GARDEN CITY HOSPITAL LABORATORY

PHLEBOTOMY EDUCATION / TRAINING MANUAL

TABLE OF CONTENTS Title Page No.

Training Objectives.....................................................................................................1

Introduction.................................................................................................................2

Section I Equipment Venipuncture Equipment…………………………………………………….3 Section II Routine Phlebotomy Procedures Routine Venipuncture……………………………………………………..13 Skin/Capillary Puncture/Fingerstick………………………………………32 Section III Special Considerations/Venipuncture Complications Difficult Patients………………………………………………………......39 Site Selection……………………………………………………………...39 Venipuncture Complications……………………………………………...40 Timed Tests…………………………………………………………….....42 Blood Cultures………………………………………………………….....43 Isolation Patients………………………………………………………......46 Section IV Neonatal Blood Collection/PKU Screening Skin/Capillary Puncture/Heelstick………………………………………..47 References………………………………………………………………...53

TRAINING OBJECTIVES

Upon completion of this segment of training, the learner will be able to:

1. Perform routine venipuncture using: a. Evacuated Tube system (Vacutainer) b. Syringe c. Winged Infusion Set (Butterfly)

2. Perform capillary blood collection - Skin/dermal Puncture a. Fingerstick b. Heelstick

3. Identify possible complications of phlebotomy

4. Identify any special considerations required to perform the above tasks

The above objectives will be accomplished by various means:

Classroom instruction

Training manual

Peer simulation

Clinical practice

INTRODUCTION

Collecting a blood specimen from a patient consists of much more than inserting a needle in a vein or drawing a drop of blood from a finger.

It is the first link in a chain of events that is completed when a physician receives test results on his/her patients. As is true of any chain, each link is important. Since blood collecting is the first link in this chain, it is especially important.

This training manual includes information about blood collecting you must know and understand.

Things To Remember:

1. You are collecting a blood specimen for laboratory analysis that is necessary for the diagnosis and care of the patient.

2. You must obtain the blood specimen as skillfully as possible.

3. You must collect enough blood to perform the desired tests.

4. You must collect a proper blood specimen. ** It may be a "clot" specimen and the blood must be collected without using

an anticoagulant. ** If an anticoagulant is to be used, you must make certain you are using the

correct one. There are several kinds.

5. When obtaining a blood specimen, the patient's veins should be injured as little as possible.

6. Nothing should be done to make the patient any Unhappier than can be helped.

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SECTION I

VENIPUNCTURE EQUIPMENT

The first step in learning to perform a venipuncture is knowledge of the needed

equipment- An adequate amount of necessary equipment is essential at all times when

performing a venipuncture.

Equipment necessary to perform a venipuncture includes: Needles Winged infusion sets - butterflies Needle adaptors/tube holders Syringes Vacutainer collection tubes Tourniquets Antiseptic cleansing pads - alcohol, betadine, chloraprep Gauze Transfer devices Bandage or tape Gloves Needle disposal containers

1. ORGANIZATION OF EQUIPMENT

- equipment for phlebotomy is usually organized in a collection tray/cart - provides a conveuient way for the phlebotomist to carry equipment to the patient's

room - should be placed on a solid surface and NEVER within a patient's reach or on the

patient's bed where it could be knocked off - only needed equipment should be brought directly to tbe patient's bedside -duties of the phlebotomist include e1eaning, disinfecting and restocking of the collection

tray/cart

2. NEEDLES

- all needles used in veuipuncture are DISPOSABLE and used ONLY ONCE - needle size varied by both length and diameter

Needle Gauge:

- refers to the diameter ofthe needle bore - the larger the gauge number, the smaller the diameter oftbe needle

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- vary from large (16 gauge) needles used to collect units of blood, to much smaller (23 gauge) needles used for very small veins

- for routine phlebotomy, most needles are 21 or 22 gauge

Needle Length

generally 1 or I,S inches in length - butterfly needle is shorter, [/2 to 3/4 inch in length - needle selected will depend on the individual patient and on depth of vein

BEVEL ,.,,~- POINT

11---- SHAFT II--~- SHAFT

ll--- HUB

JI;t-- HUB

STOPPER-PUNCTURING END SYRINGE NEEDLE

- SHEATH

EVACUATED TUBE NEEDLE

3, NEEDLE ADAPIORSITIlBE HOLDERS

- needles used in tlieevacuated tube cdllectiotl system are designed to be secured into an adaptor that 110 Ids the co llectio rt tube

- made of clear, rigid plastic and has a needle safety shield attached to it

I-~-,--\--- TUBE ADVANCEMENT MARK

~4--- RUBBER SLEEVE

k-~- ADAPTER

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4. CQILECTION TUBES AND ANTICOAGULANTS

- ptimary tube used for blood collection: Eyacuated vacuum tubes a.k.a. Vacutainers

- wide variety of sized oftube - sterile . - made of plastic usually - some tubes are silicon coated to prevent cells from adhering to the tube preventing

activation of clotting factors - SOqle tubes are manufactured metal-free - some tubes contain clot activator to enhance clotting mctors - some contain additives or anticoagulants - to aid the phlebotomist in identifYing the many types of vacuum tubes, the tops are color

coded

Principles of Color-Coded Tubes:

- collection tubes used for blood specimens are "color-coded": the color of the tube stopper indicates which type of anticoagulant or additive is in the tube

- tests may be run onplasma, serum, or whole blood - some tests require the presence of preservatives, inhibitors, clot activators, or barrier

gels - to produce these conditions, some tubes will contain anticoagulants, or additives, and

others will not

Clot activatofs:

- substances the promote the activity of clotting factors helping the blood to clot quicker

- freeze-dried onto sides of tubes causing a cloudy look

Anticoagulants:

- substances that interfere with the activity of clotting factors and prevent the blood from clotting

- can be powdered or liquid - proper anticoagulant must be used for the specific procedure/test to be done - blood collected with one anticoagulant may be suitable for one test or group of tests,

but not fOf other tests

Serum Separator Tube Containing Gel (SST):

- gel provides a barrier between the serum/plasma from the red cells after centrifugation - provides better integrity of the specimen yielding a higher quality sample for testing - longer storage capability of specimen for testing

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Tube Top Color

AnticoagulanU Additive

Uses

Tube Top Color

Anticoagulant! Additive

Uses·

Red . (empty)

Plain Red

No Additives

No Gel Glass Tube

Drugs Progesterone

f-­Blue

'-"

Lt. Blue

Sodium

Citrate

PT PIT

GoldlRed Green

Clot Activator Heparin (Na or Li) Serum Separator Plasma Separator

Lyles Ammonia Glucose LAP

CH50 Fibrinogen Chemistry Tests AntibodyTests

I-: -:'-. Purple 1--:-p.\~ 6RA,/ Y,ll~

--

'-" '--'

LavenderlPink Gray Yellow

EbTA Oxalate ACb (SOhI A or B)

CBC Lactic Acid DNA Tests Differential GTT Flow Cytomelry Tests Platelets PCR Tests Retic Sed Rate Type & Screen Type & Crossmatch

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1. All tubes containing anticoagulants should be gently illverted back and [orih 8-10 times immediately after drawing to ensure uniform mixing with the specimen.

