Phlebotomy

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Phlebotomy

• In the Emergency Department

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OBJECTIVES

• Identify and verify patient
• Assemble supplies
• Select site
• Perform venipuncture
• Label specimens
• Document

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Patient Identification

• At bedside, read ID bracelet
• CHIs TWO pt. Identifiers are full name and DOB
• If no band, get one before the draw.
• Do not draw unless proper ID!

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Bedside Identification

• Identification of the patient is critical!
• At least TWO patient identifiers MUST BE USED.
• Compare the stickers from the chart to the
  patients armband, and ask their name and
  birthday.
• Do not draw specimens from any patient who does
  not have proper ID.
• If question remains, contact the nurse. Report
  any discrepancy.

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Special Circumstances

• Unconscious patient
• If ID bracelet not available, get one.
• Use Doe,Jane or Trauma,Joe 1,2,3 etc.

• Non English speaking or deaf
• Obtain an interpreter from the foreign telephone
  language line or TV.

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Special Circumstances

• Latex allergy
• Must draw with Latex free products
• These include blue tourniquet, blue latex free
  gloves, and paper tape.

• Ensure a green allergy band is on stating the
  word latex.

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Approaching the patient

• Identify yourself!
• Explain what you are about to do.
• Tell the pt that they will feel discomfort, but
  not that it will not hurt.

• No chewing gum,food, or thermometer should be in
  pts mouth at the time of venipuncture.
• Consider the pts age and culture.

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Semiconscious states

• Special care must be taken when drawing
  unconscious, semiconscious, or sleeping patients.
• Try first to gently wake the pt.
• Anticipate unexpected movements or jerks of the
  arm.

• Request assistance if needed.
• A gauze pad should be readily available and
  tourniquet quickly released in the event of
  dislodgement.

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Information regarding the test being drawn must
be given according to policy.
General information only may be provided,
detailed info related to the test will be given
by the nurse or MD.
Do not try to give a detailed explanation of
testing and possible implications of results.
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Do not draw blood against the pts wishes!
Notify the nurse or MD who will explain the
reasons for the tests.
Document reason for delay.
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Assemble Equipment

• Gloves
• Vacutainer or butterfly
• Tourniquet, Chlorascrub, betadyne, tape, gauze
• Blood Collection tubes
• Blood transfer device
• Labels

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Vein Selection

• Apply tourniquet 3-4 inches above intended
  puncture site. Release after 1 minute.
• Have patient make a fist, no pumping.
• Select vein only. If an artery is accidentally
  punctured, apply firm, direct pressure for 5 min.
• Do not select an arm with a pink arm band
  (restricted limb).

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Vein Selection

• Veins should feel like spongy, elastic tubes.
• If it has a pulse, it is an artery, do not use.
• Thrombosed veins feel cordlike and rigid. They
  should not be used.
• Palpate and trace the path of the vein several
  times with the index finger.
• Feet may be used by physician order only.

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Special Techniques

• Arm massage
• Tapping vein with fingers
• Apply warm, damp washcloth
• Lower extrem. over bedside
• Check other arm

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Vein Exclusions
Extensive scarring
Mastectomy
Hematoma
Fistula, vascular graft
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Preferred Veins
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Arteries
Veins
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• Cephalic vein
• Basilic vein
• Median cubital vein
• Median cutaneous
• nerve
• 5. Lateral cutaneous
• nerve

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Arteries
Veins
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There are three nerves that enter the anterior
compartment 1) musculocutaneous, 2) median and
3) ulnar. The musculocutaneous nerve is the nerve
that supplies the 3 muscles of this compartment
but the other 2 nerves are merely passing through
to perform their functions in the forearm and
hand.
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Forearm veins
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Venous Layer

1. Cephalic vein
2. Basilic vein
3. Median cubital vein

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Aponeurotic Layer

1. Bicipital aponeurosis
2. Biceps tendon

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Artery-nerve Layer

1. Brachial artery
2. Median nerve

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Tendons of the Hand
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Can ya find anything?
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Cleansing the site

• Site must be cleansed to prevent contamination of
  either the patient or the specimen.
• Use an alcohol pad. Cleanse in a circular motion,
  starting from the center to the periphery.
• Allow to air dry.

• For blood cultures, cleanse with Chlorascrub
  spongesticks for 60 seconds on one side and 60
  seconds on the other. Let dry.
• Cleanse the rubber tops of each cx bottles w/ 2
  betadyne snappy stix.

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Tourniquet Application
A tourniquet is used to increase venous filling.
This makes the veins more prominent.
Wrap the tourniquet around the arm 3-4 in. above
site.
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Tourniquet Application

• Release after no more than one minute
• Localized stasis or hematoma can occur high
  values
• Can apply over gown or gauze if pt has a skin
  problem

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Inspect Equipment

1. Visually inspect the tip of the needle
2. Move syringe plunger up and down in the barrel to
   test movement
3. Tap additive tubes to dislodge from walls or
   stopper
4. Apply gloves

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Ready?
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Vacutainer draws

• Choose appropriate needle size
• Thread the needle into vacutainer holder
• Make sure pt arm is in downward position
• Grasp arm firmly. Use thumb to draw skin taught.
  Thumb will be 1-2 below venipuncture site

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Vacutainer collection
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Venipuncture

• With bevel lined upwards, line up the needle with
  the vein and puncture the vein.
• Push the needle into the the vein.

