Basic Principles of Phlebotomy

Basic Principles of Phlebotomy
CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

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Phlebotomy Video

Blood Composition: Fluid component (~55%) Formed elements (~45%) RBC
WBC Platelets Fluid component (~55%) Water (~92%) Protein (~7%) etc CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Blood Collection Tubes:
Contain a vacuum Used with Vacutainer and Syringe systems Stoppers universal color coded: indicates contents Have an expiration date CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Safety: Engineering Controls
PPE Sharps containers Safer medical devices CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Safer Medical Devices:

Equipment: PPE: gloves, lab coat, mask Cleaning agent
Alcohol pads: routine Povidone iodine: blood culture collection and blood gases Soap and water: alcohol testing, allergies Cotton balls, gauze CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: Bandage, tape (use caution with children) Sharps container:
Discard needles, lancets Biohazard marking Puncture resistant NEVER recap, bend break needles CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: 6. Tourniquets: Slows venous blood flow down
Causes veins to become more prominent NEVER leave on for >1 minute AVOID rigorous fist clenching or hand pumping (potassium, lactic acid, LD) Latex allergy CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Tying on the Tourniquet:

Equipment: 7. Needles NEVER reuse a needle
NEVER use if shield is broken NEVER recap, cut, bend or break Drop immediately into sharps container after venipuncture Size of needle is indicated by gauge: Larger gauge number indicates smaller needle diameter 21, 23 gauge needles routinely used for phlebotomy CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Needles: Used with syringe system Used with vacutainer system

Multi-sample Needle: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Butterfly Needle: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Butterfly Needle: Most often used with syringe
Expensive, thus not used for routine draws Used for small, fragile veins Increased risk of needle stick injury CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: 8. Tube holder/ vacutainer adapter Threaded Flanges

Equipment: Syringe Black water proof pen

Syringe Safety Device:

Labeling Blood Collection Tubes:
Black indelible marker (water proof) Never pencil Legal document Print legibly Required information: 5 items Patient name Identification number Date of draw (mm,dd,yyyy) Time of draw (military time) Phlebotomist initals CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Labeling Last Name, First Name Patient ID: 1234-56
June 5, :10 AM Initials: SM

Vacutainer or Syringe? Vacutainer Syringe Most often used
Most economical Quick Least risk of accidental needle stick Syringe More control Reposition easily Will see ‘flash’ of blood in syringe hub when vein successfully entered CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

The Patient: Approach Communication Empathy
Handling special situations Patient identification Arm band Legal document Prepare patient for blood draw Latex allergy? CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Great QUESTIONS TO ASK YOUR PATIENT
Have you ever had blood drawn before? Have you had problems during a venipuncture? If yes— Did you have pain, bruising or bleeding? Did you have chest pain, dizziness, fainting or nausea?

Necessary Equipment for Venipuncture
PPE Alcohol swabs Gauze pads Tourniquet Needles- sterile disposable Blood collection tubes Pediatric collection tubes Winged infusion sets Vacutainer Lancets

Patient Preparation Patient education Do not make it lengthy
Tell the steps of the procedure Instruct patient to let you know right away if they are having pain Explain possible complications Bruising, hematoma, infection, prolonged bleeding, excessive pain Ask if they have questions

Selecting the Site Begins with hand washing
Must be done before and after procedure Don gloves Ask patient to extend arm with palm facing up Search for a vein using visual examination and palpation

Selecting the Site: Antecubital area most often accessed
“ the bend of the arm” Preferred site There are 3 veins that are preferred for blood draw in this location CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

The 3 Preferred Veins Medial Cubital 1st choice In center of AC fossa
Usually does not move In obese patient- not seen by can be palpated Cephalic Vein 2nd choice Located in lateral aspect of AC fossa Large vein and can be seen *** tends to ROLL and difficult to stabilize Brachial Vein Last choice Located in medial aspect of AC fossa ** very close to brachial artery Not visible and tends ROLL