2. Light Blue Top Tubes (for coagulation testillg): ratio of blood to anticoagulant is critical in these tubes.

** These BUiE TOP TUBES MUST BE CQMPLETELY FILLED to ensure accurate results. ** Improperly filled tubes will result in rejection ofthe spccimen by lab testing personneL

3. FDPfFSP testillg - special tubes containing thrombill and a soybean trypsin inhibitor These tube will only draw 2 cc of blood and will clot Do not try to overfill.

4. Gold Top Tubes: contain a clot activator and separation gel at bottom of tube also referred to as serum separator tubes (SST)

- used for most chemistry tests

QRDER OF DRAW:

When collecting multiple specill1ens, the order in which tubes are drawn can affect some test results. Therefore, the followirlg order of draw/fill is recommended:

Order of draw usillg a vacutainer system or order offill using a syringe system: L Sterile specimens: blood cultures, SPS, ACD (yellow top) 2. Plam red top tube (glass, old blood bank: testing tube) 3. Light blue top tube 4. Gold top SST or red top tube with clot activator 5. Green top tube 6. Lavender or pillk top tube 7. Gray top tube

Order of draw usillg a butterfly syst= I. Sterile specimens: blood cultures, SPS, ACD (yellow top) 2. Clear capped discard tube or plain red top tube 3. Light blue top tube 4. Gold top SST or red top tube with clot activator 5. Green top tube 6. Lavender or pink top tube 7. Gray top tube Dark Blue Top Tubes are used for testing heavy metals. These tubes are available as three types: EDT A, beparill and non-additive. Place these ill the proper order of draw according to the type ofanticoagulant present or plam red top tube.

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Order of dnm:.Jilukin punctures; I. Lavender top tube 2. Green top tube 3. Yellow top tube

5. SYRINGES

generaHy preferred over vacuum tubes when drawing blood from patients with small or fragile veins, such as, elderly patients imd small children

- these types of veins may collapse when using an evacuated tube system

When using a syringe, the phlebotomist is able to control the suction pressure on the vein by slowly withdrawing the syringe plunger. Blood is drawn into syringe and transferred to the appropriate vacutainer tube using a transfer device. If a transfer device is not available place the tube in a rack, not held in the free hand, and the needle should be angled towards the side of the tube for gentler transfer of blood. Allow blood to be drawn by the vacuum in the tube, and not forced into the tube by pressing on the syringe plwlger. Mix tubes by gentle inversion.

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6. WINGED INFUSION SETSIBUTTERFLY NEEDLES

, c\._ ,.

- sometimes tiSedto collect blood from difficult patients, such 'as elderly patients and children with very small veins

. - butterfly needles are usUally 23 or 2i gllUgeand If2to 3/4 inches in length -butterfly need1escontain a safety shield - once the butterfly is in place, a syringeorvacut<)iner tube, With a tube holder, is used

to withdraw the blood from the vein

7. TOURNIQUETS

- used to IPake it eadiet to locate pati6nf'sveinsbyincreaSingvenousfiliing making veins

more prominent" andeasierto enter . ..' ....... .... . .•.. .' . - used to help proVide a larger amotiniofbloodfor collection - most frequently used tourniquets: .. , . flaflatex strips . .

penrose tubing blood pressure cuff . .

- tourniquets may be used only once but can be reused and cleap.ed With alcohol if soiled

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8. PUNCTURE SITE AUTLSEPTIC SUl'PLIES

- primary antiseptic used for cleansing skin in routine phlebotomy is 70% isopropyl alcohol

- when collecting blood cultures chloraprep or iodophorfbetadine is used - sterile 4" X 4 " gauze pads used for applying pressure to puncture site after the needle

has been withdrawn and used. to make a pressure bandage - bandage may be placed over puncture site when bleeding has stopped

9. TRANSFER DEVI.cEi

- used to transfer blood from a syringe to a vacutainer collection tube or blood culture bottle

- the safer way to transfer blood; less chance of source exposure than piercing needle through top of vacutainer tube or blood culture bottle

- proper use: a. unscrew safety shielded needle from syringe b. dispose of needlle in sharps container c. screw syringe into transfer device d. push vacutainer tube or blood culture bottle aU the way up on therteedle

hub inside e: ·allowthe vacuum in the. tube or bottle. withdraw the blood from the

syringe f when filled properly pull tube or bottle out of transfer d"viee g. properly mix tube or bottle

- dispose of the transfer device in the sharps contianer; like a tube h0ldertliere is a needle inside the transfer device hub

10. GLOVES

- must have an adequate supply of gloves at all times - MANDATORY when perfonuing phlebotomy - must be changed after each patient - should fit securely - provides a protective barrier between the phlebotomist and any infectious agent that

could enter the body through a cut or abrasion - protects both the patient and phlebotomist

** THERE IS NO EXCUSE FOR NOT WEARING GLOVES **

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II. NEEDLE DISPQSAL SYSTEMS

Number one personal safety rule in phlebotomy: ** NEYER RECAP A NEEDLE **

- to avoid accidental pWlctures, discard the needle directly into a puncture resistant container inrrnediateIy after use and never leave the used needle lying on the wDrk surface

- microcollection devices (Tenderfoot, lancets) and butterflies arc equally dangerolLs and should be disposed of in the same maWler

- never leave butterflies or syringes hanging out of the disposal container never reach into the dispDsal container when disposing of material as accidental pUllcture may occur from a previously discarded needle

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SECTION II

ROUTINE PHLEBOTOMY PROCEDURES

The purpose of this section is to present an overview of correct procedures for obtaining blood

specimens by venipuncture and skID puncture in an organized, patient -considerate manner on a

consistent basis.

ROUTINE VENIPUNCTURE

Basic Steps for Drawing a Blood Specimen by Vacutainer. Syringe, or Butterfly

1. Greet patient in a professional manner and explain procedure.

- explain that you are collecting a blood specimen - assure the patient and try to relieve any apprehension he/she may feel

assure them that although the venipuncture will be a little painful, it will be of short duration

- never tell the patient a venipuncture won't hurt - verilY patient's diet restrictions, as appropriate - ask patient fur allergies to latex, iodine or tape - if patient allergic to latex use latex free equipment: gloves, tourniquet, check butterfly

since latex may be present in the tubing ** A LATEX FREE PHLEBOTOMY TRAY SHOULD BE AVAILABLE **

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2.

.; .-" .. '-

IdentifY patient verbally and examine patient wrist identification band. ---.~" .--. ,. , --"- ~'.\-.

CH MRS. JONES?

