phlebotomy

Phlebotomy

MR. SURENDRA

Objectives

Theory and practice of phlebotomyHow to interact professionally with patients Occupational health hazards and appropriate

precautions Related anatomy and physiology Phlebotomy equipment and supplies Phlebotomy procedures Complications of venipuncture and how to

handle them.

Theory and Practice of Phlebotomy

What is phlebotomy

The term phlebotomy refers to the ancient practice of bloodletting

Now the term phlebotomy is used for the withdrawal of blood from a vein, artery, or the capillary bed for lab analysis or blood transfusion.

Who is a phlebotomist

Collects blood and other specimens Prepares specimens for testing

Interacts with patients & health care professionals

plays a vital role in any health care system

Who is a phlebotomist

Other medical professionals, including doctors, nurses, technologists, and medical assistants must also be trained to collect blood specimens.

Laboratory work flow cycle

Laboratory Workflow Cycle

Professionalism

Confidentiality

All employees are responsible for maintaining confidentiality of medical information

Attitude

Tone of voice and facial expression will determine how patients respond to you.

Always be polite, friendly, calm, and considerate.

Appearance

Your personal appearance will also affect the impression you make.

Comply with your facility’s dress code and personal appearance policies.

Safety

Blood-Borne Pathogens

Infectious micro-organisms which live in the bloodstream.

You can be exposed to bloodborne pathogens if you are injured with a contaminated needle.

You can also be exposed if your mucous membranes, including eyes, mouth, or the inside of your nose come into contact with contaminated body fluids.

Blood-Borne Pathogens

Diagram of Hepatitis C Virus

Occupational Health and Safety Administration of the federal government has mandated bloodborne pathogen training for all workers who are at risk of exposure.

OSHA Training

Standard PrecautionsPersonal Protective EquipmentHand WashingHazardous waste disposal Needle sticks and prevention act

Standard Precautions


Standard Precautions means treating all body fluids and substances as if they were infectious.


Potentially infectious body fluids include: Blood, Semen, Vaginal Secretion, Peritoneal, pericardial and pleural fluids, and Saliva

Sweat and tears are not generally considered infectious.

Personal Protective Equipment

Personal Protective Equipment

lab coatGlovesFace masks ( certain types of isolation)

Hand Washing

Hand washing is the single most important infection control measure.

Wash hands thoroughly before, after, and between all patient contacts.

Be sure to turn off faucets using a paper towel to avoid contamination.

Hand washing

Remove ringsStand by the sink but do not touch itApply soap and rub hands togetherBoth sides of the hand, between fingers,

around knuckles, under fingernailsRinse hands in a downward motionDry hands with a clean paper towelTurn off water with another paper towel

Hand Washing

Hazardous waste disposal

All needles & other sharps must be disposed of in approved sharps disposal containers.

Other contaminated waste must be discarded in an appropriate biohazard bag or waste receptacle.

Needlestick

Needle sticks and prevention act

Safety Devices should always be encouraged

Anatomy & Physiology


Anatomy is the branch of science concerned with the study of the structure of the body.

Physiology is the branch of science concerned with the study of the function of the body.


The cardiovascular system consists of the Heart, and Blood Vessels.

Its main function is circulate oxygenated blood from the lungs to various organs, and return blood depleted of oxygen to the lungs, where it is reoxygenated.

Blood Collection sites

Blood Components

Blood Components

Circulating whole blood is a mixture of: Plasma (which contains fluid, proteins,

and lipids), and Formed elements, consisting of red cells,

white cells, and platelets.

Whole Blood

Plasma

Blood cells

Blood Clot

When a blood sample is left standing without anticoagulant, it forms a coagulum or blood clot.

The clot contains coagulation proteins, platelets, and entrapped red and white blood cells.

Serum

Serum contains all the same substances as plasma, except for the coagulation proteins, which are left behind in the blood clot.

Equipment

Trays

Trays should be sanitized daily using appropriate disinfectant

Kept Organized and well-stocked.

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.

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.

LAVENDER

EDTA to prevent clotting

hematology studies. Should be completely

filled Must be inverted after

filling

LIGHT BLUE

sodium citrate.coagulation (clotting)

studies. must be completely

filled must be inverted

immediately after filling

GREEN

sodium or lithium heparin

for tests requiring whole blood or plasma such as ammonia

RED

No additivesBlood bank tests,

toxicology, serologyMust not be inverted

after filing

GRAY

Inhibitor for glycolysis + anticoagulant

Sodium Fluride +potassium oxalate.

glucose levels.

YELLOW

Acid citrate dextroseInactivates

complementsDNA studies,

paternity testing

ROYAL BLUE

heparin or Na EDTA anticoagulants

Tube is designed to contain no contaminating metals

Trace element and toxicology studies

Blood Culture Bottles

Different blood culture bottles are used for aerobic, anaerobic, and pediatric collections.

Blood collection tubes: Safety

The rubber stopper is positioned inside the plastic shield

Sizes

Adult:3 - 10 mlPediatric 2 - 4 ml. Tubes for fingersticks

or heelsticks ½ or less

Expiration Dates

Holders

A plastic holder must be used with the evacuated tube system.

