Title: Information about Phlebotomy.
1Basic Principles of Phlebotomy
2CongratulationsMercedes!!Skills USA1st Texas
Championship Nurse Assisting
3Phlebotomy Video
4Blood Composition
- Formed elements (45)
- RBC
- WBC
- Platelets
- Fluid component (55)
- Water (92)
- Protein (7)
- etc
5Blood Collection Tubes
- Contain a vacuum
- Used with
- Vacutainer and
- Syringe systems
- Stoppers universal
- color coded indicates contents
- Have an expiration date
6Safety Engineering Controls
- PPE
- Sharps containers
- Safer medical devices
7Safer Medical Devices
8Equipment
- PPE gloves, lab coat, mask
- Cleaning agent
- Alcohol pads routine
- Povidone iodine blood culture collection and
blood gases - Soap and water alcohol testing, allergies
- Cotton balls, gauze
9Equipment
- Bandage, tape (use caution with children)
- Sharps container
- Discard needles,
- lancets
- Biohazard marking
- Puncture resistant
- NEVER recap, bend
- break needles
10Equipment
- 6. Tourniquets
- Slows venous blood flow down
- Causes veins to become more prominent
- NEVER leave on for gt1 minute
- AVOID rigorous fist clenching or hand pumping
(potassium, lactic acid, LD) - Latex allergy
11Tying on the Tourniquet
12Equipment
- 7. Needles
- NEVER reuse a needle
- NEVER use if shield is broken
- NEVER recap, cut, bend or break
- Drop immediately into sharps container after
venipuncture - Size of needle is indicated by gauge
- Larger gauge number indicates smaller needle
diameter - 21, 23 gauge needles routinely used for phlebotomy
13Needles
Used with syringe system Used with
vacutainer system
14Multi-sample Needle
15Butterfly Needle
16Butterfly Needle
- Most often used with syringe
- Expensive, thus not used for routine draws
- Used for small, fragile veins
- Increased risk of needle stick injury
17Equipment
- 8. Tube holder/
- vacutainer adapter
- Threaded
- Flanges
18Equipment
- Syringe
- Black
- water proof
- pen
19Syringe Safety Device
20Labeling Blood Collection Tubes
- Black indelible marker (water proof)
- Never pencil
- Legal document
- Print legibly
- Required information 5 items
- Patient name
- Identification number
- Date of draw (mm,dd,yyyy)
- Time of draw (military time)
- Phlebotomist initals
21Labeling
Last Name, First Name Patient ID 1234-56 June 5,
2005 810 AM Initials SM
22Vacutainer or Syringe?
- Vacutainer
- Most often used
- Most economical
- Quick
- Least risk of accidental needle stick
- Syringe
- More control
- Reposition easily
- Will see flash of blood in syringe hub when
vein successfully entered
23The Patient
- Approach
- Communication
- Empathy
- Handling special situations
- Patient identification
- Arm band
- Legal document
- Prepare patient for blood draw
- Latex allergy?
24Great QUESTIONS TO ASK YOUR PATIENT
- Have you ever had blood drawn before?
- Have you had problems during a venipuncture?
- If yes
- Did you have pain, bruising or bleeding?
- Did you have chest pain, dizziness, fainting or
nausea?
25Necessary Equipment for Venipuncture
- PPE
- Alcohol swabs
- Gauze pads
- Tourniquet
- Needles- sterile disposable
- Blood collection tubes
- Pediatric collection tubes
- Winged infusion sets
- Vacutainer
- Lancets
26Patient Preparation
- Patient education
- Do not make it lengthy
- Tell the steps of the procedure
- Instruct patient to let you know right away if
they are having pain - Explain possible complications
- Bruising, hematoma, infection, prolonged
bleeding, excessive pain - Ask if they have questions
27Selecting the Site
- Begins with hand washing
- Must be done before and after procedure
- Don gloves
- Ask patient to extend arm with palm facing up
- Search for a vein using visual examination and
palpation
28Selecting the Site
- Antecubital area most often accessed
- the bend of the arm
- Preferred site
- There are 3 veins that are preferred for blood
draw in this location
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30The 3 Preferred Veins
- Medial Cubital
- 1st choice
- In center of AC fossa
- Usually does not move
- In obese patient- not seen by can be palpated
- Cephalic Vein
- 2nd choice
- Located in lateral aspect of AC fossa
- Large vein and can be seen
- tends to ROLL and difficult to stabilize
- Brachial Vein
- Last choice
- Located in medial aspect of AC fossa
- very close to brachial artery
- Not visible and tends ROLL
31Examine the Patients AC FOSSA!!