Mrs. R. U. Jones Mrs. I. M. Jones

- most important procedure in phlebotomy is correct identification of the patient. - diagnostic or treatment errors, and even death, can occur when blood is drawn from the

wrong patient

** Identification is made by comparing information obtained verbally and from patient's wrist identification(ID) band with the information on the paperwork

(Cemer bar code label, addressograph, requisition or script). **

- all information on wrist ill band should match the information on the paperwork - if there are discrepancies; blood should not be drilwn until they are investigated and

resolved

** A PArTENT WUl, NOT HAVE PIDEBOIOMY PERFORMED IF WRIST ill BAND IS NOr PRESENT ON TIIE PATIENT'S BODY **

3. Put on gloves.

- mandatory, when performing venipuncture - do not pull fingertip of glove llway - must follow Universal Precautions and utilize Personal Protective Equipment (PPE) - this protects both you and the patient .

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4. Examine paperwork

Cerner bar code label is essential to provide: a. Information needed to correctly identifY the patient b. Organize necessary equipment c. Test orders d. Provide legal protection

Cerner bar code label should include the following infonnation: a. Patient's name. b. Patient's medical record c. Patient's location d. Tests requested e. Test priority f Requested collection date and time

- check the labels to make sure you understand all the orders on them - make sure you know what type ofblobd specimen is required, with or without

anticoagulant, and the amount of blood needed for each test ordered, and if special handling requirements are needed (hot, cold, light)

- if you do not understand an order ask and investigate

5. Select and organize correct tubes and required equipment for venipuncture.

Assemble the following supplies: a. Collection tubes as per test requirements b. Tourniquet c. Alcohol swabs, cWoraprep or iodine d. Gauze pads e. Evacuated system or syringe or butterfly (based on patient requirements) f. Needle and needle holder g. Tape or bandage

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6. Assemble and conveniently place equipment within easy reach

- assemble collection equipment, ready for use - place equipment so that it is readily available but not in danger of being upset by the

patient

7. Position patient for venipuncture

Position patient safely and conveniently for procedure so that: a. The vein you will use is readily accessible b. You are able to work in a comfortable position

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If a patient is in bed, he/she should be lying down on his/her back in acomfortable position

If a patient is not in bed ask him/her to lie down in bed or be seated in a chair and position and extend the arm on the annrest so as to form a straight line from the shoulder to the

. Wrist. - you may place a pillow or towel under the patient's arm for better support

l~ .• -l.. 1.0. SAND ------:,

TOURNIQUET

NOTE· NEVER attempt a venipuncture on a standing patient. Patients sometimes fullt after venipuncture and a standing patient might suddenly collapse.

Patients should remove any objects such as thermometers or gum from their mouths prior to the performance of the venipuncture.

8. Check for best suitable venipuncture site

Preferred Site: antecubital fossa located anterior to the elbow

The three major veins located in this area: a. Median Cubital- vein of choice b.Cephalic c. Basilic

- in most patients, at least one of these veins can be easily located

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CEPHAUCVEIN

_+-__ ElASIUC YElN

_l-'f--- MEOlAN CUBITAL VEIN

.... -1-___ BASIUC VBN

18~ <c~l ---'~~CL'-····-··- ..-£:B

vein

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[n some case, it may be necessary to lL';e the v,Tist or back of the hand veins. These may require use of a bunerily or syTinge (or venipuncture.

Crplulic Voin

OioiW V.i",

SUPERF.IClAl VEINS OF THE DORSAL ASPECT OF THEHAiJb

Areas to avoid when selecting a venipuncture site: a. Thrombosed Veins

- feel hard (sclerosed) and should be avoided as they may be blocked (occluded) and have impaired circulation

b. Mastectomy Side - can be harmful to patient; area more prone to infection due to removal oflymph

nodes - may produce erroneous test results (removal of lymph nodes interferes with flow

oflymph fluid and increases level ofwaste products nOIlllaily contained in the lymph fluid

c. Hematoma Sites - indicates blood has accumulated in the tissue suno unding a vein - puncturing into a hematoma is not only painful for the paticnt, but will also

result in the coilection of old hemolyzed blood from the hematoma - may cause h-r:l(lXth'"'ate results

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d. Shunt of Graft Sites - these af!1JS should be avoided due to possibility of infections

e. ScarredIBumed Sites - including tattooed areas (new tattoo within last year) - more susceptible to infection - have decreased circulation and veins are difficult to palpate

f. IV Infusion Sites - should perform venipuncture on other ann, if possible - if an arm containing an IV drip must be used, site selected must be below IV and

preferable in a different vein, disconnect IV for a couple of minutes when possible

- arm containing a Heparin IV drip can not be used for venipuncture if coagulation tests are requested

9. Apply tourniquet - should be applied 3 - 4 inches above sit~ where venipuncture will be made - do not apply too tight, may cut offblood flow or hurt the patient NOTE: Never leave tourniquet on for longer than I - 2 minutes - to do so may result in

hemoconcentration and homeless and in turn, a variation in test results.

A B

c _. 20 0

. Toumiq.ue:t 2pplia.tion. A...-Position th~-hta strip 3 to 4: inches:zOOve the v(':rupunaure SIte. B, Cross the tournIquet over ~e patient's :mn. G Tuck -a portion .of .one ~d under rhe .opPosite end to form :2 loop. D, Properly ::tpplied tourniquet

. ,", ,-

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10. IdentifY vein by palpation

, ' .. -

- apply tourniquet - ask patient to clench their fist - veins are located by sight and touch (palpation)

PALPATION is performed using your index finger with a pushing rather than a stroking motion. Helps to: a. Locate deep veins b. Distinguish veins, which feel spnogy, from rigid tendons c. Differentiates veins from arteries, which produce a pulse d. Determine direction and depth of vein to aid phlebotomist during needle insertion

11. Cleanse site and allow it to air dry a. Appropriate vein is located. b. Tourniqnet is released c. Remove the alcohol pad (70% isopropyl alcohol) from sterile package d. Cleansing is performed with a circular motion from the center of the site to the

periphery e. Allow the area to dry to prevent hemolysis of the specimen and a burning

sensation to the patient when the venipuncture is perfortned

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vqnlpuncture Site

** . NEVER WIPE ALCOHOL OFF WITII GAUZE, FAN OR BLOW ON PUNCTURE SITE **

NOTE: If additional palPation is necessary after the cleansing process, the phlebotomist should use alcohol to cleanse the gloved end of the finger to be used for palpatioIL

12. Perform the venipuncture

a. Re-apply the tourniquet and re-confirm suitability of site selected b. Grasp the patient's arm firmly, using your thumb to dr<iw the skin taut and

"anchor" the vein c. Line up the needle and holder/syringe parallel with the veip from which the blood

will be drawn. Needle is positioned for entry into vein with bevel facing up.

