep into an
  infants heel could injure the heel bone, and
  cause osteomyelitis (bone infection).

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Heel stick

• Firmly grasp the infants foot.
• Do not use a tourniquet.
• The heel may be warmed with a cloth to help
  increase blood flow.
• Wipe the collection site with an alcohol prep
  pad, and allow the alcohol to dry.
• Wipe the site with sterile cotton or gauze, to be
  sure all the alcohol has been removed.

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Heel stick

• Puncture the left or right side (outskirt) of the
  heel, not the bottom of the foot.
• Wipe away the first drop of blood since it may
  contain excess tissue fluid or alcohol which
  could alter test results.

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Heel stick

• Collect the blood into the appropriate tube.
• Do not Squeeze the infants foot too tightly and
  wipe with alcohol during the collection.

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Heel stick

• After collection is completed, apply pressure to
  the puncture site with a sterile gauze pad until
  bleeding has stopped.
• Do not apply an adhesive bandage to an infants
  foot since it may injure its delicate skin.

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Heel stick
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Heel stick
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Heel stick
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Heel stick
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Butterfly

• Butterfly needles (winged infusion set)
• are available in smaller gauges, and are used to
  draw venous blood from children, and adults with
  difficult veins.

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Butterfly

• Butterfly needles come attached to a small tube
  which may be connected to
• An evacuated tube holder, or A syringe.

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Butterfly
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Special situations
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Patients refusing blood work

• If someone hesitates to let you collect a blood
  specimen, explain to them that their blood test
  results are important to their care.
• Patients have a right to refuse blood tests
• If the patient still refuses, report and document
  patient refusal

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Fainting

• Rarely, patients will faint during venipuncture.
   
• It is therefore important that patients are
  properly seated or lying in such a way during
  venipuncture so that if they do faint, they wont
  hurt themselves.
• self-limited

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Fainting what to do?

• Gently remove the tourniquet and needle from the
  patients arm, apply gauze and pressure to the
  skin puncture site. 
• Call for help. 
• If the patient is seated, place his head between
  his knees. 
• A cold compress on the back of the neck may help
  to revive the patient more quickly.
•  

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Unsatisfactory Specimens

• They can cause misleading laboratory results
• Must be rejected by the laboratory.
• The patient must then undergo another
  venipuncture to get a better specimen. 
• It costs time money to redraw the specimen.
• The credibility of the laboratory is reduced if
  too many unsatisfactory specimens are drawn.

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Causes of Unsatisfactory Specimens
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Hemolysis
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Hemolysis

• Hemolysis means the breakup of fragile red blood
  cells within the specimen, and the release of
  their hemoglobin and other substances, into the
  plasma.
• A hemolyzed specimen can be recognized after it
  is centrifuged by the red color of the plasma.

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Causes of Hemolysis

• Using a too small needle for a relatively bigger
  vein
• Pulling a syringe plunger too rapidly
• Expelling blood vigorously into a tube,
• Shaking a tube of blood too hard.

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Hemolysis
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Hemolysis
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Hemolysis

• Hemolysis can cause falsely increased potassium,
  magnesium, iron, and ammonia levels, and other
  aberrant lab results.

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Clots
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Clots

• Blood clots when the coagulation factors within
  the plasma are activated.
• Blood starts to clot almost immediately after it
  is drawn unless it is exposed to an
  anticoagulant.
• Clots within the blood specimen, even if not
  visible to the naked eye, will yield inaccurate
  results.

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Causes of Clots

• Inadequate mixing of blood and anticoagulant
• Delay in expelling blood within a syringe into a
  collection tube

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Insufficient volume
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Insufficient volume

• short draws will result in an incorrect ratio of
  blood to anticoagulant, and yield incorrect test
  results.
• Short draws can be caused by
• A vein collapsing during phlebotomy.
• The needle coming out of the vein before the
  collection tube is full.
• Loss of collection tube vacuum before the tube is
  full.

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Labeling Errorrs

• Labeling errors are the most common cause of
  incorrect laboratory results.
• If detected, the incorrectly labeled specimen
  will be rejected.
• If undetected, it will produce incorrect results
  which might adversely affect your patients care.

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Causes

• Failure to follow proper patient identification
  procedure.
• Failure to label the specimen completely and
  immediately after collection.

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Ten Commandments

•  
• I. Thou shalt protect thyself from injury 
• II. Thou shalt identify thy patients 
• III. Thou shalt stretch the skin at the puncture
  site
• IV. Thou shalt puncture the skin at about a 15
  degree angle 
• V. Thou shalt glorify the median vein 
• VI. Thou shalt invert tubes containing
  anticoagulants immediately after collection 
• VII. Thou shalt attempt to collect specimens only
  from an acceptable site 
• VIII. Thou shalt label specimens at the bedside 
• IX. Thou shalt know when to quit  
• X.Thou shalt treat patient's like they are family
•  

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Healthcare in the new millennium
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THE END
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