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PHLEBOTOMY REVIEW SHEET

HIPAA Health insurance and portability accountability act

Joint Commission a voluntary no governmental agency, establishes standards for the

operations of healthcare facilities and services

CLSI clinical laboratory standards institute

CLIA 1988 clinical laboratory improvement amendments of 1998

OSHA occupational safety and health administration

MSDS material safety data sheet, contains general information as well as precautionary and

emergency information for any product with hazardous warning label

National Patient Safety Goals overall CQI requirements for accreditation, establishes in 2002

the goal have specific requirements for protecting patients... Identify patients, improve staff

communication, and prevent infection.

Negligence failure to exercise due care

Assault and Battery assault an act or threat causing another to be fear of immediately

batterybattery intentional harmful or offensive touching or use of force on a person

without that person consent or legal justification.

Consents ask for permission before treat patientthere are five kinds of consent.. Inform

consent, expressed consent, implied consent, HIV consent, and consent for minors.

Chain of custody for legal proceeding strict protocols that require detailed documentation

tracking the specimen from the time it is collected until the result are reported

Patients Bill of Rights

Hand Hygiene it is the most important means of preventing the spread of infection. Hand

washing should take at least 15 sec. CDC recommends the use of alcohol based antiseptic in

place of hand washing as long the hands are not visible soiled

Signs and symptoms of shock common signs and symptoms are pale, cold, clammy skin,

expressionless face and staring eyes. If the phlebotomy is performing venipuncture the first

step is to remove the tourniquet, remove the needle, call for assistance and place the patient

lying down with the head lower than the rest of the body

Signs and Symptoms of syncope, stroke, and seizure the medical term for fainting is syncope,

described as a loss of consciousness and postural tone. Any patient has the potential to faint.

Signs to watch for include pallor, perspiration, and hyperventilation or indication from the

patient that they are experiencing vertigo, dizziness, light headedness or nausea.

If any of these signs and symptoms occur release the tourniquet and remove the needle as

quick as possible, apply pressure to the site while having the patient the patient lower the

head and breathe deeply

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Seizures could occur during venipuncture, in the rare event that the patient has a seizure

during a blood specimen collection, discontinue the blood collection removing the tourniquet

first and then the needle, hold pressure on the site, do not attempt to put anything into the

patients mouth, try to protect the patient from self-injury, without restricting the patient and

call for help.

Complications of venipuncture. Hematoma, hemoconcentration, phlebitis, petechiae,

thrombus, thrombophlebitis, septicemia, trauma.

Considerations, challenges and complications on a pediatric patient

Considerations for a psychiatric patient

Proper positioning for patients with syncope, seizures

Preferred veins for venipuncture and locations of the veins veins to avoid for venipuncture

the preferred site for venipuncture is the anticubital fossa where you will see the

Medial cubital vein, the vein of choice because is large and doesnt not tent to move when the

needle is inserted.

Cephalic vein, the second choice. Its more difficult to locate and has the tendency to move,

however is the only vein that can be palpate in an obese patient

Basilica vein the third choice, its the least firmly anchored and located near to the brachial

artery, if the needle is inserted too deep the artery may be puncture

Differences between plasma and serum blood that has been removed from the body will

coagulate within 30- 60 min, the clot consist of the blood cells enmeshed in a fibrin network.

The remaining fluid portion is called serum. Serum has the same composition of the plasma

except that it does not contain fibrinogen, because the fibrinogen was used in the formation of

the clot. Blood can be preventing from clotting by adding a substance called anticoagulant.

Adding an anticoagulant initially creates a whole blood specimen, but when it is centrifuged, it

separates into three different layers, bottom layer of red blood cells, a thin fluffy looking

whitish color middle of WBC and platelets referred as a buffy coat, and the top layer of liquid

called plasma

Anatomical terms

Lumbar punctures cerebrospinal fluid CSF is a clear, colorless liquid that surrounds the brain

and the spinal cord. Specimens are collected by the physician through lumbar puncture- spinal

tap, the main reason to collect CSF is to diagnose meningitis, and the specimen is collected in

three different tubes used for chemistry, microbiology and cell count. Should be storage a

room temperature, delivered stat.

