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Objectives
Describe the venipuncture process:
Proper patient ID procedures Proper equipment selection/ use
laboratory requisitions Order of draw for multiple tube phlebotomy Preferred venous access sites, & factors to consider in site selection, & ability to differentiate between the feel of a vein, tendon & artery
Objectives
Patient care following completion of
venipuncture Safety & infection control procedures Quality assurance issues Identify the additive, its function, volume, & specimen considerations to be followed for each of the various color coded tubes List 6 areas to be avoided when performing venipuncture & the reasons for the restrictions
Objectives
Summarize the problems that may be
encountered in accessing a vein, including the procedure to follow when a specimen is not obtained List several effects of exercise, posture, & tourniquet application upon laboratory values
The quality of laboratory results is critically dependent on the specimen presented for analysis.
PHLEBOTOMY
Procedure wherein blood is collected
from a vein using a needle for diagnostic, therapeutic, or blood donation purposes.
physician & clinical laboratory Delivers quality laboratory services & over-all patient care through correct blood collection practices.
SCOPE OF PHLEBOTOMY
Arterial puncture
Bleeding time
VENIPUNCTURE PROCEDURE
Complex procedure (knowledge & skill)
Phlebotomist establishes a routine of her/
his own Essential steps for successful collection procedure: ID patient Assess patient's physical disposition (i.e. diet, exercise, stress, basal state)
VENIPUNCTURE PROCEDURE
Check requisition form for requested tests,
patient information, & any special requirements Select suitable site for venipuncture Prepare equipment, patient & puncture site Perform venipuncture Collect sample in appropriate container
VENIPUNCTURE PROCEDURE
Recognize complications associated w/ procedure Assess need for sample recollection &/or rejection Label collection tubes at bedside or drawing area Promptly send specimens w/ requisition to the laboratory
sample submitted. Essential elements: Patient's surname, first name, & middle initial Patient's ID number Patient's date of birth & gender Requesting physician's complete name
cytology, fluid analysis, or other testing where analysis & reporting is site specific) Date & time of collection Initials of phlebotomist Indicating test(s) requested
NOTE: Both of the above MUST match same on the requisition form
EQUIPMENT
Evacuated Collection Tubes:
Designed to fill w/ a predetermined vol of
blood by vacuum Rubber stoppers (color coded according to additive content) Various sizes are available Blood should NEVER be poured from 1 tube to another (tubes can have different additives or coatings)
EQUIPMENT
Needles
Holder/ Adapter
Gauge # = bore size For evacuated systems, use w/ a syringe, single draw or butterfly system
(vacutainer) Tourniquet Wipe off with alcohol & replace frequently Alcohol Wipes 70% isopropyl alcohol
EQUIPMENT
Povidone-iodine
wipes/ swabs (blood culture) Gauze spongesApply on site from site of puncture Adhesive bandages/ tape protects puncture site post collection
NEVER be broken, bent, or recapped Should be placed in proper disposal unit IMMEDIATELY after use
EQUIPMENT
Gloves (latex, rubber, vinyl) to protect
patient & phlebotomist Syringes used in place of evacuated collection tube for special circumstances
ORDER OF DRAW
To avoid cross-
ORDER OF DRAW
3rd- coagulation tube (light blue
stopper) NEVER the first tube drawn If a coagulation assay is the only test ordered, draw a non-additive tube (red stopper or SST) first, then draw the light blue stopper tube
ORDER OF DRAW
Last draw- additive tubes in this order:
Heparin (dark green stopper) EDTA (lavender stopper) Oxalate/ fluoride (light gray stopper) NOTE: Tubes w/ additives must be thoroughly mixed. Erroneous test results may be obtained if not thoroughly mixed
PROCEDURAL ISSUES
PATIENT RELATIONS & IDENTIFICATION:
Phlebotomist's role (A Professional),
courteous & understanding manner in all contacts w/ patient Greet patient & identify yourself & indicate procedure that will take place Effective communication- both verbal & nonverbal- is essential
PROCEDURAL ISSUES
PATIENT RELATIONS & IDENTIFICATION:
Proper patient ID MANDATORY In-patient able to respond, ask full name &
always check armband for confirmation DO NOT DRAW BLOOD IF ARMBAND IS MISSING OPD must provide ID other than verbal statement of name. Using requisition for reference, ask patient to provide additional information (surname or birthdate)
PROCEDURAL ISSUES
PATIENT RELATIONS & IDENTIFICATION:
Speak w/ the patient during the process.