Examine the Patients AC FOSSA!!
If you see a good vein it is time to palpate! Touch the vein with you fingers Vein should feel Soft Flexible Non- tender The vein SHOULD NOT BE HARD, INFLEXIBLE OF TENDER

Conditions The following conditions cause veins to be unsuitable for venipuncture Sclerosis HARD, INFLEXIBLE,NARROW Tortuous veins TWISTED, TURN EASILY Thrombotic veins BLOOD CLOT(S) IN THE VEIN Fragile veins THIN, DARK, CLOSE TO SURFACE, COLLAPSE EASILY Phlebitis INFLAMMED BLOOD VESSELS, TENDER TO TOUCH

Complications If performed on any of the aforementioned categories
Vein will be difficult to access Impossible to puncture Painful Easily damaged Blood supply through the vein will be POOR

Troubleshooting to Locate a Vein
Place the arm below the level of the heart for several minutes Place a warm compress *** The best technique is to slow down and take your time Ask someone else to try Notify supervisor Notify Physician

Other Veins Hand and wrist veins Dorsum area of the hand
Easily seen--- *** are more fragile!! ** ROLL easily– superficial,small and painful Short length– difficult to to angle needle Vein on underside of wirst CLOSE to Artery and Nerves Physically challenging to access

Hand Vein Draw CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

NO BLOOD DRAW On arm with IVF Dialysis Shunt Mastectomy side

Collection Site Problems:
Intravenous line NEVER draw above an IV Draw from other arm Draw from hand on other arm Draw below the IV CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Draw Below IV site: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Cleaning the SITE Invasive procedure Scrub with isopropyl alcohol 70%
Other germicides include- chlorhexidine and iodine Alcohol preferred Dries fast No residue Not highly irritating Does not obscure Not drying to the skin

Proper Venipuncture Technique
Introduce self Identify the patient Check laboratory requisition form Have patient sit or lie down- NEVER STANDING Assemble equipment – check expiration Wash hands Don gloves Locate vein Apply tourniquet

STEPS Do not touch area after prepping site
Use your fingers to spread the skin & make tight Uncap and inspect the needle tip Discard if defective or if sterility was compromised Insert the needle at °angle – BEVEL UP This angle Allow room to work Reduces pushing the needle through the vein Allow best blood flow

Needle Position: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Releasing the Tourniquet
Once the needle has entered the vein and you have attached the 1st tube to the infusion set or vacutainer RELEASE the tourniquet The tourniquet should NOT be left on for more than 1 minute

Complications of Leaving Tourniquet Applied Too Long
Hemolysis Destruction of blood cell Will cause abnormal electrolyte readings Petechiae Very tiny hemorrhages-appear in red and purple spot on the skin Hemoconcentration Tourniquet application can force fluids out of cells and leak into blood volume

Petechiae

Attach the Collection Tubes
After you have successful accessed the vein Attach the blood collection tubes to vacutainer or infusion set Tubes will fill in about 5 seconds Tubes must be filled in the correct sequence Tubes must be handled correction after filling At most– if you fill 6 tubes with blood– 30 ml or cc’s will be the amount of blood removed

Order of the DRAW Blood cultures or sterile specimens Blue top Red top
Gold or Green top Lavender or Purple top Gray top

Fill Tubes: Use correct order of draw:
Sterile/Blood cultures SALLY Blue BRINGS Red REALLY Gold/Green GOOD GREASE and Purple/ Lavender LEAVES the Gray GRAVEY CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Inverting the Tubes Once filled– tubes must be inverted
Invert by holding it in your hand and turning your wrist Blue top- 3-4 inversions Lavender and Green top inversions Serum separator tubes ( SST, red tops) and serum tubes ( red tops without the separating gel) 5 inversions

Removing the Needle Place gauze over the needle
Quickly remove needle and apply firm pressure to site Always use gauze pad and wear gloves Allow patient to apply pressure ( if possible) so you can invert tubes You can place pressure for 30 seconds and apply adhesive bandage over the gauzes

Recheck Draw Site: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Labeling the Tubes Immediately:
In sight of patient Patient name Identification number Date of draw Time of draw (military time) Your initials **This is a critical step **Mislabeling can lead to serious consequences CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Handling and Transporting Specimens
All specimens must be handled correctly Most have a standard # of inversions Most can be stored at room temp **** There are exceptions!!! Learn the proper transport policy of the facility

Finishing the Procedure
Discard the needle in sharps container NEVER REUSE!!! NEVER RECAP!! Remove gloves and wash your hands!!!

