Information about Phlebotomy.

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Basic Principles of Phlebotomy
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Phlebotomy Video
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Blood Composition

• Formed elements (45)
• RBC
• WBC
• Platelets

• Fluid component (55)
• Water (92)
• Protein (7)
• etc

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Blood Collection Tubes

• Contain a vacuum
• Used with
• Vacutainer and
• Syringe systems
• Stoppers universal
• color coded indicates contents
• Have an expiration date

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Safety Engineering Controls

• PPE
• Sharps containers
• Safer medical devices

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Safer Medical Devices
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Equipment

• 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

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Equipment

• Bandage, tape (use caution with children)
• Sharps container
• Discard needles,
• lancets
• Biohazard marking
• Puncture resistant
• NEVER recap, bend
• break needles

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Equipment

• 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

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Tying on the Tourniquet
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Equipment

• 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

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Needles
Used with syringe system Used with
vacutainer system
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Multi-sample Needle
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Butterfly Needle
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Butterfly Needle

• Most often used with syringe
• Expensive, thus not used for routine draws
• Used for small, fragile veins
• Increased risk of needle stick injury

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Equipment

• 8. Tube holder/
• vacutainer adapter
• Threaded
• Flanges

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Equipment

• Syringe
• Black
• water proof
• pen

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Syringe Safety Device
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Labeling 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

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Labeling
Last Name, First Name Patient ID 1234-56 June 5,
2005 810 AM Initials SM
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Vacutainer 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

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The Patient

• Approach
• Communication
• Empathy
• Handling special situations
• Patient identification
• Arm band
• Legal document
• Prepare patient for blood draw
• Latex allergy?

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Great 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?

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Necessary Equipment for Venipuncture

• Equipment

• Equipment

• PPE
• Alcohol swabs
• Gauze pads
• Tourniquet
• Needles- sterile disposable
• Blood collection tubes
• Pediatric collection tubes

• Winged infusion sets
• Vacutainer
• Lancets

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Patient 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

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Selecting the Site

1. Begins with hand washing
2. Must be done before and after procedure
3. Don gloves
4. Ask patient to extend arm with palm facing up
5. Search for a vein using visual examination and
   palpation

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Selecting 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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The 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

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Examine 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

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Conditions

• 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

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Complications

• 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

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Troubleshooting 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

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Other 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

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Hand Vein Draw
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NO BLOOD DRAW

• On arm with IVF
• Dialysis Shunt
• Mastectomy side

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Collection Site Problems

• Intravenous line
• NEVER draw above an IV
• Draw from other arm
• Draw from hand
• on other arm
• Draw below the IV

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Draw Below IV site
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Cleaning 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

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Proper 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

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STEPS

• 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

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Needle Position
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Releasing 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

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Complications of Leaving Tourniquet Applied Too
Long

1. Hemolysis
2. Destruction of blood cell
3. Will cause abnormal electrolyte readings
4. Petechiae
5. Very tiny hemorrhages-appear in red and purple
   spot on the skin
6. Hemoconcentration
7. Tourniquet application can force fluids out of
   cells and leak into blood volume

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Petechiae
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Attach 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

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Order of the DRAW

1. Blood cultures or sterile specimens
2. Blue top
3. Red top
4. Gold or Green top
5. Lavender or Purple top
6. Gray top

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Fill 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

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Inverting 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

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Removing 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

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Recheck Draw Site
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Labeling 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

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Handling 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

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Finishing the Procedure

• Discard the needle in sharps container
• NEVER REUSE!!!
• NEVER RECAP!!
• Remove gloves and wash your hands!!!