- If you see a good vein it is time to palpate!
- Touch the vein with you fingers
- Vein should feel
- Soft
- Flexible
- Non- tender
- The vein SHOULD NOT BE HARD, INFLEXIBLE OF TENDER
32Conditions
- The following conditions cause veins to be
unsuitable for venipuncture - Sclerosis
- HARD, INFLEXIBLE,NARROW
- Tortuous veins
- TWISTED, TURN EASILY
- Thrombotic veins
- BLOOD CLOT(S) IN THE VEIN
- Fragile veins
- THIN, DARK, CLOSE TO SURFACE, COLLAPSE EASILY
- Phlebitis
- INFLAMMED BLOOD VESSELS, TENDER TO TOUCH
33Complications
- If performed on any of the aforementioned
categories - Vein will be difficult to access
- Impossible to puncture
- Painful
- Easily damaged
- Blood supply through the vein will be POOR
34Troubleshooting to Locate a Vein
- Place the arm below the level of the heart for
several minutes - Place a warm compress
- The best technique is to slow down and take
your time - Ask someone else to try
- Notify supervisor
- Notify Physician
35Other Veins
- Hand and wrist veins
- Dorsum area of the hand
- Easily seen--- are more fragile!!
- ROLL easily superficial,small and painful
- Short length difficult to to angle needle
- Vein on underside of wirst
- CLOSE to Artery and Nerves
- Physically challenging to access
36Hand Vein Draw
37NO BLOOD DRAW
- On arm with IVF
- Dialysis Shunt
- Mastectomy side
38Collection Site Problems
- Intravenous line
- NEVER draw above an IV
- Draw from other arm
- Draw from hand
- on other arm
- Draw below the IV
39Draw Below IV site
40Cleaning the SITE
- Invasive procedure
- Scrub with isopropyl alcohol 70
- Other germicides include- chlorhexidine and
iodine - Alcohol preferred
- Dries fast
- No residue
- Not highly irritating
- Does not obscure
- Not drying to the skin
41Proper Venipuncture Technique
- Introduce self
- Identify the patient
- Check laboratory requisition form
- Have patient sit or lie down- NEVER STANDING
- Assemble equipment check expiration
- Wash hands
- Don gloves
- Locate vein
- Apply tourniquet
42STEPS
- Do not touch area after prepping site
- Use your fingers to spread the skin make tight
- Uncap and inspect the needle tip
- Discard if defective or if sterility was
compromised - Insert the needle at 15-30 angle BEVEL UP
- This angle
- Allow room to work
- Reduces pushing the needle through the vein
- Allow best blood flow
43Needle Position
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45Releasing the Tourniquet
- Once the needle has entered the vein and you have
attached the 1st tube to the infusion set or
vacutainer - RELEASE the tourniquet
- The tourniquet should NOT be left on for more
than 1 minute
46Complications of Leaving Tourniquet Applied Too
Long
- Hemolysis
- Destruction of blood cell
- Will cause abnormal electrolyte readings
- Petechiae
- Very tiny hemorrhages-appear in red and purple
spot on the skin - Hemoconcentration
- Tourniquet application can force fluids out of
cells and leak into blood volume
47Petechiae
48Attach the Collection Tubes
- After you have successful accessed the vein
- Attach the blood collection tubes to vacutainer
or infusion set - Tubes will fill in about 5 seconds
- Tubes must be filled in the correct sequence
- Tubes must be handled correction after filling
- At most if you fill 6 tubes with blood 30 ml or
ccs will be the amount of blood removed
49Order of the DRAW
- Blood cultures or sterile specimens
- Blue top
- Red top
- Gold or Green top
- Lavender or Purple top
- Gray top
50Fill Tubes
- Use correct order of draw
- Sterile/Blood cultures-----------SALLY
- Blue------------------------------------BRINGS
- Red-------------------------------------REALLY
- Gold/Green---------------------------GOOD GREASE
- and
- Purple/ Lavender-------------------LEAVES
- the
- Gray------------------------------------GRAVEY
51Inverting the Tubes
- Once filled tubes must be inverted
- Invert by holding it in your hand and turning
your wrist - Blue top- 3-4 inversions
- Lavender and Green top- 8-10 inversions
- Serum separator tubes ( SST, red tops) and
serum tubes ( red tops without the separating
gel) 5 inversions
52Removing the Needle
- Place gauze over the needle
- Quickly remove needle and apply firm pressure to
site - Always use gauze pad and wear gloves
- Allow patient to apply pressure ( if possible) so
you can invert tubes - You can place pressure for 30 seconds and apply
adhesive bandage over the gauzes
53Recheck Draw Site
54Labeling the Tubes Immediately
- In sight of patient
- Patient name
- Identification number
- Date of draw
- Time of draw
- (military time)
- Your initials
- This is a critical step
- Mislabeling can lead to serious consequences
55Handling and Transporting Specimens
- All specimens must be handled correctly
- Most have a standard of inversions
- Most can be stored at room temp
- There are exceptions!!!