Reporting Test Results
There may be occasions in which you will be asked to transmit lab results The keys to doing this accurately and correctly are repetition and confirmation

After the Venipuncture
Check the patient for: Excessive bleeding Excessive pain Lack of sensation Excessive bruising Signs of infection How the patient feels

Troubleshooting Technical Problems during Venipuncture
Most are done quickly and with ease What do you do if the blood flow stops? *** This occurs when the vacuum is not enough ***Patency of the system has been compromised Try another tube check to see if you have released the tourniquet Needle is in too far or not far enough

Collection Site Problems: Complications
Nerve damage Hematomas Phlebitis Petechiae Thrombus Physical Reactions Collection or processing errors Edematous area CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Collection or Processing
Misidentification of patient Improper site selection and preparation Incorrect order of the draw Under filling of tubes Failure to invert tubes Failure to document when a specimen was obtained and when it was received Mislabeling of the specimen

Needle Sticks and Contact with Body Fluids and Secretions
Good technique and PPE is KEY!! If you have contact with skin– WASH Immediately with soap and water EYE contact= Eye wash for 15 minutes with lukewarm water Inhalation of body fluid=leave area and seek fresh air ** Report exposure soon after you finish basic first aid measures

Needlesticks Milk and wash the area with soap and water
Cover with dressing Report the incident ASAP Any break in the skin can be a portal of entry!! Risk of HIV, Hepatitis B & C

First Aid, Medical Emergencies and the Phlebotomy
You must be prepared to deal with medical emergencies excessive bleeding- apply direct pressure & call for help Patient faints-call for help – try to prevent patient injury- check for breathing and pulse Know how and when to start CPR Know who and what to do quickly

Finger and Heel Stick Phlebotomy
If blood is needed and venipuncture is contraindicated Heel or finger stick may be used These are NOT venipuncture- because you are not drawing from veins You are drawing from capillaries There are differences between a HEEL and FINGER sticks

Capillary Blood Mixture of arterial, venous, capillary blood and fluid from surrounding tissues Fluid from surrounding tissues may interfere and/or contaminate the specimen Warming skin puncture site increases arterial blood flow to the area Reference ranges often differ from venous CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Fingersticks Done when only a small amount of blood is needed
When venous access is difficult Commonly done on children Commonly done on adults who need very frequent blood checks Can be used to check for lead, hemoglobin and other blood components including blood glucose

Fingerstick Procedure
Infection control Assemble equipment AIDET- Position patient wash hands Don gloves ID site- middle and ring finger are best Use side of the finger Avoid cold, cyanotic, scarred, fingers Clean site with alcohol 70% Gently massage- milk finger puncture fingertip with lancet Wipe away first drop Allow blood to drip into collection tube Cap when filled Position and massage site as needed- careful not to over milk/massage may damage cells Cap filled tube Label specimen Check patient Discard equipment Remove glove & wash hands

Heelstick Procedure Assemble equipment
Select site Best sites are lateral and medial sides of the heel DO NOT USE back of heel Clean site Puncture skin with lancet Use your thumb and fingers to gently squeeze heel Wipe away first drop of blood Allow blood to drip into collection tube Do not over squeeze Cap tube when filled Label specimen check patient discard equipment remove gloves & wash hands Assemble equipment Choose correct lancet- will puncture the skin to a specific depth If infant <2.2 lb. choose lancet which punctures depth of 0.65mm Positon patient Apply heel warmer for 3-5 minutes Wash hands and don gloves