Needle holders with built-in protection devices

Syringes

Syringes with built-in safety devices

Needles

Needles

Different sizes. size =gauge. The larger the needle, the smaller the

gauge number. 21 or 22 gauge needle is mostly used.

Needle Components

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.

Multiple Draw Needle

Used with vacuum collection tubes.

They have a retractable sheath over the portion of the needle that penetrates the blood tube.

Needles with built-in safety devices

An internal blunt needle that is activated with forward pressure on the final blood tube prior to withdrawal of the needle from the vein.

Butterfly Needle

Winged infusion setDifficult venipunctures

including pediatric draws

with a syringe or a holder and vacuum collection tube system.

21, 23, or 25 gauge.

Butterflies with built-in safety features

number-one cause of needlestick injuries, so proper use of their safety devices is critical.

Butterflies with built-in safety features

Lancets

Lancets are used for difficult venipunctures, including pediatric draws.

Tourniquets

Vein easier to SEE, FEEL, and PUNCTURE

Sterilization

Bandaging Material

Gloves

Gloves must be worn for all procedures requiring vascular access.

Non-powdered latex gloves are most commonly used;

Sharp Disposal Container

Marking Pen

Collecting Blood

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.

Knock on the patient’s door before entering.

Identify yourself by name and department. Explain the reason for your presence.

The more relaxed and trusting your patient, the greater chance of a successful atraumatic venipuncture.

Technical Tip

Good verbal, listening, and nonverbal skills are very important for patient reassurance

Technical Tip

Patient Identification

Make sure the name, medical record number, and date of birth on your order/requisition match those on the patient’s armband.

Verify the patient’s 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.

A hospitalized patient must always be correctly identified by an ID band that is attached to the patient.

Technical Tip

Wash hands

Apply gloves

Patients are often reassured that proper safety measures are being followed when gloves are put on in their presence.

Technical Tip

Position the Patient

Comfortable positionTurn the arm so that the wrist and palm

face upward, and the antecubital area is accessible

When supporting the patient’s arm, do not hyperextend the elbow. This may make vein palpation difficult.

Technical Tip

Applying the tourniquet

Tie the tourniquet just above the elbow.The tourniquet should be tight enough to

stop venous blood flow in the superficial arm veins.

The tourniquet should be applied a maximum of 1 – 2 minutes.

Applying the tourniquet

After applying the tourniquet, you may ask the patient to make a fist to further distend the arm veins.

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

Technical Tip

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.

Using the nondominant hand routinely for palpation may be helpful when additional palpation is required immediately before performing the puncture.

Often, a patient has veins that are more prominent in the dominant arm.

Technical Tip

Scarred, abraded, or inflamed skinArms containing IV cathetersEdematous armsOccluded VeinsShunts

draw from these areasNever

Cleansing the site

Isopropyl alcohol swab Outward expanding spiral starting with the

actual venipuncture site.Allow the alcohol to dry:- 1-disinfect the site2-prevent a burning sensation

Cleansing the site

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.

Technical Tip

Attach needle to holder

Place tube into holder

Hold vein in place

Insert needle

the needle bevel up

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.

Allow tubes to fill until the vacuum is exhausted to ensure the correct blood to anticoagulant ratio.

Technical Tip

Blood won’t flow

If you do not see blood flow, the tip of the needle:

1. May not yet be within the vein.2. May have already passed through the

vein.3. May have missed the vein entirely.4. May be pushed up against the inside wall

of the vein.

TROUBLESHOOTING

Incomplete collection or no blood is obtained:


Change the position of the needle. Move it forward (it may not be in the lumen)


or move it backward (it may have penetrated too far).


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


Loosen the tourniquet. It may be obstructing blood flow.

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.

Other Problems

A hematoma forms under the skin adjacent to the puncture site - release the tourniquet immediately and withdraw the needle. Apply firm pressure.

Other Problems

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

Multiple Tube Collection

If you are drawing more than one tube:

Keep a firm grip in the needle holder while pressing down on the patients arm.

Use your other arm to interchange tubes.

Order Of Draw

Order of draw

Removing the Needle

Gently release the tourniquet before the last tube of blood is filled

Remove the last tube from the needleWithdraw the needle in a single quick

movement

Apply Pressure

Quickly place clean gauze over the site, and apply pressure.

You may ask the patient to continue applying pressure until bleeding stops.

Apply Adhesive bandage

The practice of quickly applying tape over the gauze without checking the puncture site frequently produces a hematoma

Technical Tip

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.

Specimen Labeling

Label specimens at the bedside according to your institution’s standard procedures, or apply preprinted labels.

Proper labeling is the single most critical task you are asked to perform.

Proper labeling generally includes:

Patient’s first and last nameHospital identification numberDate & timePhlebotomist initialsYour institution may provide bar coded

computer generated labels that contain this information.