- Learn the proper transport policy of the
facility
56Finishing the Procedure
- Discard the needle in sharps container
- NEVER REUSE!!!
- NEVER RECAP!!
- Remove gloves and wash your hands!!!
57Recheck Draw Site
58Reporting Test Results
- There may be occasions in which you will be asked
to transmit lab results - The keys to doing this accurately and correctly
are repetition and confirmation
59After the Venipuncture
- Check the patient for
- Excessive bleeding
- Excessive pain
- Lack of sensation
- Excessive bruising
- Signs of infection
- How the patient feels
60Troubleshooting Technical Problems during
Venipuncture
- Most are done quickly and with ease
- What do you do if the blood flow stops?
- This occurs when the vacuum is not enough
- Patency of the system has been compromised
- Try another tube
- check to see if you have released the tourniquet
- Needle is in too far or not far enough
61Collection Site ProblemsComplications
- Nerve damage
- Hematomas
- Phlebitis
- Petechiae
- Thrombus
- Physical Reactions
- Collection or processing errors
- Edematous area
62Collection or Processing
- Misidentification of patient
- Improper site selection and preparation
- Incorrect order of the draw
- Under filling of tubes
- Failure to invert tubes
- Failure to document when a specimen was obtained
and when it was received - Mislabeling of the specimen
63Needle Sticks and Contact with Body Fluids and
Secretions
- Good technique and PPE is KEY!!
- If you have contact with skin WASH Immediately
with soap and water - EYE contact Eye wash for 15 minutes with
lukewarm water - Inhalation of body fluidleave area and seek
fresh air - Report exposure soon after you finish basic
first aid measures
64Needlesticks
- Milk and wash the area with soap and water
- Cover with dressing
- Report the incident ASAP
- Any break in the skin can be a portal of entry!!