SPECIAL COLLECTIONS This refers to any collection that is different from the standard blood draw Uses techniques that are a bit more complicated You may be required to perform or assist in a special collection

Peripheral Blood Smears
A peripheral blood smear is a blood collection that is used most often to diagnose a hematologic disorder The smear is used to examine different types of white blood cells ---WBCs This is call checking the DIFFERENTIAL Peripheral blood smears also are used to detect malarial parasites in the blood

Peripheral Blood Smears
Can be done using capillary or venous blood It can be collect at the bedside or using blood from an EDTA collection tube You will need the following equipment: Lens cleaner Lens paper glass slides gloves EDTA tube

Peripheral Smears Take 2 glass slides
Apply drop of lens cleaner on each slide and use the lens paper to rub the slides until they are dry Invert the EDTA tube 8-10 times Open the stopper & use a stick or other pipette to remove a small amount of blood Place a drop of blood 2mm in diameter onto the slide just in front of frosted area Drop of blood should be in the center of the slide & approximately ¼ inch from the back edge of the slide Smear immediately after the blood is applied** a delay will affect the test Do this by using the end of the other slide, hold at 30° just in front of the blood and then pull the slide until it just touches the blood

Peripheral Smears The blood will begin to spread towards the edge of the bottom slide Wait until the blood has almost reached the edges of the bottom slide Maintain a 30°- push the spreader slide rapidly across the bottom slide Do not press down The smear should be across ¾ of the bottom slide There should be a smooth appearance and no holes or lines It should have rainbow sheen when reflected in light Allow smear to air dry and label correctly

How to Prepare a Peripheral Blood Smear Slide
Peripheral Blood Slide Preparation

Blood Culture Collection
Obtained to detect the presence of microorganisms in the blood= bacteremia Blood Culture or Blood C & S requires a specific collection procedure

Assemble equipment Blood Culture Bottles 2( anaerobic & aerobic) Tourniquet Gloves Alcohol 70 % swabs Gauze pads Chlorhexidine Syringe & winged infusion set

Clean top of bottles with alcohol ( NOT with CHOLORHEXADINE OR IODINE allow to dry for 30 seconds Find suitable site and clean with chlorhexidine scrubbing firmly a 5 cm area for 30 seconds Allow to dry and DO NOT TOUCH the area once prepped Perform venipuncture and remove 20 ml of blood using butterfly device with special BC vacutainer device Transfer the blood to the bottles filling the aerobic 1st then the anaerobic bottle Divide blood amounts evenly between the 2 bottles *** it is helpful to mark off the fill level on the bottles for filling accuracy

Blood Culture Collection Procedure

Blood Samples for Inborn Errors of Metabolism
Genetic disorders that affect the way the body metabolizes certain nutrients Will affect the enzyme systems Diagnosed by blood tests 3 common blood tests are: Serum Ammonia Serum Lactate Serum Pyruvate

Blood Samples for Inborn Errors of Metabolism
Use the standard venipuncture procedure DO NOT use a tourniquet or have the patient make a fist Patient should be fasting for the serum pyruvate level These specimens are collected in special tubes MUST BE PLACED ON ICE & immediately transported to the lab for processing

Phlebotomy for Blood Donation
Collecting specimens for blood donation follow the same principles Patient ID Patient assessment Site preparation Vein access Infection control

Phlebotomy for Blood Donation
Screening for BLOOD donation includes: Age weight Blood- borne disease exposure ** Today guidelines are very specific and extensive Maximum amount of blood that is taken is 525 ml American Academy of Blood Banks recommendation is 10.5 ML per kg of body weight– assuming a minimum weight of 110 lb or 50 kg

Draw Below IV site: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

No Needle Movement! You must anchor the blood-drawing equipment on the patient’s arm to minimize chance of injury CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Withdraw Needle: First release tourniquet Disengage tube
Place cotton directly over needle, without pressing down Withdraw needle in swift, smooth motion Immediately apply pressure to wound Do not bend arm CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