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Venipuncture

• Grasp the flange of the needle holder and push
  tube forward.
• Tube will start to fill with blood.
• It will stop when the correct blood level is
  reached.

• Do not change position of tube until withdrawn
  from needle.
• Keep constant slight forward pressure.
• Be careful not to move needle from vein

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Venipuncture

• Mix immediately after drawing each tube by gently
  rotating 5-10 times.
• DO NOT SHAKE!

• Insert next tube into holder.
• Observe CHI order of draw.
• Do NOT draw above a running IV.

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Order of Draw

1. Blood cultures
2. Red-tox screen
3. Blue-coags
4. Yellow-chemistry
5. Green-cardiac
6. Lavender-CBC

7. Grey
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Troubleshooting

• Change position of the needle
• Try another tube
• Loosen the tourniquet
• Do not probe.

NO FISHING!
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Venipuncture

• CHI policy Do not attempt a venipuncture more
  than twice.
• Notify the nurse.
• Notify the lab to come over and draw.

• Other alternatives
• Safety Lok Butterfly draw
• Fingerstick
• Lower extrem. access. (Order only)

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Needle Withdrawal

• Release tourniquet
• Ensure pt hand is open
• Place gauze pad
• Remove the needle
• Engage safety device
• Hold pressure 2-3 min. Observe for excess
  bleeding. Pt. not to bend arm.

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Hemolysis in Blood Collection

• Dont do it.

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What is Hemolysis

• Rupture or breakage of the red blood cells
  (RBCs) membrane, causing the release of the
  hemoglobin and other internal components into the
  surrounding fluid.
• Visually detected by showing a pink to red tinge
  in serum or plasma.
• Common occurrence seen in serum samples and may
  compromise the laboratorys test parameters.

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Hemolysis Cause and Effect

• Hemolysis is caused by many variables including
• Traumatic Venipuncture
• Improper Handling and Processing of blood tubes
• Adverse conditions when transporting blood
  specimens

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Specimen Collection Technique

• Vein Size and Trauma
• Puncturing small or fragile veins and probing or
  fishing for the vein can lead to hemolysis
• If a vein is traumatized during puncture, the
  tube collected may be hemolyzed
• Avoid puncturing sites that have a hematoma.
  Hematomas are caused by blood leaking under the
  surface of the skin around the vein. If this old
  blood gets into your sample it will cause
  hemolysis

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Specimen Collection Technique

• Needle Size
• Using large bore needles can cause hemolysis by
  allowing a large amount of blood to suddenly
  enter the tube with great force
• Using needles that are too small causes hemolysis
  by forcing blood to travel through a small
  opening under great force due to the vacuum
  suction from the blood tubes.

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Alcohol Preparation

• Allow alcohol to dry completely prior to
  venipuncture. The needle can transfer wet alcohol
  from the skin into the blood sample and cause
  hemolysis

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Specimen Collection Technique

• Under filled Tubes
• Fill all tube to full capacity to ensure proper
  blood-to-additive ratio. Certain tubes contain
  additives and in high concentration due to
  insufficient blood sample these additives will
  cause hemolysis.

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Specimen Collection Technique

• Loose Connections
• Ensure that all components are tightened. Loose
  connection introduce air into the system and
  cause frothing in the specimen which will cause
  hemolysis.

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Specimen Collection Technique

• Extended tourniquet time
• A prolonged tourniquet time may lead to blood
  pooling at the venipuncture site, a condition
  called hemoconcentration. Hemoconcentration can
  cause hemolysis
• Ideally, the tourniquet should be in place no
  longer than one minute to prevent
  hemoconcentration

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Specimen Collection Technique

• Peripheral Catheter Collections
• Studies show that specimens drawn through an IV
  catheter are 3 times more likely to hemolyze than
  blood drawn through a straight venipuncture.

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Specimen Handling Techniques
                  
     

• Do Not draw above and IV.
• Mix the tubes through gentle tube inversion. DO
  NOT shake the tubes after collection.

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Why is Hemolysis so Important?

• Hemolysis can significantly elevate some results
  while significantly decreasing others.

Seriously Affected Noticeably Affected Slightly Affected
Potassium (K) LDH AST Troponin, HGB, Platelet Iron (Fe) ALT T4 Phosphorus Total Protein Mg Ca
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Post-care

• Release tourniquet
• Open pts hand
• Place gauze pad
• Remove needle
• Bandage the arm
• Dispose in sharps container

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Labeling Specimens

• At the Bedside

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Specimen Labeling

• The patient and patients blood sample MUST BE
  POSITIVELY IDENTIFIED AT THE BEDSIDE.
• Use TWO patient identifiers name and birth
  date.
• Position label over stickered area long-ways.
• Chill if required (gray) lactic acid or (green)
  ammonia.

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Documentation

• Location
• Number of attempts
• Name and title
• Time to lab
• Any patient comments

• Example
• Blood drawn left AC 1st attempt. Pt stated You
  are awesome! Blood to lab at this time.
• B. Safe, EDT.

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Blood Culture Collection

• Adult- 2 sets at different sites
• One green and one lavender
• Green only if not enough blood
• 8-10 cc per bottle
• Pedi-one set
• Yellow 1-4 cc

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Type and Screen

• BB band must contain 6 things
• BB, Pt name, Pt birthday, Date
• Phlebotomists initials and time.
• ID band and Orange Band must match.
• Label tube with BB small sticker
• Send rest of labels to lab

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QUESTIONS?