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d. Needle is inserted at an angle of 15 - 30 degrees depending on depth of the vein

EVACUATED TUBE

- should be done in a smooth continuous movement should be able to tell when tb,e vein has been entered by the feeling of a lessening of resistance to the needle movement

., If the vacutainer system is used to perform venipuncture: - Insert the vacutainer tube into the holder up to the reces:.;ed guideline. Do not puncture

seal in tube top .. If top is punctured the vacuum has escaped and the tube should not be used.

- Brace the hand holding the needle assembly on the patient's arm so as to minimize movement of the needle when changing tubes.

1'o$Irlonlnt of th~ ~ durlng V¢nlpunaut<O.. A, Anchorlng w vein. Il, lns=ing W .. =lie os- to 3O-<ks=: V1gr~). C; Adv:mdng the lUbe ontO th<: noedI", D, ~ IDe tub<: from the ~d.opcef.

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Figure 2. Proper Ahgle of Insertion (figure-contributed by the Center for Phlebotomy EDucation, Inc_)

Figure 3. Improper Angle of Insertion (Figure contributed by the Center for Phlebotomy Education, Inc)

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If a syringe is used to perfonn venipuncture: - \Vithdraw blood by slowly pulling back on the plunger of the syringe. - Brace the hand holding tbe syringe finnly on the patient's ann so that the needle will not

move when the plnager is pnUed. - Withdraw the reqnired amount of blood.

C. Co Uect and fill tubes in correct order

NOTE:If using a syringe, tubes will be filled with blood using a transfer device. Activate safety shield on needle and remove from syringe by tWisting. Dispose of needle in disposal container. Screw transfer device onto hnb of syringe. Place vacutainer tube inside transfer device and push all the way up. The vacuum from the tubes will draw the blood out from the syringe. Remove tube from transfer device and mix by gentle inversion. If a transfer device is not available, tubes may be filled when the needle is withdrawn from the patieut and puncturing the rubber tube stopper using a one-handed technique as described on page 9 and allowing the blood to flow slowly into the tube.

f Mix tubes promptly. - mixing is done by gently inversion as soon as the tube is removed, before

another tube is placed in the assembly - DO NOT SHAKE TUBE! MIX ONLY BY INVERTING. - vigorous mixing may cause hemolysis

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- last tube is removed from the assembly and mixed prior to completing venipuncture

- failure to do so may result in blood dripping from the end of the needle upon removal from arm

h. Release tourniquet

- remove the tourniquet prior to removing the needle by pulling on the free end of the tourniquet

- ask patient to relax hislher band

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L Remove needle smoothly and apply pressure 10 site

place sterile gauze pad over vcnipunc[1l[c site remove the needle apply pressure to the site as sooo as needle is withdrawn

[3. Dispose of needle in sharps container

- dispose of cootaminated needlelho[der or entire syringe assembly into appropriate sharps container

NEVERRBCAP A NEEDLE I!!

14. Examine venipuncture site to determine ifb[eeding has stopped

- ask patient is he/she is on blood thinners or daily aspirin - bleeding should stop with 5 minutes - before applying bandage examine patient's arm to make sure bleeding has stopped

If a patient continues to bleed: a, Apply pressure to site with gauze pad b. Wrap a gauze bandage tightly around the arm over the pad c. Ask the patient not to remove it for at least 15 minutes d. Ifbleeding persists fur longer than IS minutes, notifY nurse responsible for patient

15. Apply bandage to venipuncture site

bandage patient's arm after bleeding has stopped - instruct patient to keep the bandage on for at least IS minutes

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16. Label tubes properly

ADHESIVE BANDAGE

lubes must be labeled at time of specimen collection label tubes prior to leaving patient's room

Properly labeled tubes should conlain the following infonnation: a. Patient's full name b. Patient's medical record number c. Patient's location d. Collector tD. e. Collection date and time

If any of this information is missing, the specimen may be rejected by the laboratory.

Blood Bank speciffiens Patients that have an order for type & cross or type & screen need to have aBlood Bank patient identification wristband plaoedoll his!IJ.er arm. Thewcistbandisused for patient identification for blood transfusion and labeling the. specimelL .. The patient and specimen {;<.lllection infonnation is written on the yellow side <.If the 'i'flistba!1d. After the specimen is collected the wristband is placed on the patient's wrist. Making sure the wristband is not {oo tight, dose the lat{;h a!1d snap tightly. The wristband sfioWd not {;{}ffie <.lff or slip over the patient's wrist. Pull off the set ofyeUow numbered labels that is hanging from the wristband and deliver with tfiespecimen. Pull tfie yellow label Gmtaining tfie patient alld collection infonnation off the wristband and place on the specimen with the patient name t<.lward the top Dftfie vacutainer tube. Properly labeled Blood Bank specimens should contain the following infonnation on the patient Blood Bank identification wristband:

17. Remove gloves. - remove gloves before leaving the room - dispose of gloves in normal trash can, in bioha7Md containers if heavily soiled

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18. Wash hands - hands must be washed as per [nfectron Control Hand Washing Procedure

H CHANGE GLOVES AND WASH HANDS BET\VEEN EACH PATIENT **

19. Thank patient for hislher cooperation

20. Complete any required paperwork

21. Specimens should be placed in plastic bag with paperwork in outside pouch. Deliver specimens to appropriate location.

22. Clean up collection tray and restock

- tray must be kept clean at all times - should be checked frequently and supplies should be replenished as needed

NOTE' If a phlebotomist is unsuccessful in obtaining a blood specimen after two attempts at venipuncture, another phlebotomist should be asked to complete the procedure. A skin puncture may be perfonned if testing volume of blood allows it.

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SUMMARY OF VENIPUNCTURE TECHNIQUE USING A VACUTAINER

1" Obtain and examine the paperwork 2" Greet the patient 3" Identify the patient (compare information on paperwork with patient wrist lD band) 4" Reassure the patient 5" Put on gloves 6" Position (he patient 7" Assemble (he equipment and supplies 8" Apply the tourniquet 9" Select the venipuncture site 10" Release the toumiquet 11 " Cleanse the site and allo w to air dry 12_ Survey the supplies and equipment 13" Reapply the tourniquet 14_ ConfiIm the venipwlcture site 15_ Anchor the vein 16" Insert the needle, bevel up 17" Collect the required specinlellS, in the correct order; invert and mix each tube as required

Order 0 f draw: 3_ Sterile specinlens: blood cultures, SPS, ACD (yellow top tube) b" Plain red top tube (glass, no clot activator) c. Light blue top tube d" Gold top tube with gel or red top tube with clot activator e" Green top tube f Lavender or pink top tube g" Gray top tube

IS. Remove the last tubeforrn the holder 19" Release the tourniquet 20_ Place sterile gauze over the needle 21" Remove the needle and apply pressure 22" Dispose of the needle in the sharps container 23" Label tubes 24" Examine the patient's arm 25" Bandage the patient' s arm 26" Dispose of used supplies 27" Remove and dispose of gloves 28. Wash hands 29. Thank patient 30" Complete any required paperwork 31 _ Deliver specinlens to appropriate location 32. Clean up phlebotomy tray and restock