Bilirubin specimen collection, post venipuncture precautions to ensure an accurate result

Neonates is commonly tested to detect and monitor bilirubin levels. Bilirubin can cross the

blood barrier in infants, accumulating to toxic levels that can cause permanent brain damage

or even dead. Bilirubin specimens are collects by heel puncture, proper collection procedure is

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very important for the test results. Specimens has to be protected from light during

transportation and handling, to reduce light exposure specimens are collected in an amber

colored micro collection tube, and must to be handle carefully to void hemolysis, also must to

be collected as close as possible to the time requested

Steps for verification of patient before venipuncture the process of verifying a patient is the

most important step in the specimen collection. The patient has to be actively involved in the

identification process. When identifying the patient ask the patient to state her- full name an

date of birth, the patient response must to match with the requisition slip. Any errors or

differences must to be resolved before a sample is collected

Information in the doctors requisition form

Patient identification 3 way ID - missing ID Emergency Room ID procedure to void

identification errors, some facilities require what is called 3 way ID, in which the patient is

identified by three means, the patients verbal ID statement, a check of the ID band, and a

visual comparison del specimen labeled against the patient ID band before leaving the bedside.

Never verify information from an ID band that is not attached to the patient or collect a

specimen from a patient who is not wearing an ID band. If there is no ID band ask the patient

if you can check if the ID is in the ankle.

It is not uncommon to receive unconscious patients in the emergency room, so clear guidelines

are to follow to this circumstances, assign a temporary number to the patient and record it on

the request forms, fill out labels and apply them to the test request and specimen after

collection, when a permanent number is issued must to be cross-referenced to the temporary

number. In many institutions is used a 3 part identification band to the unidentified ER patient

wrist , all three part contain the same number, the first becomes the patient ID band, the

second part is attach to the specimen and the third is used if the patient needs a transfusion

and it is attach to the unit blood .

Most important information to verify prior to obtaining a specimen collected by a patient, and

before to do venipuncture before performing blood collection make sure you have the ,

laboratory requisition, all the supplies_ antiseptic 70 percent isopropyl alcohol, ETS, tubes,

tourniquet, gauze, bandage, verify patient identity, specimen labels, gloves.

Proper labeling of specimens tubes must to be labeled in the presence of the patient

immediately after blood collection. Before leaving compare the information on each labeled

tube with the patient ID band and requisition

Dermal puncture for patients older than one year old location the CLSI recommended site for

capillary puncture on adults and children older than 1 year old is the palmar surface of the

distal or end segment of the middle or ring finger of the no dominant hand. The puncture

should be in the central, fleshy portion of the finger, slightly to the side of center and

perpendicular to the grooves in the whorls of the fingerprint

Dermal puncture on an infant, depth of dermal puncture and selection of lancet the heel is

the recommended site of capillary puncture specimens on infants less than 1 year old.

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According to CLSI the safe areas for heel puncture are on the plantar surface of the heel,

medial to an imaginary line extending from the middle of the great toe to the heel. To void any

risk of puncturing the bone osteomyelitis the puncture has to be 2.0 mm deep or less, and the

lancet selection has to be the adequate

Complications of dermal puncture

Finger stick procedure selects the puncture site... Middle finger. Clean the site with 70

isopropanol alcohol and allow it to air dry , prepare the equipment , puncture the site, and

discard the lancet, wipe away the first blood drop, collect the blood, place a gauze an apply

pressure, label the specimen, double check the site and apply bandage.

Point of care testing also known as alternative site testing, brings laboratory testing to the

location of the patient, to the convenience to the patient and a short turnaround time for

results that allow healthcare providers to address patients needs. An example of this test

could be a urine dipstick, pregnancy test, glucose test, occult blood-guaiac, hemoglobin

Peripheral blood smear blood to make a slide can be obtained by normal finger puncture,

following the same steps, the drop should be 1 to 2 mm in diameter and centered on the slide,

the second slide called pusher is held at one end making a 3 degree angle the blood must to

spread the width of the pusher slide. The correct blood smear result is going to reflects a

feathered edge

Causes of Hemolysis results when RBc are damaged or destroyed and the hemoglobin they

contain escapes into the fluid portion of the specimen, the red color of the hemoglobin makes

the serum o plasma appear pink. Causes for a hemolyzed specimen are, drawing blood from a

hematoma, mixing the tubes vigorously, shaking them or inverting to quickly, needle too small

Causes of Hemoconcentration a decrease in the fluid content of the blood with a subsequent

increase in noon filterable large molecule or protein based blood components such a red blood

cells. Causes for hemoconcentration are, patient keeping a fist during venipuncture, or allow

the patient to pump the fist, massage of the area to being puncture, probing the needle, and

keep the tourniquet longer than a min.

