Venipuncture

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Venipuncture

• AKA Phlebotomy
• The Practice of Drawing Blood

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Objectives

• Learn phlebotomy terminology
• Understand the art of phlebotomy (venipuncture)
• Learn some interesting facts about how phlebotomy
  got its start
• Understand order of draw
• Understand capillary draws

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The humors

• Blood, phlegm, yellow bile, black bile
• The foundation of med tx was (at one time) to
  keep the biles balanced by bloodletting, purging,
  starving, vomiting
• Bloodletting was flourishing by middle ages

4
Barbers (??) Surgeons

• Barbers and surgeons performed bloodletting
• Barber pole red stripes represented blood,
  white represented tourniquet, pole represented
  the stick the pt squeezed during bloodletting

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Bloodletting

• It was thought that blood was the carrier of
  disease, and by letting blood out it would be
  replaced by new, healthy blood. So 1 to 4 pints
  of blood was removed from the patient
• It is believed that bloodletting killed George
  Washington. He had a throat infection that was
  thought would be cured by bloodletting
• By end of 19th century bloodletting declared
  quackery

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Bloodletting today

• Modern phlebotomy is used for diagnosis, and
  monitoring pts condition
• Highly developed pt safety, comfort are
  important
• MAs are trained, and may be certified or
  licensed as phlebotomists, but that is not
  required in Oregon
• Certification requires course work and training
  at accredited institution, passing national exam

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Venipuncture/Phlebotomy

• Venipuncture most common method of obtaining
  blood taken directly from superficial vein
• Vein is punctured by needle, and blood is
  collected in syringe or stoppered tube
• Takes a lot to become skilled and confident

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Venipuncture Equipment

• Chair w/locking arm to catch pt who faints during
  blood draw
• Double pointed safety needles usually 21g
• Evacuated stoppered tubes
• Needle/tube holder (vacutainer holder)

• Syringes
• Butterfly needles
• Sharps container
• Tourniquet
• Marking pen
• Alcohol swabs
• Gauze pads
• Tape and cotton balls
• Gloves

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Vacutainer Tubes

• Stoppered tubes vacutainers, evacuated
  collection tubes
• Most common system includes tubes of various
  sizes, with color-coded tops indicating tubes
  content
• Tubes all have additives except the red one
• Additives include anticoagulants, clot
  activators, and thixotropic gels
• Each test requires specific tubes usually with
  specific additives

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More about tubes

• Each tube has vacuum the larger the tube, the
  greater the vacuum
• Each test requires specific amt of blood, the
  size of vacuum tube used depends on amount of
  specimen required for the test
• Example a red top contains 10ml, to draw a pint
  would require 40-50 tubes

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Tubes continued

• Tubes may be glass or plastic
• Additives
• Powder or liquid additives are visible in the
  tube
• liquid might be sprayed on interior of tube
• Red top has no additive
• Anticoagulants additives are to prevent blood
  clotting, and might be in lgt blue, lavender,
  grey, green, dark blue, or pink tubes

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Tubes continued

• SST tubes contain a coagulant additive (clot
  activator) and gel for serum separation
• SST tubes need to be centrifuged to separate
  serum from RBCs
• Other special tubes contain coags

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Draw Order

• First - blood culture bottle or tube (yellow or
  yellow-black top)
• Second - coagulation tube (light blue top)
• Third - non-additive tube (red top)

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Draw Order continued

• Last draw - additive tubes in this order
• SST (red-gray or gold top). Contains a gel
  separator and clot activator.
• Sodium heparin (dark green top)
• PST (light green top). Contains lithium heparin
  anticoagulant and a gel separator (centrifuge)
• EDTA (lavender top)
• ACDA or ACDB (pale yellow top). Contains acid
  citrate dextrose.
• Oxalate/fluoride (light gray top)

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Invert your tubes to mix

• NOTE Tubes with additives must be thoroughly
  mixed. Erroneous test results may be obtained
  when the blood is not thoroughly mixed with the
  additive.

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The Needles

• Routine venipuncture uses 21g
• Smallest are butterflies or 23g used for fragile
  and small veins
• For typical blood draw a multisample (double
  pointed) needle is used. One ends punctures the
  skin, the other end punctures the rubber stopper
• Use a larger lumen needle to prevent blood from
  hemolyzing (destruction of RBCs)

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Syringe Draws

• Syringe used when concern that the strong
  vacuum in the vacutainer will cause the vein to
  collapse because it draws out too rapidly we
  will do three of these small veins are most
  likely to collapse

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Syringes
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Tourniquet

• Apply to prevent venous flow out of the site,
  making veins bulge
• Different types, but NOT using latex these days
• Placement about 3-4 inches above the AC area
• Leaving on over 2 minutes can alter the test
  results One minute is recommended limit

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Tourniquet

• Can also tie on wrist for hand draw and on ankle
  for foot draw (dont go there)
• Make sure tourniquet lies flat on arm
• Place over clothes when possible
• Clean between uses

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Tourniquet Practice
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Antiseptic

• Do not use alcohol to cleanse before blood
  alcohol testing
• For blood culture tests use povidone iodine
  (betadine) to cleanse site

• Cleanse venipuncture site before using w/alcohol
  prep pads Clean in circular motion inner to outer
  circle
• Alcohol does not sterilize the skin, but inhibits
  the reproduction of bacteria

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Routine venipuncture

• Veins in forearm or inner elbow (Antecubital/AC
  area)
• The median cephalic vein is considered to be the
  best vein to use for venipuncture
• Inspect both arms
• Do not use scarred, bruised, burned skin, or
  areas that are more painful to pt. A scarred
  vein will feel stiff and hard and maybe lumpy

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Venipuncture Steps see Steps PPRemember this
information

• Remember to apply traction by applying firm
  pressure below the vein to help keep it from
  rolling
• Insert needle at 15-30 degree angle, bevel up
  if you go in at less than 15 degrees the needle
  may enter above the vein and not puncture it

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Caution!

• Cover the needle w/the safety device and dispose
  in sharps
• Disposing of a needle in a biohazard bag is a
  violation of OSHA standards

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Capillary puncture

• Collect capillary blood specimen when only a
  small amount is needed
• Reasons to use older pts, peds
• Point of care testing like glucose,
  cholesterol, coumadin
• Lastly filter paper like PKU for infants
• Lancet tool for capillary puncture spring
  loaded puncturing device with a sharp tip
  always discard in sharps container

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Capillary Collection containers

• Microtainer tubes color-coded like vacutainer
  tubes called unopettes

• Capillary tubes fill without need for suction
  red band signifies heparin anticoagulant used
  for microhematocrit testing

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Suggested Sites for Cap Specimens

• Infant, plantar surface of the heel, R or L side
• Middle and ring fingers at
• the sides of the tip (NOT
• the index
• finger)

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Patient Prep

• Cleanse site well pt should wash hands prior if
  they are noticeably dirty
• If hands are cold, warm them by rubbing or with
  warm water
• Puncture dermis
• Wipe away 1st drop
• Grasp finger firmly but dont milk it as that can
  affect results

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Chain of custody

• Evidence in legal proceedings/job testing
• Chain of custody legal term -the ability to
  guarantee the identity and integrity of specimen
  from collection to reporting results of test

• Collection kit - has tube, needle or urine cup,
  chain of custody forms and seals, antiseptic, and
  tourniquet you are required to sign
  off/initial, date, and add required information

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The End