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SUMMARY OE~ENIPUNCT1)RE TECHNIQUE USING A SYRINGE

I. Obtain and examine the paperwork 2. Greet the patient 3. Identify the patient (compare information on paperwork with patient wrist ill band) 4. Reassure the patient S. Put on gloves 6. Position the patient 7. Assemble the equipment and supplies 8. Apply the tourniquet 9. Select the venipuncture site

- 10. Release the tourniquet II. Cleanse the site and allow to air dry 12. Survey the supplies and equipment 13. Reapply the tourniquet 14. Confirm the venipuncture site 15. Anchor the vein 16. Insert the needle, bevel up 17. Pull back on plunger slowly and collect appropriate anlOunt of blood 18. Release the tourniquet 19. Place sterile gauze over the needle 20. Remove the needle and apply pressure 21. Fill tubes in correct order using a transfer device

Order of draw: a Sterile specimens: blood cultures, SPS, ACD (yellow top tube) b. Clear cap discard tube or plain red top tube (giass,nodot activator) c. Light blue top tube d. Gold top tube with gel or red top tube with clot activator e. Green top tube f Lavender or pink top tube g. Gray top tube

22. Invert and gently mix tubes, as necessary 23. Dispose of the needle in the sharps container 24. Label tubes 25. Examine the patient's arm 26. Bandage the patient's arm 27. Dispose of used supplies 28. Remove and dispose of gloves 29. Wash hands 30. Thank patient 31. Complete any required paperwork 32. Deliver specinlens to appropriate location 33. Clean up phlebotomy tray and restock

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I. Obtain ;U!d examine the paperwork 2. Greet the patient 3. IdentifY the patient (compare information on paperwork with patient wrist ill band) 4. Reassure the patient 5. Put on gloves 6. Position the patient 7. Assemble the equipment and supplies 8. Apply the tourniquet 9. Select the venipuncture site 10. Release the toumiquet 11. Cleanse the site and allow to air dry 12. Survey the supplies and equipment 13. Reapply the tourniquet 14. Confirm the venipuncture site 15. Anchor the vein 16. Insert the needle, bevel up 17. Blood may be collected using a tube holder or syringe 18. Collect the required specimens, in the correct order; invert and mix each tube as required

Order ofdraw: a. Sterile specimens: blood cultures, SPS, ACD (yellow top tube) b. Clear cap discard tube or plain red top tube (glass, no clot activator) c. Light blue top tube d. Gold top tube with gel or red top tube with clot activator e. Green top tube f Lavender or pink top tube g. Gray top tube

19. Remove the last tube fonn the holder 20. Release the tourniquet 21. Place sterile gauze over the needle 22. Remove the needle and apply pressure 23. If a syringe was used transfer blood to tubes using a transfer device 24. Dispose of the needle in the sharps container 25. Label tubes 26. Exanaine the patient's arm 27. Bandage the patient's arm 28. Dispose of used supplies 29. Remove and dispose of gloves 30. Wash hands 3 1. Thank patient 32. Complete any required paperwork 33. Deliver specimens to appropriate location 34. CICful up prJebotomy tray and restock

31

30

CAPILLARY PUNCTURE f DERMAL PUNCTURE I FINGERS TICK

Although venipuncture is the most common phlebotomy procedure, it is not always appropriate or possible rn all circumstances. It is now possible to perform a majority oflaboratory tests on microsamples of blood obtaioed by dermal puncture (fingerstick) on both pediatric and adult patients. Dermal (capillary) puncture may be required because of the ioability to locate a suitable vern rn:

I. 2.

3. 4. 5. 6.

Burned or sC<jITed patients Patients receiviog chemotherapy who require frequent tests and whose veins must be reserved for therapy Patients with thrombotic tendencies Geriatric or other patients with very fragile veins Bandaged patients whose veins may be ioaccessibIe ., capillary glucose testrng

32

,-: ,

31

Many of the procedure steps associated with venipuncture also apply to capiUary puncture, therefore, in this section, major emphasis will be placed on technique unique to capillary puncture.

1. Patient preparation and identification·

- as per venipuncture procedure steps 1 - 7 check/examine paperwork verify patient lD pul on gloves select and organize equipment for pllJlcture

- ako ho I pad gauze skin puncture devices rnicrosarnple specimen containers

- bandage position patient for puncture

2. Cheek for suitable pllJlcture site

Primary capillary puncture sites: a Middle and ring fingers 0 f hand

- used on adults and children over 1 year of age - use central fleshy area on the pahnar side of these fingers

33

32

b. Heelstick - only used in infants less than 1 year of age

Areas to avoid when selecting a site: - callused areas - scarred areas - bruised areas - edematous (swollen) areas - infected areas - previous puncture sites - cyanotic (blue) fingers

Performing a fingerstick in any of the above areas is painful to the patient and will not yield a satisfuctory specimen.

3. Wann and massage the puncture site if necessary a. Warming the site before puncture may be required for patients with very cold

fingers b. Moisten a towel with warm water (40 degrees C) or use a commercial warming

pack/heel warmer and cover the site for 3 - 5 minutes c. Massaging the area before puncture increases blood flow to area d. Apply a massaging motion to the fleshy portion of the finger selected for

puncture

4. Cleanse and dry the puncture site

- cleanse selected'site with 70% isopropyl alcohol using a circular motion - allow alcohol to air dry

** DO NOT WIPE ALCOHOL OFF WITH GAUZE, FAN OR BLOW ON PUNCTURE SITE **

Failure to allow alcohol to dry will: a. Cause a stinging sensation for the patient b. Contaminate the specimen c. Hemolyze the red cells d. Prevent formation of a rounded blood drop because blood will mix with alcohol

and run down the finger

34

33

5. Perfonn the puncture

, .. ,.

a. Finger or heel should be well supported and held firmly, without squeezing the puncture site

b. Patient's middle or ring finger, palniar surfuce facing up, is held between the phlebotomist's thumb and index finger

c. Finnly grasp the sterile micro collection device

d. Finnly press the micro collection device against the finger. Depress trigger making a single punc,ture, perpendicular to the surfuce ofthe skir1, without delay in one smooth, downward motion. Cut should be made on the side of the finger and aligned to cut across (perpendicular to) the fingerprints.

e. Wipe the first drop of blood away with sterile gauze

- . prevents contamination of specimen with any residual alcohol and tissue fluid released during the puncture

f. Alternately apply and release pressure to area to obtain satisfuctory blood flow

** DO NOT MILK SURROUNDING TISSUE **

35

-' '"

34

6.

g. Collect the required specimens

- remove top from microtainer and place scoop on ~ microtainers will fill by capillary action; the collection top can be lightly touched

to the drop of blood and the blood will be drawn into the container - gently tap bottom of tube to force blood to the bottom - when enough blood has been collected, remove scoop, and attach color-coded

top to microtainer

NOTE: Microcollection devices should not touch the puncture site and should not be scraped over the skin.