Patient who is at ease will be less focused on the procedure Always thank patient & excuse yourself courteously when done
(most frequent) Wrist & hand veins also acceptable Areas to be avoided: Extensive scars (burns & surgery) Upper extremity on side of previous mastectomy Hematoma- If another site not available, collect specimen distal to hematoma
possible. Or, draw below IV by follow procedures: Turn off IV at least 2 mins pre venipuncture Apply tourniquet below IV site. Select vein other than one w/ IV Perform venipuncture. Draw 5 ml of blood & discard before drawing specimen tubes for testing
Areas are to be avoided: Cannula/ fistula/ heparin lock- consult 1st attending physician Edematous extremities
into vein by: Massage arm from wrist to elbow Tap site w/ index & 2nd finger Apply warm, damp washcloth to the site for 5 mins Lower extremity over bedside to allow veins to fill
PERFORMANCE OF A VENIpuncture
Approach patient in a friendly, calm manner.
Provide comfort as much as possible, gain patient's cooperation Identify patient correctly Properly fill out appropriate requisition forms, indicating test(s) ordered Verify patient's condition. Fasting, dietary restrictions, medications, timing, & medical treatment noted on requisition
PERFORMANCE OF A VENIpuncture
Position the patient (sit on a chair, lie down
or sit up in bed). Hyperextend patient's arm Apply tourniquet 3 - 4 inches above selected puncture site. Do not place too tightly or leave on > 2 mins The patient should make a fist w/o pumping the hand Select venipuncture site
PERFORMANCE OF A VENIpuncture
Prepare patient's arm using an alcohol prep.
Cleanse in a circular fashion, beginning at the site & working outward. Allow to air dry Grasp patient's arm firmly using your thumb to draw skin taut & anchor the vein. Needle should form a 15 to 30 degree angle w/ the surface of the arm. Swiftly insert needle through skin & into lumen of the vein. Avoid trauma & excessive probing
CLEANSE BY MOVING ALCOHOL PREP PAD IN CONCENTRIC CIRCLES AWAY FROM SITE
PERFORMANCE OF A VENIpuncture
When last tube to be drawn is filling, remove tourniquet Remove needle from patient's arm using a swift backward motion Press down on the gauze once needle is out of the arm, applying adequate pressure to avoid formation of a hematoma
PERFORMANCE OF A VENIpuncture
Dispose of contaminated materials/ supplies in designated containers Mix & label all appropriate tubes at patient bedside Deliver specimens promptly to the laboratory
ADDITIONAL CONSIDERATIONS
To prevent a hematoma:
Puncture only uppermost wall of vein Remove tourniquet before removing needle
most wall of vein. (Partial penetration allow blood to leak into soft tissue surrounding vein via the needle bevel) Apply pressure to venipuncture site
ADDITIONAL CONSIDERATIONS
To prevent hemolysis:
Mix tubes w/ AC additives gently 5-10 times Avoid drawing blood from a hematoma
using a needle & syringe, & avoid frothing of sample Make sure venipuncture site is dry Avoid a probing, traumatic venipuncture
ADDITIONAL CONSIDERATIONS
Indwelling Lines or Catheters:
Potential source of test error Most lines are flushed w/ a solution of
heparin to reduce risk of thrombosis Discard sample at least 3x the volume of the line before a specimen is obtained for analysis
ADDITIONAL CONSIDERATIONS
Hemoconcentration due to:
Prolonged tourniquet application (no > 2
minutes) Massaging, squeezing, or probing a site Long- term IVT Sclerosed or occluded veins
ADDITIONAL CONSIDERATIONS
Prolonged Tourniquet Application:
Primary effect is hemoconcentration of non-
filterable elements (proteins). HP causes some H2O & filterable elements to leave extracellular space Significant increases in TP, AST, total lipids, cholesterol, Fe Affects packed cell volume & other cellular elements
Preparation Factors:
Therapeutic Drug Monitoring:
Pharmacologic agents have patterns of
administration, body distribution, metabolism, & elimination that affect drug concentration as measured in the blood. Drugs will have "peak" & "trough" levels that vary according to dosage levels & intervals Check for timing instructions for drawing appropriate samples
Preparation Factors:
Effects of Exercise:
Muscular activity w/ transient & longer term
effects. Inc in CK, AST, LDH, & platelet ct Stress: Transient elevation in WBC's & elevated adrenal hormone values (cortisol/ catecholamines) Anxiety resulting to hyperventilation may cause acid-base imbalances, & increased lactate
Preparation Factors:
Diurnal Rhythms:
Body fluid & analyte fluctuations during day Serum cortisol levels highest in early AM
but decreased in PM Serum Fe levels drop in AM Check timing of variations for desired collection point
Preparation Factors:
Posture: (supine to sitting etc.)