Hemostatic process is a process by the body stops the leakage of blood from the vascular

system after an injury, also known as coagulation process. This involves 4 interrelated

responses, vasoconstriction, formation of the platelet plug, in the injured area, if is needed

formation of a second hemostatic plug, and fibrinolysis.

Causes of Hematoma- actions taken for a phlebotomist when developing a hematoma

hematoma is common complication of venipuncture, is caused for blood leaking into the

tissues during o following venipuncture, and is identified by rapid swelling at or near the

venipuncture site. This can occur when the vein is too small for the needle size, the needle

penetrates all the way through the vein, the needle is removed while the tourniquet is on, and

pressure is not adequately applied after venipuncture. Collecting specimen from a hematoma

that is forming has the high probability of being hemolyzed and being rejecting for testing

because the blood has mixed with tissue fluids from outside of the vein

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Thrombus this is a blood clot usually a consequence of insufficient pressure applied after the

withdrawal of the needle

Thrombophlebitis Inflammation of a vein with formation of a clot

Petechiae these are tiny non raised red spots that appear on the skin from rupturing of the

capillaries due to the tourniquet being left on too long or too tight

Edema is swelling caused by abnormal accumulation of fluid in the tissues. Specimens

collected from edematous areas may yield inaccurate test results owing to contamination with

tissue fluid or altered blood composition.

Mastectomy Blood should never be drawn from an arm on the same side as a mastectomy

without asking the physician first.

ABG test transportation

Iatrogenic anemia blood loss as a result of blood removed for testing is called iatrogenic

anemia. The main reason for blood transfusion in PICU is to replace the iatrogenic blood loss.

The volume of blood that can be safely remove at once or during a short period of time is 10

percent of the body weight

Blood culture for pediatric - proper procedure for collecting blood culture for adults patients

it is known that bacteria can enter to the circulatory system causing bacteremia o septicemia.

Blood cultures help to determine the present and extent of infection as well as indicating the

type of organism responsible. Skin antisepsis is a critical part of the blood culture collection.

Traditionally povidone iodine, betadine swabs, cloroprep, are used to clean the collection site,

cleaning in concentric circles without going to the area more than once. The area covered

should be 3 to 4 inches in diameter, with a 30 sec scrub. Blood cultures are collected in special

bottles, one aerobic with air, and one anaerobic without air, being the anaerobic bottle filled

first. Typically adult blood culture require 10 to 20 ml per set, while pediatric blood culture

require 1 to 2 ml per set

Precautions taken when performing venipuncture on a patient with mastectomy, fistulas, IV

never apply a tourniquet o perform venipuncture in an arm with an arterial line, shunt, or from

a mastectomy site. If patient has an IV collect the specimen from the other arm, if not able to

do it collect the specimen from bellow the IV site

Preanalitical considerations for a GTT test GTT test is used to diagnose problems of

carbohydrate metabolism, evaluates the bodys ability to metabolize glucose. Preparation is

very important, the patient must to fast at least 12 hours, but not more than 16 hours before

the test. The GTT test is collected 30 min, 1 h, 2h, 3h and so forth, after the patient finishes the

glucose beverage

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Start timing for a GTT this test is to diagnose diabetes, for hyperglycemia is a 3 hours test, for

hypoglycemia is a 5 hour test, usually are scheduled to begin between 0700 and 0900 am. The

GTT are typically collected after 30 min, after the patient finishes the beverage

Reasons for a finger stick though point of care testing

1. PKU test in newborn this test is ordered for infant to detect phenylketonuria, a genetic

disease that causes mental retardation and brain damage. Its required by law in all 50

states. The PKU testing typically requires the collection of two specimens, one shortly

the infant is born and another after the infant is 10 to 15 days old. The test is done

from blood from the newborns heel or on urine

Urinalysis testing and proper collection techniques UA is the most common urine test

requested, it screens for urinary and systematic disorders. UA typically includes physical,

chemical, and microscopic analysis.