{I .

l'

Position container directlY beneath

puncture site

Order of Draw: .

a. b. c.

Lavender top (EDTA) - must be collected first Green top (Heparin, gel) Yellow top (no additives, gel)

Mix the specimens as necessary

- tubes with anticoagulants should be gently inverted 8 - 10 times - lavender and green top microtainers should be shakeh intermittently while collecting the

specunen

7. Apply pressure to site

- elevate finger - use sterile gauze to apply pressure to puncture site

36

., '0

35

8. Dispose of puncture device in sharps container

9. Label specimens

- must be labeled with same information required for venipuncture specimens

10. Completion of procedure.

- same as for venipuncture

dispose of all used materials in appropriate containers remove gloves wash hands thank patient complete any required paperwork deliver specimens to appropriate location clean up collection tray and restock

NOTE: If a phlebotomist fails to draw the required specimens after two punctures, another phlebotomist should attempt to complete the collection.

37

36

SUMMARY OF DERMAL P1JNCTURE (CAPILLARY PIJNCnJRE) TECHNIQUE

L Obtain and examine the paperwork. 2. Assemble equipment and supplies 3. Greet and reassure the patient 4. IdentifY the patient. (compare information on label with patient's wrist ID band) 5. Put on gloves 6. Position the patient 7. Organize equipment and supplies 8. Select the puncture site 9. Warm and massage the puncture site, if necessary 10. Cleanse and dry the puncture site 11. Perform the puncture 12. Wipe away the first drop of blood 13. Collect the microtainers in the following order: lavender, green and yellow 14. Mix the specimens intermittently during collectio~ if necessary 15. Apply pressure to site 16. Dispose of puncture device in sharps container 17. Label specimens 18. Dispose of used supplies 19. Remove and dispose of gloves 20. Wash hands 2 L Thank patient 22. Complete any required paperwork 23. Deliver specimens to appropriate location 24. Clean up phlebotomy cart and restock

38

37

SECTION III

SPECIAL CONSIDERATIONS & VENIPUNCTURE COMPLICATIONS

The previous sections of this manual discussed the phlebotomy process in a routine situation.

This section will place emphasis on the complications andlor variances that may be encountered

when perfonning these procedures.

1. The Difficult Patient (uncooperative patient)

- patient may refuse to allow you to collect a blood specimen - some may be extremely apprehensive

What do you do? Never force a patient against their wishes. Use gently persuasion to reassure and calm the patient's fears and to convince the patient to allow you to collect the blood specimen. If this does not succeed, report situation to nursing.

2. Site Selection

Some factors may make site selection difficult: a. veins may have been damaged by many previous punctures or introduction

ofN fluids, chemotherapy drugs, etc. b. patients may be obese so that veins are hidden or deep c. veins may be small and delicate d. not all patients have veins that become immediately prominent when a

tourniquet is applied

Phlebotomists may have to use a variety of techniques to locate a suitable site: a. some patients have prominent veins in one arm and not in the other -

therefore, always check patient's other arm b. patients sometimes point out areas where they remember previous

successful venipunctures - palpation of the areas may prove beneficial and is also good for patient relations

c. techniques used to enhance prominence of veins include: - tapping the antecubital area with the index finger - massaging the ann upward from the wrist to the elbow - briefly hanging the ann down - applying heat to the site

NOTE· WHEN PERFORMING THESE TECHNIQUES, TOURNIQUET SHOULD NOT REMAIN TIED FOR MORE THAN 1 - 2 MINUTES

43

38

If no veins are found in the antecubital area of both arms, the wrist and hand veins should be examined or substitute a fingerstick for venipuIicture and obtain blood this way.

3. Venipuncture Complications

a. Failure to Obtain Blopd

Not all venipunctures result in the immediate appearance of blood - this is only a temporary setback that can usually be corrected by slight movement of the needle

Ifblood falls to enter the vacutainer or syringe, try the following: - the needle may not have been introduced fur e}lough - slowly advance it a little

more - if needle appears to have gone to one side of vein - partially withdraw the needle

and allow the needle to be slightly redirected - if you think that you have gone coropletely through a vein - slowly withdraw the

needle. As needle moves back into the lumen, blood will flow. Be careful not to withdraw the needle further once flow is established.

.

NOTE: Movement of needle should not include vigorous probing as this is not only painful to the patient, but also enlarges the puncture site so that blood can leak into the tissues and form a HEMATOMA.

• Col'rect Insertio!l technique . . (BIQOd flows freely Intoneedlel

' .• Needle rotated 45· {Allows blood to flow}

--- -.---

.• Bevel on loWer Wall of veIn ,(Does not allOW bloodto ":flow) '. .

• Nee<lle Inserte<ltoofar

. $) .•.

•. NOOdlepartiallylnserte<l (causes.blood to leak Into 44 tissue)

• Collapsed vein

i"-' p~c [C/SQ(l5 for .6.llurc to obt::ln bkxxi 39

-, e . b.

c.

What do you do if you still can't get blood from a vein?

- release tourniquet and give both patient and yourself a brief rest - reapply tourniquet to the other ann if available, and look for another vein - if you feel confident and have found an adequate vein, repeat the procedure

You still don't get blood - What now?

- don't try again after the second attempt - at this point, have another phlebotomist attempt and notifY nursing

Hematomas

- common cpmplication from venipuncture - occurs when needle is improperly placed in the vein, allowing blood to escape

from vein and collect under the skin

Bloodleakage foims hematoma

->:===Skin Vessel

Errors in technique that cause hematomas include:

- failure to remove tourniquet prior to removing needle - failure to remove last tube of blood from holder before removing needle - application of inadequate pressure to site after removal of needle - excessive probing to obtain blood - failure to insert the needle fur enough into the vein - inserting the needle through the vein , - bending the arm while applying pressure

Hemolyzed Specimens

- the liberation ofheruoglobin after RBCs have rupture . - w4en hemolysis occurs, the serum or plasma has a pink to red color -hemolysis produces interferences with many test results so that specimens may

be rejected by the laboratory and thus have to be redrawn

Common Lab Tests Affected By Hemolysis Potassium PT LDH PIT AST(SGOT)

45

40

Venipuncture Canses of Hemolysis

- using too smaJl a needle - forcing blood through the needle into the tubes when using a syringe - forcing blood through the syringe needle when blood is starting to clot - shaking the tubes too vigorously, instead of by gently inversion - drawing blood from a hematoma - pulling back on the plunger of the syringe too forcefully/too fast - leaving tourniquet on arm for too long

In Capillary Punctures, Hemolysis Occurs From:

- alcohol left on the skin mixes with blood to canse hemolysis - squeezing the finger (or heel) too hard causing RBCs to rupture

d. Specimen Rejection by Laboratory Personnel

SpecimeJ;1S will be rejected by laboratory personnel and reported to the nursing unit involved if the following problems should occur: - paperwork/order received, but no specimen sent - specimen sent, but no requisition or order in computer - incorrect specimen collected - unlabelled or mislabeled specimen - paperwork and specimen ID do not match - multiple orders, different sites, and no source is on specimen - inadequate volume of specimen (QNS) - hemolyzed specimen - clotted anticoagulated specimen received - specimen not labeled with collector ID, collection date and collection time

4. Special Considerations

a. Timed Tests

Some specimens need to be taken at specific timed intervals due to - medication - biologic variations

It is important that collection of specimens for timed tests be obtained the precisely specified interval/time.