Certain larger molecules not filterable into
tissue, therefore more concentrated in blood Enzymes, CHONs, lipids, Fe, & Ca significantly increased
Preparation Factors:
Other Factors:
Age Gender
Pregnancy
Normal reference ranges are often noted
according to age
YOURSELF
Universal Precautions: Wear gloves & lab coat/ gown when handling
blood/ body fluids Change gloves after each patient or when contaminated Wash hands frequently Dispose of items in appropriate containers Dispose of needles ASAP upon removal from patient's vein. Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or splashing of contents
YOURSELF
Clean up any blood spills w/ disinfectant
(freshly 10% bleach) If you stick yourself w/ contaminated needle: Remove your gloves & dispose properly Squeeze puncture site to promote bleeding Wash area well w/ soap & water Record patient's name & ID number Follow institution's guidelines regarding treatment & follow-up
YOURSELF
Use of prophylactic zidovudine following
blood exposure to HIV has shown effectiveness (about 79%) in preventing seroconversion
patients (children & psychiatric patients) Practice hygiene for patient's protection. When wearing gloves, change them between each patient & wash your hands frequently Always wear a clean lab coat or gown
TROUBLESHOOTING GUIDELINES:
IF AN INCOMPLETE
COLLECTION OR NO BLOOD IS OBTAINED: Change position of needle (Move it forward) May not be in the lumen
TROUBLESHOOTING GUIDELINES:
Or move it
TROUBLESHOOTING GUIDELINES:
Adjust the angle
Bevel may be
TROUBLESHOOTING GUIDELINES:
Loosen tourniquet
Try another tube
It may be obstructing
blood flow There may be no vacuum in the one being used Veins sometimes roll away from the point of the needle & puncture site
TROUBLESHOOTING GUIDELINES:
IF BLOOD STOPS
FLOWING INTO THE TUBE: Vein collapsed; resecure tourniquet to ^ venous filling. If unsuccessful, remove needle, take care of puncture site, & redraw
TROUBLESHOOTING GUIDELINES:
Needle may have Hold equipment
firmly & place fingers against patient's arm, using the flange for leverage when withdrawing & inserting tubes
under the skin adjacent to puncture site release tourniquet ASAP & withdraw needle. Apply firm pressure.
(arterial) rather than venous Apply firm pressure for more than 5 mins
RXN Fainting
FIRST AID Rx tourniquet & needle, apply pressure on site & elevate arm, spirit of ammonia, orange drink when conscious
SYMPTOMS
FIRST AID
vomiting
Same
Ask patient to take deep breath; cold compress on nape & forehead Remove tourniquet, needle.