Culture and sensitive test may be requested for patient with symptoms of urinary tract

infection UTI. The urine must to be collected in a sterile container, following clean catch

procedures to ensure that the specimen is free of contamination. Also must to be midstream

collected. For clean catch the patient must to specially clean the genital area and then proceed

to collect the urine mid-stream. To collect a midstream specimen, the patient void the initial

urine flow into the toilet, and then the middle stream must to be collected in the sterile

container, the last urine flow is voided into the toilet.

24 hour urine specimen. The best time to begin the collection is when the patient wakes up in

the morning

Stool sample and testing fecal specimen are used to evaluation of gastrointestinal disorders.

Stool specimens can be evaluated for the presence of intestinal parasites and their eggs ova

and parasites, checked for fat and urobilinogen content, culture to detect pathogenic bacteria,

viruses and to detect occult blood using the guaiac test. Stool specimen should be collect in dry

and clean containers and sent to the lab immediately. Preserved specimens used for 24, 48, 72

hour stool collection for fecal fat and urobilinogen are normally refrigerated throughout the

collection period and collected in large gallon containers t

Fasting specimens test

Alcohol specimens the antiseptic used to clean the site of the collection must not contain

alcohol. A gray tube sodium fluoride is typically used for collection of alcohol levels. Order test

for medical reason does not need chain of custody. Occasionally a law enforcement agency

may request a blood alcohol concentration on an individual who has been involved in a traffic

accident. In this case sample requires that chain of custody protocol be strictly followed.

Considerations for patient religious beliefs

Steps for capillary collection

Blood bank specimens blood banks specimens require strict patient identification and

specimen labeling procedures. An undetected error can result in an administration of an

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incompatible blood product and the possibility of fatal transfusion reaction. Patient full name,

date of birth, date and time of the collection, hospital identification of patient, phlebotomist

initials, has to be check for two hospitals personal

Blood donor requirements needle size to donate blood a person must to be between the

ages of 17 and 66 year old and weight at least 110 pounds. Minors must have a writing

permission from their parents. In addition, the donor must give writing permission for the

blood bank to use the blood. The donor blood is collect from a large antecubital vein, with a

needle 16 to 18 gauge

Order of draw for venipuncture first, blood cultures second sodium citrate tubes, blue tops,

third serum tubes with or without clot activator or gel, red tops, fourth heparin tubes green

tops, fifth EDTA tubes lavender tops, sixth oxalate-fluoride tubes, gray tubes

Order of draw for capillary specimen lavender tube, tubes with other additives, tubes without

additive

Additives in tubes functions of additives color coding expiration dates page 209

Lavender top tube contains the anticoagulant EDTA inhibits coagulation by binding to calcium

present in the specimen. Tubes have to be inverted 8 times. Common test is a CBC-complete

blood count.

Light blue top tube contains the anticoagulant Sodium Citrate that prevents coagulation by

binding the calcium in the specimen. Sodium Citrate preservers the coagulation factors, the

tube must to be filled complete to maintain the radio of 9 parts of blood, 1 of additive, and has

to be inverted 3 to 4 times. Common test is a PT, APTT

Yellow top tube contains the anticoagulant SPS, these are used to collect specimen to be

cultured for the presence of microorganisms. This tube should be inverted 8 times

Green top tube contains the anticoagulant heparin combined with sodium, lithium, and

ammonium. Heparin works by inhibiting thrombin in the coagulation cascade. This tube should

be inverted 8 times. Common test are stat test on plasma

Gray top tube contains additives and anticoagulants. All gray tubes contain glucose

preservatives; sodium fluoride preserves glucose for 3 days. The gray tube may also contain

the anticoagulant potassium oxalate which prevents clotting by binding calcium. This tube

should be inverted 8 times. Common test FBS, GTT, alcohol levels, lactic acid

Red-gray speckled top tube, also called tiger top and serum separator contains clot activator, a

serum separator which when centrifuged forms a barrier between the serum and the cells

preventing contamination of the serum with cellular elements. Tubes has to be inverted 5 time

Evacuated tube system

Needle gauge - proper use and complications needle insertion

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