Examples of these are: Glucose Tolerance Test Dexamethasone Suppression Test Drug levels for therapeutic drug monitoring

46

Renin Study 2 hour glucose Digoxin

41

b. Blood Cultures

Venipuncture technique for collecting blood cultures follows routine procedure with the exception of - increased requirements for asepsis - special collection vials for this purpose - can not collect specimen via vacutainer system

Eq uipment Required: synnge needlelbntterfly alcohol swabs iodophor preps chloraprep blood culture bottles (aerobic, anaerobic, pediatric) gauze bandages/tape tourniquet gloves transfer device

ProcedJlfe Steps For DrawingJilllQillLCulll1!:h

Follow procedure fur routine venipuncture using a syringe or butterfly and incorporate the following key steps: L Ask patient ifhe/she is allergic to iodine - may have to use more alcohol

scrubs or heavy duty soap 2. Cleanse area thoroughly as follows:

FIRST CHOICE: - squeeze chloraprep ampule until you hear it pop, then saturate the

applicator sponge tip - scrub pnncture site vigorously in all directions for 30 seconds - let air dry for 30 seconds 'without fanning, blowing or wiping away

gauze SECOND CHOICE: - using an alcohol prep;\~gorously scrub site, starting in the center and

progressing outward - apply iodophor prep to the area using the same technique - allow iodine to air dry, do not wipe oifwith gauze, fan or blow on

plll1cture site 3. Remove plastic cap from blood culture bottles and swab the rubber

stoppers ,,"ith alcohol pad and allow to air dry. Ifbottle is discolored, cracked, excessively cloudy or has bulging or indented stoppers do not m;e. Do not use past expiration date.

DO NOT TOUCH THE STERlLE RUBBER STOPPER

47

42

4. Using sterile s]Tingeibutrcrfly, draw 20 ccs of blood according to proper venipuncture technique.

5. Using a transfer device or the same needle, empty blood into blood culture bottles as follows:

10 ccs into BacT/ALERT FA (aerobic bottle, green cap) 10 ccs into BacT/ALERT FN (anaerobic bottle, orange cap)

Insert needle through sterile stopper. DO NOT touch stopper with fingers!

Ifblood is transferred from a syringe to the bottles, inoculate the anaerobic bottle firsL Ifblood is collected through a butterfly, inoculate the aerobic bottle first.

Ifless than 20 ccs blood collected, place equal amounts of blood in each bottle.

If4 ccs blood collected, place into BacT/ALERT PF pediatric blood culture bottle yellow cap).

If 5 - 10 ccs blood collected, place into the aerobic bottle only.

If a transfer device is not available, do not change needles to inoculate bottles. Use the same needle that is used for blood draw to enter into the blood culture bottles.

Transferring blood from other collection tubes (such as heparin or EDTA) into the blood culture bottles is unacceptable. Preservatives are toxic to bacteria and will inhibit or kill the organisms.

48

43

If specimen was collected fiorn a line enter this comment into computer and 13 bel specimen as SUelL

6. Mix bottles 2 - 3 times by gently inversion. 7. Properly label hoth bottles.

DO NOT COVER BAR CODE on blood culture holtles with ID label - do not place patient ID labdon bottom of bottle - hand write collector information on label: collector ill, collect date and

co lIect time if wlequal amounts of blood were placed into the blood culture bottles label each with tbe correct volume

Flf:ure 1-1 TypIClI/ IJ..aaJA.lBrr Culwrtc BOttle

~-TOf'

'"

PU= b~­

cod, labd hOT' (if ured)

8. Remove iodine from patient's arm 9. Place blood culture hottles in plastic bag and deliver to tbe appropriate

10catioLL

Blood cultures should be ordered X2 for most patients. 20 cc / drdw X 2 = 40ccs blood total for the two draws

A mininlUm 0 f 60 minutes time interval between the two blood culture draws unless otherwise specified by the physician.

Obtain two blood specimens, preferably from separate sites, prior to initiating antibiotic therapy. If this is not possible, draw blood immediately before administering the next antibiotic dose.

For Jimgal blood cultures, collect 10 ccs blood and inoculate aerobic FA (green cap) hottle.

49

44

For MycobacteriwnJ/IFB/TB blood cultures: Disinfect top of yellow top SPS tube with iodine. Allow (0 air dry.

~ Collect 10 ccs blood and inoculate SPS tube. ~ Invert 8 ~ to times to mix.

c. Isolation Patients

Patients are isolated for the following reasons: ~ to prevent disease 1rom spreading to other patients, fan1ily members, and

employees - to protect the patient from outside contamination

Isolation Category System ~ see isolation policy for detailed explanations Respiratory

~ Acid Fast Bacilli (AFB) or TB Modified Protective Isolation

l'rocedure to Follow When Drawing Blood EmrnJilllsiililtNul'aiimL

Prior to entering patient's room: ~ read and follow posted specific isolation precautions as per Infection Control

policy check orders and prepare supplies outside isolation room door

~ take in the minimum equipment needed

Upon entering the room: ~ place four or five paper towels on the table and place equipment on one or two

towels ~ washhands

put on gloves ~ follow proper venipuncture procedure to obtain specimens in the usual manner

place obtained specimens on paper towels discard needle in sharps container provided in patient's room

~ discard tourniquet and needle holder in appropriate biohazard container provided inpatient's room

~ clean tubes with an alcohol swab and place on a clean paper towel remove gown, mask, and gloves and dispose of them in the proper receptacle

~ wash hands ~ thank patient ~ place specimens in bag and deliver to the appropriate location

50

45

SECTION IV

NEONATE BLOOD COLLECTION

Microsamples from a heel stick are preferred for routine laboratory testing from neonates and

premature babies. This section will emphasize specimen collection te9hniques that are unique to

heel sticks and also neonatal screening procedures (i.e. PKU testing cards).

