Blood collection

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Blood collection
Islamic University Gaza (IUG)
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Introduction

• Hematology Is defined as the study of blood.
• Everybody is familiar with the sight of blood -
  the red fluid that oozes out of your body when
  you've sustained a cut or a deep injury, which is
  slightly denser and approximately 3-4 times more
  viscous than water.

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• Blood Volume-
  
• Blood volume is variable, but tend to be about
  5- 6 liters , or 7- 8 of the body weight.
  Factors such as body size, amount of adipose
  tissue, and electrolyte concentrations all affect
  volume.
• Blood Composition-
• Approximately 45 of the blood is composed of
  formed elements red blood cells , white blood
  cells , and platelets. The remaining 55 of the
  blood is fluid portion, of which approximately
  90 is water and 10 is composed of proteins,
  carbohydrates, vitamins, hormones, enzymes,
  lipids, and salts

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The components of blood can be separated by
filtration, however, the most common method of
separating blood is to centrifuge (spin)
it.Three layers are visible in centrifuged
blood. The straw-colored liquid portion, called
plasma, forms at the top (55). A thin
cream-colored layer, called the Buffy coat, forms
below the plasma.The Buffy coat consists of
white blood cells and platelets. The red blood
cells form the heavy bottom portion of the
separated mixture (45).

• Note-

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Venipuncture (Phlebotomy)

• The process of obtaining intravenous access.

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• There are three veins most commonly used in
  venipuncture, or phlebotomy
• The cephalic
• The median cubital
• The basilic veins
• These three veins are found in the antecubital
  area.
• The cephalic vein is found on the lateral, or
  outside, of the arm.
• The median cubital vein, the preferred one to
  use, is found close to the center.
• The basilic vein is located on the inner, or
  medial part of the antecubital area.

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• The median cubital vein is the preferred vein for
  phlebotomy because
• It is usually larger than the other veins.
• Best anchored vein (More stationary(.
• Veins can move, or roll, which makes it more
  difficult to perform phlebotomy. The median
  cubital is typically well anchored, which makes
  it less likely that the patient will feel pain
  during phlebotomy, or bruise afterwards.

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Median Cubital First Choice

• This vein is located in the antecubital fossa.
  (the area of the arm in front of the elbow)
• Well anchored vein, usually large and prominent.
• Very few problems. Offering the best chance for a
  close to painless puncture, as there are few
  nerve endings close to this vein.

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Cephalic Vein Second Choice

• Cephalic vein which is located on the lateral
  side of the arm.
• This vein is usually well anchored.
• The cephalic vein may lie close to the surface.

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Basilic Vein Third Choice

• Located on the medial side of the arm.
• In many patients this vein may not be well
  anchored and will roll, making it difficult to
  access with the needle.
• Additionally, this area is often more sensitive,
  thus a stick is slightly more painful for the
  patient

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• The cephalic and basilic veins are only used if
  the medial cubital vein is not felt.
• The cephalic vein is the second choice usually,
  since it is fairly well anchored. This is often
  the only vein that can be felt in patients who
  are obese.
• The basilic vein is kept as a last choice option.
  It rolls more easily and runs directly over a
  nerve and an artery, making it a more dangerous
  and painful area to use.

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Hand Veins

• At times, none of the veins of the antecubital
  fossa will be felt or not be able to be used due
  to intravenous placement or injury, hand veins
  may be used.
• Veins of the hand and wrist are usually close to
  the surface, but they are prone to movement and
  rolling.
• Using these veins tends to be more painful for
  the patient, since there are nerves running
  through the hand as well.
• If using these veins, it is important to anchor
  the vein with your hand, holding it in place,
  when you are drawing the blood.

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Venipuncture, why?

• Intravenous therapy
• Venous blood sample
• Parenteral nutrition

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Anticoagulants

• Most hematology and coagulation procedures must
  be performed on whole blood or plasma. There for,
  as soon as the blood is withdrawn from the
  patient, it is mixed with an anticoagulant to
  prevent coagulation. The three most commonly used
  anticoagulants in the hematology laboratory are
  discussed below
• 1- EDTA
• Is generally available as the sodium, dipotassium
  or tripotassium salt of ethylene diamine tetra
  acetic acid. It is used in concentration of
  1.5(.25).
• EDTA prevents coagulation by binding the calcium
  in the blood (calcium is required for blood
  coagulation).

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• Excessive concentration of EDTA cause
• Shrinkage of the red blood cells leading to
  decreased hematocrit, increased MCHC, falsely
  low ESR.
• Degenerative changes in the white cells and the
  platelets will swill and break up causing a
  falsely increased in platelet counts.

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• 2- Sodium citrate
• Is used for coagulation studies in a
  concentration of 1 part 0.109M sodium citrate
  (tri sodium citrate dehydrate) to9 part whole
  blood.
• Sodium citrate prevents coagulation by binding
  the calcium of the blood in a soluble complex.
• 3- Heparin
• May be used in concentration of 15 to 30 units/ml
  of whole blood. its may cause clumping of
  platelets and white cells.
• Coagulation is prevented by interaction with anti
  thrombin III and subsequent inhibition of
  thrombin.

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Equipments(Instruments)
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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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Blood collection tubes Safety

• The rubber stopper is positioned inside the
  plastic shield

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Syringes
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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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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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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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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.
• 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 non traumatic
  venipuncture.
• 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.
• 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.
• 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 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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Never draw from these areas

• 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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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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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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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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REVIEW OF VENIPUNCTURE PROCEDURE

• Patient identification
• Filling out the requisition
• Equipment
• Apply tourniquet and palpate for vein
• Sterilize the site
• Insert needle
• Drawing the specimen
• Releasing the tourniquet
• Applying pressure over the vein
• Applying bandage
• Disposing needle into sharps
• labeling the specimens

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

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

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

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Capillary Puncture

• Safe
• Quick
• Small amount of blood
• Increased use

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Capillary Puncture Sites

• Fingertip
• Great toe
• Heel

• Fingertip
• Great toe
• Heel

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Lancets

• Sterile
• Single-use
• Different lengths

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Finger stick-Specimen collection

• A safety Lancet, which controls the depth of
  incision

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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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• Peform finger or heel puncture across the
  fingerprints as the blood will more likely bead
  rather than run down the "channels" of the
  fingerprints.

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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

• 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 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.

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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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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 him on his back,
  with his hips flexed to help blood return to the
  brain. 
• A cold compress on the back of the neck may help
  to revive the patient more quickly.

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