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Recheck Draw Site
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Reporting 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

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After the Venipuncture

• Check the patient for
• Excessive bleeding
• Excessive pain
• Lack of sensation
• Excessive bruising
• Signs of infection
• How the patient feels

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Troubleshooting 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

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Collection Site ProblemsComplications

• Nerve damage
• Hematomas
• Phlebitis
• Petechiae
• Thrombus
• Physical Reactions
• Collection or processing errors
• Edematous area

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Collection 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

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Needle 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

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Needlesticks

• 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

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First 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

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Finger 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

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Capillary 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

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Fingersticks

• 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

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Fingerstick 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

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Heelstick 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

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Recheck Draw Site
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SPECIAL 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

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Peripheral 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

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Peripheral 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

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Peripheral 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

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Peripheral 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

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How to Prepare a Peripheral Blood Smear Slide

• Peripheral Blood Slide Preparation

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Blood Culture Collection

• Obtained to detect the presence of microorganisms
  in the blood bacteremia
• Blood Culture or Blood C S requires a specific
  collection procedure

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Blood Culture Collection

• Assemble equipment
• Blood Culture Bottles
• 2( anaerobic aerobic)
• Tourniquet
• Gloves
• Alcohol 70 swabs
• Gauze pads
• Chlorhexidine
• Syringe winged infusion set

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Blood 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

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Blood Culture Collection Procedure

• Blood Culture Collection Procedure

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Recheck Draw Site
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Blood 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

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Blood 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

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Phlebotomy for Blood Donation

• Collecting specimens for blood donation follow
  the same principles
• Patient ID
• Patient assessment
• Site preparation
• Vein access
• Infection control

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Phlebotomy 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

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Draw Below IV site
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No Needle Movement!

• You must anchor the blood-drawing equipment on
  the patients arm to minimize chance of injury

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Withdraw 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

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You should try again

• Look at alternate site
• Other arm
• Hand
• Use clean needle
• Use fresh syringe if contaminated
• Only try twice

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Venipuncture Procedure

• Wash hands
• Put on gloves
• Identify patient
• Latex allergy?
• Position arm
• Apply tourniquet

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Venipuncture Procedure

• Locate vein
• Release tourniquet
• Cleanse site in outward rotation
• Allow to air dry

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Mark your spot
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Venipuncture Procedure

• Reapply tourniquet
• Do not contaminate site
• Anchor vein
• Insert needle
• Fill tubes
• Quick mix additive tubes
• Release tourniquet
• Withdraw needle

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Venipuncture Procedure

• Engage safety device
• Dispose of needle immediately
• Apply pressure to puncture site
• Label tubes
• Recheck puncture site
• Thank patient
• Remove gloves,
• wash hands

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Syringe draw
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Be 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

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Syringe Safety Transfer Device
101
Skin Puncture Procedure

1. Wash hands
2. Approaching the patient
3. Patient identification
4. Latex allergy?
5. Bedside manner
6. Site selection
7. Cleanse site DO NOT use providone- idodine
8. Perform puncture Wipe away first drop of blood
9. Label the specimen

102
Skin Puncture

• Method of choice for infants, children under 1
  year
• Adults
• Scarred
• Fragile veins
• Hardened veins
• Home glucose monitoring (POCT)
• Patients with IV

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Skin 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

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Skin Puncture Site Selection
105
Skin Puncture Equipment

• PPE
• Cleaning agent
• Alcohol pads routine
• Soap and water alcohol testing, allergies
• DO NOT use providone iodine
• Cotton balls, gauze

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Skin Puncture Equipment

• Bandage/tape
• Sharps container
• Warming device
• Commercial warmer
• Warm wet washcloth

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Skin Puncture Equipment

• Lancet
• Always use standardized equipment
• NEVER use a surgical blade

108
Skin Puncture Equipment

• Micro-specimen containers
• Capillary tubes
• Microtainers
• Capillary blood gas tubes
• Micropipet diluting system

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Skin Puncture Equipment

• Glass slides
• used to prepare
• blood smears

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Skin 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

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Skin 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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Specimen Processing Essential Knowledge
116
Labeling 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

117
CLIA 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

118
Good 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

119
Non-Blood Specimen Collection Transport

• Include
• Semen
• Sputum
• Stool
• urine

120
Collection

• 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

121
Sterile 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

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Pre-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

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Chain 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

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Chain 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

125
Chain 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

126
Communication 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

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Entering 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

128
Reporting 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

129
Summary

• Basic venipuncture
• Proper venipuncture technique
• Proper
• patient ID
• Preparation
• Troubleshooting
• Potential complications
• Finger stick
• Heel stick
• Special collections
• Processing of specimens

130
Tubes 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

131
Practice 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.