- Risk of HIV, Hepatitis B C
65First Aid, Medical Emergencies and the
Phlebotomy
- You must be prepared to deal with medical
emergencies - excessive bleeding- apply direct pressure call
for help - Patient faints-call for help try to prevent
patient injury- check for breathing and pulse - Know how and when to start CPR
- Know who and what to do quickly
66Finger and Heel Stick Phlebotomy
- If blood is needed and venipuncture is
contraindicated - Heel or finger stick may be used
- These are NOT venipuncture- because you are not
drawing from veins - You are drawing from capillaries
- There are differences between a HEEL and FINGER
sticks -
67Capillary Blood
- Mixture of arterial, venous, capillary blood and
fluid from surrounding tissues - Fluid from surrounding tissues may interfere
and/or contaminate the specimen - Warming skin puncture site increases arterial
blood flow to the area - Reference ranges often differ from venous
68Fingersticks
- Done when only a small amount of blood is needed
- When venous access is difficult
- Commonly done on children
- Commonly done on adults who need very frequent
blood checks - Can be used to check for lead, hemoglobin and
other blood components including blood glucose
69Fingerstick Procedure
- Infection control
- Assemble equipment
- AIDET-
- Position patient
- wash hands
- Don gloves
- ID site- middle and ring finger are best
- Use side of the finger
- Avoid cold, cyanotic, scarred, fingers
- Clean site with alcohol 70
- Gently massage- milk finger puncture fingertip
with lancet - Wipe away first drop
- Allow blood to drip into collection tube
- Cap when filled
- Position and massage site as needed- careful not
to over milk/massage may damage cells - Cap filled tube
- Label specimen
- Check patient
- Discard equipment
- Remove glove wash hands
70Heelstick Procedure
- Select site
- Best sites are lateral and medial sides of the
heel - DO NOT USE back of heel
- Clean site
- Puncture skin with lancet
- Use your thumb and fingers to gently squeeze
heel - Wipe away first drop of blood
- Allow blood to drip into collection tube
- Do not over squeeze
- Cap tube when filled
- Label specimen
- check patient
- discard equipment
- remove gloves wash hands
-
- Assemble equipment
- Choose correct lancet- will puncture the skin to
a specific depth - If infant lt2.2 lb. choose lancet which punctures
depth of 0.65mm - Positon patient
- Apply heel warmer for 3-5 minutes
- Wash hands and don gloves
71Recheck Draw Site
72SPECIAL COLLECTIONS
- This refers to any collection that is different
from the standard blood draw - Uses techniques that are a bit more complicated
- You may be required to perform or assist in a
special collection
73Peripheral Blood Smears
- A peripheral blood smear is a blood collection
that is used most often to diagnose a hematologic
disorder - The smear is used to examine different types of
white blood cells ---WBCs - This is call checking the DIFFERENTIAL
- Peripheral blood smears also are used to detect
malarial parasites in the blood
74Peripheral Blood Smears
- Can be done using capillary or venous blood
- It can be collect at the bedside or using blood
from an EDTA collection tube - You will need the following equipment
- Lens cleaner
- Lens paper
- glass slides
- gloves
- EDTA tube
75Peripheral Smears
- Take 2 glass slides
- Apply drop of lens cleaner on each slide and use
the lens paper to rub the slides until they are
dry - Invert the EDTA tube 8-10 times
- Open the stopper use a stick or other pipette
to remove a small amount of blood - Place a drop of blood 2mm in diameter onto the
slide just in front of frosted area - Drop of blood should be in the center of the
slide approximately ¼ inch from the back edge
of the slide - Smear immediately after the blood is applied a
delay will affect the test - Do this by using the end of the other slide, hold
at 30 just in front of the blood and then pull
the slide until it just touches the blood
76Peripheral Smears
- The blood will begin to spread towards the edge
of the bottom slide - Wait until the blood has almost reached the edges
of the bottom slide - Maintain a 30- push the spreader slide rapidly
across the bottom slide - Do not press down
- The smear should be across ¾ of the bottom slide
- There should be a smooth appearance and no holes
or lines - It should have rainbow sheen when reflected in
light - Allow smear to air dry and label correctly
77How to Prepare a Peripheral Blood Smear Slide
- Peripheral Blood Slide Preparation
78Blood Culture Collection
- Obtained to detect the presence of microorganisms
in the blood bacteremia - Blood Culture or Blood C S requires a specific
collection procedure -
79Blood Culture Collection
- Assemble equipment
- Blood Culture Bottles
- 2( anaerobic aerobic)
- Tourniquet
- Gloves
- Alcohol 70 swabs
- Gauze pads
- Chlorhexidine
- Syringe winged infusion set
-
80Blood Culture Collection
- Clean top of bottles with alcohol ( NOT with
CHOLORHEXADINE OR IODINE allow to dry for 30
seconds - Find suitable site and clean with chlorhexidine
--------scrubbing firmly a 5 cm area for 30
seconds - Allow to dry and DO NOT TOUCH the area once
prepped - Perform venipuncture and remove 20 ml of blood
using butterfly device with special BC vacutainer
device - Transfer the blood to the bottles filling the
aerobic 1st then the anaerobic bottle - Divide blood amounts evenly between the 2 bottles
- it is helpful to mark off the fill level on
the bottles for filling accuracy
81Blood Culture Collection Procedure
- Blood Culture Collection Procedure
82Recheck Draw Site
83Blood Samples for Inborn Errors of Metabolism
- Genetic disorders that affect the way the body
metabolizes certain nutrients - Will affect the enzyme systems
- Diagnosed by blood tests
- 3 common blood tests are
- Serum Ammonia
- Serum Lactate
- Serum Pyruvate
84Blood Samples for Inborn Errors of Metabolism
- Use the standard venipuncture procedure
- DO NOT use a tourniquet or have the patient make
a fist - Patient should be fasting for the serum pyruvate
level - These specimens are collected in special tubes
- MUST BE PLACED ON ICE immediately transported
to the lab for processing
85Phlebotomy for Blood Donation
- Collecting specimens for blood donation follow
the same principles - Patient ID
- Patient assessment
- Site preparation
- Vein access
- Infection control
86Phlebotomy for Blood Donation
- Screening for BLOOD donation includes
- Age
- weight
- Blood- borne disease exposure
- Today guidelines are very specific and
extensive - Maximum amount of blood that is taken is 525 ml
- American Academy of Blood Banks recommendation
is 10.5 ML per kg of body weight assuming a
minimum weight of 110 lb or 50 kg
87Draw Below IV site
88No Needle Movement!