ROUTINE BLOOD COLLECTION BY HEEL STICK

1. Patient preparation and identification a. Review paperwork b. VerifY the patient ID by checking the patient ID band against the paperwork

" if the patient does not have an ID band the blood specimen is not collected

2, Gather necessary equipment a. nllcrotainer collection tubes b. ruicrocollection device or lancet c. alcohol prep d. gauze e. heel warmer £ bandage g. neonatal screening card ifPKU testing ordered

* use blue cards for initial screening, collected between 24 • 72 hours from birth

* USe pink cards fOr repeat testing h. gloves

3. Examine foot for puncture site a. The most desirable site for neonates is the MEDIAL (inside) or LATERAL

(outside) of the heel ' '

** To avoid injury to the heel bone, NEVER use the posterior curve (middle) .,. ofthe heeL **

\

CAL.:~OUS som;

46

b. Do not collect blood from a heel stick ifany of the following are evident: - compromised circulation to the extremity - edema is present - infection at the puncture site - patient is in shock

4. Heel Stick Procedure

a. Wash hands and put on gloves and other personal protective equipment as required b. Warm the heel with a warm washcloth or a commercial heel warming device c. Clean the puncture site with an alcohol prep and let air dry. Do not wipe alcohol

offwith gauze, fan or blow on puncture site. d. Hold the foot .gently but firmly "tennis racket" style - forefinger across the arch

and the thumb supporting the heel ** Holding the foot too tightly will cause bruising and restrict blood flow **

e. Puncture the heel. Hold the lancet device perpendicular to the heel and depress the lever.

f Wipe away the first drop of blood with gauze g. Gently squeeze the foot and relax to allow the blood to flow freely to the puncture h. Allow a large drop to collect and "hang" at the puncture site i Holding the microtainer tube at a downward angle, touch the tube "scoop"

opening to the drop of the blood. The blood will flow down the side and into the tube.

J. Continue to allow large drops to form, drawing the blood into the microtainers until the required amount is collected. It may be necessary to intermittently mix anticoagulated microtainers durJlg collection to prevent clotting of specimen.

k. Remove the "scoops" and seal the microtainers with the appropriate colored cap 1. The yellow top tube should be left to clot m Mix all anticoagulated tubes by gentle inversion. This is necessary to mix the

blood with the anticoagulant and thus prevent clotting.

5. Care of the puncture site

a. Place a piece of gauze over the puncture site and apply gentle pressure until the bleeding stops.

b. Report any abnormalities to the nurse, including: - any bruising at the puncture site or ankle - excessive bleeding - red marks

c. Do not apply adhesive bandage over the puncture site in neonates and preemies: - damage the skin of the baby when removed - baby may place bandage in its mouth and aspirate

55

47

6. Clean up

a. Dispose of the rr..icrocollection device in a 'sharps container b. Dispose ofthe gloves and equipment c. Wash hands

7. Finishing

a. Firmly attach correct patient labels to each tube of blood. Hand write collector ID, collection date and collection time.

b. Place specimen in baggie and paperwork in outside pouch c. Deliver specimen to appropriate IQcation

PEDIA TRICINEONATE BLOOD DRAW VOLUME LIMIT A nONS

The charts below indicate the blood draw limitation volrunes as stated in the "Handbook of Phlebotomy by Pendergraft: These volrunes indicate the rnaximrun volume of blood which can be drawn from a pediatric/neonate patient at anyone time.

Inpatient Draws Weight in lbs Maximum ccs/draw

0-8 2.5 8 - 10 3.5

10-15 5.0 16 - 40 10.0 41 - 60 15.0 61 - 100 ' 20.0

Outpatient Draws Weight in Ibs Maximrun ccs/draw

0-8 5.0 8 - 15 7.0

16-40 15.0 41 - 100 20.0

56

48

NEONATE PKU SCREENING

Neonate screening for phenylketonuria (pKU), hypothyroidisni, and other genetic anomalies is

mandatory by law. These diseases cause severe abnonnalities including mental retardation, ifnot

detected and treated early. Therefore, every newborn between 24 and 36 hours old is tested. The

neonate screening cards are supplied by the Michigan Department of Public Health. The cards are

color coded - blue cards for initial testing and pink cards for repeat testing.

Blood Collection for Neonate Screening

L The neonate screening may be collected with other routine blood work or separately as directed the physician

2. The preferred method of collection is the heel stick

3. Follow the heel stick procedure as listed to the point of collecting the blood into the rnicrotaiuer tubes

4. Applying the blood to the screening cards:

a Allow a large drop of blood to collect and "hang" at the puncture site b. Touch one of the circled areas of the filter paper to the drop of blood

- the drop of blood should be of sufficient six to fill, but not overfill the circle - The blood should be allowed to saturate through the filter paper. The circles

should look the same on both sides, - multiple drops on the same circle should be avoided - blood must be applied to only one side of the filter paper

c. Continue to fill each circle on the filter paper d, Allow the card to air dry flat at foam temperature for 3 - 6 hours

- DO NOT expose the cards to heat or direct swilight - DO NOT stack wet cards together

e. Review the information on the card, complete everything, including the date and time of collection

f Once the card is completely dry, place in a baggie and transport to the birthing center

5. DO NOT discard any PKU cards that are damaged, torn, scratched, unsatisfactorily collected, or in any way unacceptable

a. Indicate on the card that is unacceptable to use b. Cards may be returned to the state for a credit

57

49

Unacceptable Neonatal Screening Cards

The MDPH will reject any cards for testing if any of the following are present:

1. Missing patient information

2. The circle is not filled completely

3. The circle is overfilled or runs into another circle

4. There is evidence of multiple applications to the same circle

~. Clotted or caked blood on the filter paper

6. Filter paper is damaged, scratched, or non absorbent

7. Filter card is separated form the form

8. The specimen was not mailed within 24 hours or received at MDPB: within 14 days of collection

9. Specimen appears contaminated

10. Specimen placed in plastic bag while wet

58

50

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REFERENCES

NCCLS. ID-A4, Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard-Fourth Edition, June 1998.

NCCLS. H4-A4, Procedures and Devices for the Collection of Diagnostic Blood Specimens by Skin Puncture; Approved Standard-Fourth Edition, 1999.

Strasinger, Susan K, Dilorenzo, Mmjorie A., Phlebotomy Workbook For The Multiskilled Healthcare Professional; F. A. davis, Philadelphia: 1995.

Flynn, John C. (Ir), Procedures in Phlebotomy; W. B. Saunders Co., Philadelphis: 1994.

Homell-Kimmo, Lillian D., Laboratory Techniques for the Hemostasis of Blood; Organon-Teknika, Inc., Scarborough: 1984.

Blumenfeld, Thomas A., Stockbower, Jean M., Collection and Handling..QfLaboratory Specimens: A Practical Guide; J. B. Lippincott co., Philadelphia: 1983.

College of Amercian Pathologists, So You're Going To Collect A Blood Specimen, C.A.P., Skokie: 1980.

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53

PHLEBOTOMY H'LiMOR

"Pull Qut!PUllout! ... You've hftanartery!"

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