1. requisition form.2. Greet the patient.3. Identify the patient.4. Reassure the patient and explain the procedure.5. Prepare the patient.6. Select equipment and supplies.7. Wash hands and apply gloves.8. Apply the tourniquet.9. Select the venipuncture site.10.Release the tourniquet.11.Cleanse the site.12.Assemble equipment.

Summary Of Venipuncture Technique


13.Reapply the tourniquet.14.Confirm the venipuncture site.15.Examine the needle.16.Anchor the vein.17.Insert the needle.18.Push the evacuated tube completely into adapter.19.Gently invert the specimens, as they are collected.20.Remove the last tube from the adapter.21.Release the tourniquet.22.Place sterile gauze over the needle.23.Remove the needle, and apply pressure.24.Activate needle safety device.


25.Dispose of the needle.26.Label the tubes.27.Examine the patient’s arm.28.Bandage the patient’s arm.29.Dispose of used supplies.30.Remove and dispose of gloves.31.Wash hands.32.Complete any required paperwork.33.Thank the patient.34.Deliver specimens to appropriate locations.

Syringe Specimen Collection

Small or delicate veins that might be collapsed by the vacuum of the evacuated tube system.

May also be used to collect blood culture specimens.

Finger stick-Specimen collection

A safety Lancet, which controls the depth of incision

Finger-sticks should not be performed on children under one year of age.

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.

Finger stick

Select a safety lancet appropriate for the size of the patient’s finger.

You may warm the finger prior to puncture to increase blood flow.

Make the puncture perpendicular, rather than parallel, to the finger print.

Finger stick

Wipe away the first drop of blood using gauze to remove tissue fluid contamination.

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.

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.

Heel stick neonatal blood collection

These devices are designed to control the depth of incision, since going too deep into an infant’s heel could injure the heel bone, and cause osteomyelitis (bone infection).

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.

Heel stick

Puncture the left or right side (outskirt) 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.

Heel stick

Collect the blood into the appropriate tube.

Do not: Squeeze the infant’s foot too tightly and wipe with alcohol during the collection.

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 infant’s foot since it may injure its delicate skin.

Heel stick

Butterfly

Butterfly needles (winged infusion set)

are available in smaller gauges, and are used to draw venous blood from children, and adults with difficult veins.

Butterfly

Butterfly needles come attached to a small tube which may be connected to:

An evacuated tube holder, or A syringe.

Butterfly

Special situations

Patients refusing blood work

If someone hesitates to let you collect a blood specimen, explain to them that their blood test results are important to their care.

Patients have a right to refuse blood tests If the patient still refuses, report and

document patient refusal

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 won’t hurt themselves.

self-limited

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 his head between

his knees. A cold compress on the back of the neck may

help to revive the patient more quickly.

Unsatisfactory Specimens

They can cause misleading laboratory results Must be rejected by the laboratory. The patient must then undergo another

venipuncture to get a better specimen. It costs time & money to redraw the specimen. The credibility of the laboratory is reduced if too

many unsatisfactory specimens are drawn.

Causes of Unsatisfactory Specimens

Hemolysis

Hemolysis

Hemolysis means the breakup of fragile red blood cells within the specimen, and the release of their hemoglobin and other substances, into the plasma.

A hemolyzed specimen can be recognized after it is centrifuged by the red color of the plasma.

Causes of Hemolysis

Using a too small needle for a relatively bigger vein

Pulling a syringe plunger too rapidlyExpelling blood vigorously into a tube, Shaking a tube of blood too hard.

Hemolysis

Hemolysis

Hemolysis can cause falsely increased potassium, magnesium, iron, and ammonia levels, and other aberrant lab results.

Clots

Blood clots when the coagulation factors within the plasma are activated.

Blood starts to clot almost immediately after it is drawn unless it is exposed to an anticoagulant.

Clots within the blood specimen, even if not visible to the naked eye, will yield inaccurate results.

Causes of Clots

Inadequate mixing of blood and anticoagulant

Delay in expelling blood within a syringe into a collection tube

Insufficient volume

Insufficient volume

short draws will result in an incorrect ratio of blood to anticoagulant, and yield incorrect test results.

Short draws can be caused by:A vein collapsing during phlebotomy.The needle coming out of the vein before

the collection tube is full.Loss of collection tube vacuum before the

tube is full.

Labeling Errorrs

Labeling errors are the most common cause of incorrect laboratory results.

If detected, the incorrectly labeled specimen will be rejected.

If undetected, it will produce incorrect results which might adversely affect your patient’s care.

Causes

Failure to follow proper patient identification procedure.

Failure to label the specimen completely and immediately after collection.

Ten Commandments I. Thou shalt protect thyself from injury II. Thou shalt identify thy patients III. Thou shalt stretch the skin at the puncture siteIV. Thou shalt puncture the skin at about a 15 degree angle V. Thou shalt glorify the median vein VI. Thou shalt invert tubes containing anticoagulants

immediately after collection VII. Thou shalt attempt to collect specimens only from an

acceptable site VIII. Thou shalt label specimens at the bedside IX. Thou shalt know when to quit X.Thou shalt treat patient's like they are family

Healthcare in the new millennium

THE END

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