- You must anchor the blood-drawing equipment on
the patients arm to minimize chance of injury
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90Withdraw Needle
- First release tourniquet
- Disengage tube
- Place cotton directly over needle, without
pressing down - Withdraw needle in swift, smooth motion
- Immediately apply pressure to wound
- Do not bend arm
91You should try again
- Look at alternate site
- Other arm
- Hand
- Use clean needle
- Use fresh syringe if contaminated
- Only try twice
92Venipuncture Procedure
- Wash hands
- Put on gloves
- Identify patient
- Latex allergy?
- Position arm
- Apply tourniquet
93Venipuncture Procedure
- Locate vein
- Release tourniquet
- Cleanse site in outward rotation
- Allow to air dry
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95Mark your spot
96Venipuncture Procedure
- Reapply tourniquet
- Do not contaminate site
- Anchor vein
- Insert needle
- Fill tubes
- Quick mix additive tubes
- Release tourniquet
- Withdraw needle
97Venipuncture Procedure
- Engage safety device
- Dispose of needle immediately
- Apply pressure to puncture site
- Label tubes
- Recheck puncture site
- Thank patient
- Remove gloves,
- wash hands
98Syringe draw
99Be careful not to
- Push needle further into vein when engaging
evacuated tube - Pull needle out of vein when disengaging tube
- Pull needle out of vein as you pull back on the
plunger - Pull up or press down when needle in vein
- Forget to mix additive tubes 8-10 times
100Syringe Safety Transfer Device
101Skin Puncture Procedure
- Wash hands
- Approaching the patient
- Patient identification
- Latex allergy?
- Bedside manner
- Site selection
- Cleanse site DO NOT use providone- idodine
- Perform puncture Wipe away first drop of blood
- Label the specimen
102Skin Puncture
- Method of choice for infants, children under 1
year - Adults
- Scarred
- Fragile veins
- Hardened veins
- Home glucose monitoring (POCT)
- Patients with IV
103Skin Puncture Procedure
- Hold finger between your index finger and thumb
- Puncture the finger using a quick, smooth motion
- Wipe away the first drop of blood
104Skin Puncture Site Selection
105Skin Puncture Equipment
- PPE
- Cleaning agent
- Alcohol pads routine
- Soap and water alcohol testing, allergies
- DO NOT use providone iodine
- Cotton balls, gauze
106Skin Puncture Equipment
- Bandage/tape
- Sharps container
- Warming device
- Commercial warmer
- Warm wet washcloth
107Skin Puncture Equipment
- Lancet
- Always use standardized equipment
- NEVER use a surgical blade
108Skin Puncture Equipment
- Micro-specimen containers
- Capillary tubes
- Microtainers
- Capillary blood gas tubes
- Micropipet diluting system
109Skin Puncture Equipment
- Glass slides
- used to prepare
- blood smears
110Skin Puncture Procedure
- Collect sample
- DO NOT touch collecting device to skin surface
- DO NOT scrape collecting device across skin
surface - DO NOT scoop blood into collecting device
111Skin Puncture Procedure
- Order of draw is critical platelets accumulate
at puncture site causing clot formation - Blood smear
- EDTA
- Heparin
- Serum
- Apply pressure to puncture site
- Label specimen in sight of patient (indelible
marker)
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115Specimen Processing Essential Knowledge
116Labeling and Transporting Specimens
- Each facility has a protocol for transporting
specimens - The time from collection to transport
- Storage requirements for the specimen during
transport - Most can be transported on room Air
- Some require traveling on ice
117CLIA Quality Control
- Clinical Laboratory Improvement Amendments
- Federal regulatory standards for labs that
perform testing of human samples - CLIA standards stipulate that certain simple, low
risk lab tests may be waived - There does not have to be any direct routine
oversight of the labs in regards to how they