Apply pressure & elevate arm. Cold compress after 5 min. if needed
Hematoma
Swelling;
purple color at site
SYMPTOMS
Muscular twitches & spasms
FIRST AID
placed around
mouth & nose
tube (SST) contains gel at bottom to separate blood from serum on centrifugation USES: Chemistries, Immunology & Serology
(PST) w/ Li heparin MODE OF ACTION: Anticoagulates w/ Li heparin; Plasma separated w/ PST gel at bottom of tube USES: Chemistries
w/ clot activator MODE OF ACTION: Forms clot quickly & separates serum w/ SST gel at bottom of tube USES: Chemistries
remove Ca USES: Hematology (CBC) & BB (Xmatch); requires full draw- invert 8 X to prevent clotting & platelet clumping
remove Ca USES: Coagulation tests (PT & APTT), full draw required
thrombin & thromboplastin USES: For Li level (use Na heparin) For NH3 level (use Na or Li heparin)
Tube is designed to contain no contaminating metals USES: For Li level (use Na heparin) Trace element testing (zinc, copper, lead, mercury) & toxicology
preserves glucose up to 5 days USES: For Li level (Na heparin) Glucoses, requires full draw (may cause hemolysis if short draw)
satisfy order & where venous access is limited) For certain Point-ofCare (POC) testing (glucose & protime (INR) monitoring)
chemotherapy Some geriatric patients Obese patients Drug addicts Severe burn patients Patients w/ clotting tendencies
Coagulation studies
lacerates venules, arterioles & capillaries (mixture of venous & arterial blood + intracellular/ interstitial fluids)
Pressure, higher portion of blood collected by skin puncture is arterial More pronounced when skin is prewarmed before puncture (arterialization of capillary blood)
values may differ when blood is collected by skin puncture Glucose is higher in capillary puncture Calcium, TP & K are lower in capillary puncture
Puncture Sites:
Most frequent:
Lateral surface of Heel
for neonates/ infants (small/ premature) Fingers (large infants, children & adults) Plantar surface of great toe (larger infant)
children Fleshy area of distal portion of index, middle & ring finger Most adults will prefer non-dominant hand
Precautions:
Never perform capillary puncture of:
Earlobe Central area of the infant's heel
Precautions:
Isopropyl alcohol must DO NOT use Betadine
be used for cleansing site Site must be air dried or wiped w/ sterile gauze (w/ alcohol hemolysis unreliable results)
PERFORMANCE OF A FINGERSTICK
Follow steps 1- 5 as for venipuncture
Best sites: 3rd & 4th fingers of non-dominant
hand Do not use tip or center of finger (less soft tissue, vessels & nerves are located, & bone closer to surface) 2nd (index) finger (thicker, callused skin) 5th finger (less soft tissue overlying bone)
PERFORMANCE OF A FINGERSTICK
Use sterile lancet, skin puncture just off
center of finger pad. Perpendicular to ridges of fingerprint so drop of blood does not run down ridges Wipe away 1st drop of blood (excess tissue fluid) Collect drops of blood into collection device by gently massaging finger. Avoid excessive pressure, may squeeze tissue fluid into drop of blood
Puncture Sites:
Incision made should run
across grain of the fingerprint If in the same direction as the fingerprint, blood will tend to flow down the finger instead of collecting in a nice large, round drop
PERFORMANCE OF A FINGERSTICK
Cap, rotate & invert collection device to mix
blood collected Have patient hold a small gauze pad over puncture site for a couple of minutes to stop bleeding Follow steps 14- 16 as venipuncture
for blood collection on a NB or infant is the heel Green- proper area to use for heel punctures
obtain capillary blood for blood gas samples & increases blood flow for collection of other specimens. Do not use too high a temperature warmer, because baby's skin is thin & susceptible to thermal injury Clean site to be punctured w/ alcohol sponge. Dry cleaned area w/ dry cotton sponge. Hold baby's foot firmly to avoid sudden movement
heel in appropriate regions Do not use central portion of heel (injure underlying bone close to skin surface Do not use a previous puncture site Make cut across heelprint lines so that a drop of blood can well up & not run down along the lines
cotton Newborns do not often bleed immediately, use gentle pressure to produce a rounded drop of blood (excessive pressure or heavy massaging cause blood to become diluted with tissue fluid Fill capillary tube(s) or micro collection device(s) as needed.
clean, dry cotton on puncture site, hold in place until bleeding has stopped Dispose lancet in appropriate sharps container & contaminated materials in appropriate waste receptacles Remove your gloves & wash your hands
Heelstick Technique:
Inspect heel &
Heelstick Technique:
Preheat area w/
Heelstick Technique:
Grasp foot so heel
is exposed between thumb & index finger Disinfect w/ alcohol Wipe dry w/ sterile 2x2 gauze pads
Heelstick Technique:
Gently squeeze heel to
help pool blood Orient blade to cut across grain of heel Apply firm pressure & activate lancet trigger Correct amount of pressure comes w/ experience Newer devices automatically pierce a defined depth of approximately 1.0 mm
Heelstick Technique:
Wipe 1st drop
Heelstick Technique:
Allow drops to collect
on heel & gently touch drop w/ lip of specimen tube Try not to scrap lip against incision site Anticoagulated specimens, agitate frequently during collection (snap finger against bottom of tube)
Heelstick Technique:
Apply gentle
pressure to site till bleeding ceases Properly dispose of lancet on sharps container & contaminated supplies in appropriate biohazard container
Order of Draw:
Blood gases EDTA - Lavender Blood film Other additives Clot tubes - Red top