perform these tests
118Good Lab Practices
- Include
- Using recent package insert from the kits
manufacturer - Doing quality control or calibration on equipment
- Documenting quality control
- Storing and handling according to manufacturer
- Provide personnel with training and document
training - Using OSH regulations that pertain to labs
119Non-Blood Specimen Collection Transport
- Include
- Semen
- Sputum
- Stool
- urine
120Collection
- All will require a simple collection
- This means the patient is given a cup and the
specimen is placed in the cup - The only exception is
- Sterile urine
121Sterile Urine Collection
- Wait 2-3 hr. for urine to be in the bladder
- wash hands
- Men- clean head of penis with sterile wipe
- Women- must separate labia and wipe front to back
use a second wipe to clean area around the
urethra - Void for several seconds
- STOP urine stream
- Urinate in the sterile cup
- DO not touch inside of cup
- Seal cup and properly label
122Pre-Analytical Errors
- Common errors include
- Insufficient specimen QNS
- Hemolysis
- The destruction of red blood cells which leads to
the release of hemoglobin from within the red
blood cells into the blood plasma. - Hemoconcentration
- Decrease in the volume of plasma in relation to
the number of red blood cells increase in the
concentration of red blood cells in the
circulating blood - Specimen contamination
- Allergic reactions
123Chain of Custody
- The process through which specimens must be
obtained, processed and transported for legal
purposes - Refers to the documentation that must be done
when these specimens are obtained, processed and
transported - Examples
- Bld ETOH levels
- Test for illicit drug
- Workplace drug testing
- Specimens that may be part of a crime-
- ie sexual assault
124Chain of Custody
- The following must be carefully documented
- When, how and by whom specimen was collected
- When, how and by whom specimen was transported
- Who received the specimen and when where and how
it was stored - How and when the specimen was processed
- When, by whom and to whom the results were
reported
125Chain of Custody
- Most labs will have specific forms and a protocol
in place to handle chain of custody - Refer to handout for more information on Chain of
Custody
126Communication and Specimen Collection and
Processing
- Communication during specimen collection and
processing is very important - Accurate communication is vital
- The best way to ensure accurate communication is
to use repetition and confirmation
127Entering and Retrieving Laboratory Values
- Lab values must be entered correctly
- You must pay special attention to the values and
the units that are used to report - You must also have basic knowledge of normal and
abnormal values - Entering or retrieving values incorrectly could
have serious consequences
128Reporting Routine and Critical Values
- When you are reporting routine and critical lab
values --- use repetition and confirmation - You must document to whom you report the values
and when - Doing this especially when you are reporting
critical lab values
129Summary
- Basic venipuncture
- Proper venipuncture technique
- Proper
- patient ID
- Preparation
- Troubleshooting
- Potential complications
- Finger stick
- Heel stick
- Special collections
- Processing of specimens
130Tubes and Tests
- Gray top- fbs, gtt, bld etoh, lactic acid
- Lavender top- CBC, HH, ESR, Sickle Cell
screening - Light Blue top- PT, PTT, Fibrinogen Degradation
Product FDP, - Red top- Blood bank, immunohematology
- Red/gray(speckled)- most chemistry tests
131Practice Skills
- The following is a more simply stated order of
the draw. Keep in mind that other, less
frequently used tubes, will be placed in the
order below based on the additive present.
MEMORIZE! - blood cultures
- light blue
- red
- green
- purple
- gray
- Other.