You should try again Look at alternate site Use clean needle
Other arm Hand Use clean needle Use fresh syringe if contaminated Only try twice CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Venipuncture Procedure:
Wash hands Put on gloves Identify patient Latex allergy? Position arm Apply tourniquet CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Locate vein Release tourniquet Cleanse site in outward rotation Allow to air dry CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Mark your spot CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Reapply tourniquet Do not contaminate site Anchor vein Insert needle Fill tubes Quick mix additive tubes Release tourniquet Withdraw needle CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Engage safety device Dispose of needle immediately Apply pressure to puncture site Label tubes Recheck puncture site Thank patient Remove gloves, wash hands CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Syringe draw CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Be careful not to: Push needle further into vein when engaging evacuated tube Pull needle out of vein when disengaging tube Pull needle out of vein as you pull back on the plunger Pull up or press down when needle in vein Forget to mix additive tubes 8-10 times CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Syringe Safety Transfer Device

Skin Puncture Procedure:
Wash hands Approaching the patient Patient identification Latex allergy? Bedside manner Site selection Cleanse site: DO NOT use providone- idodine Perform puncture: Wipe away first drop of blood Label the specimen CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture: Method of choice for infants, children under 1 year
Adults Scarred Fragile veins Hardened veins Home glucose monitoring (POCT) Patients with IV CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Hold finger between your index finger and thumb Puncture the finger using a quick, smooth motion Wipe away the first drop of blood CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Site Selection:

Skin Puncture Equipment:
PPE Cleaning agent Alcohol pads: routine Soap and water: alcohol testing, allergies DO NOT use providone iodine Cotton balls, gauze CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Bandage/tape Sharps container Warming device Commercial warmer Warm wet washcloth CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Lancet Always use standardized equipment NEVER use a surgical blade CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Micro-specimen containers Capillary tubes Microtainers Capillary blood gas tubes Micropipet diluting system CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Glass slides: used to prepare blood smears CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Collect sample DO NOT touch collecting device to skin surface DO NOT scrape collecting device across skin surface DO NOT scoop blood into collecting device CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Order of draw is critical: platelets accumulate at puncture site causing clot formation Blood smear EDTA Heparin Serum Apply pressure to puncture site Label specimen in sight of patient (indelible marker) CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Specimen Processing Essential Knowledge

Labeling and Transporting Specimens
Each facility has a protocol for transporting specimens The time from collection to transport Storage requirements for the specimen during transport Most can be transported on room Air Some require traveling on ice

CLIA Quality Control Clinical Laboratory Improvement Amendments
Federal regulatory standards for labs that perform testing of human samples CLIA standards stipulate that certain simple, low risk lab tests may be waived There does not have to be any direct routine oversight of the labs in regards to how they perform these tests

Good Lab Practices Include:
Using recent package insert from the kits manufacturer Doing quality control or calibration on equipment Documenting quality control Storing and handling according to manufacturer Provide personnel with training and document training Using OSH regulations that pertain to labs

Non-Blood Specimen Collection Transport
Include; Semen Sputum Stool urine

Collection All will require a simple collection
This means the patient is given a cup and the specimen is placed in the cup The only exception is Sterile urine

Sterile Urine Collection
Wait 2-3 hr. for urine to be in the bladder wash hands Men- clean head of penis with sterile wipe Women- must separate labia and wipe front to back – use a second wipe to clean area around the urethra Void for several seconds STOP urine stream Urinate in the sterile cup DO not touch inside of cup Seal cup and properly label

Pre-Analytical Errors
Common errors include: Insufficient specimen– QNS Hemolysis The destruction of red blood cells which leads to the release of hemoglobin from within the red blood cells into the blood plasma. Hemoconcentration Decrease in the volume of plasma in relation to the number of red blood cells; increase in the concentration of red blood cells in the circulating blood Specimen contamination Allergic reactions

Chain of Custody The process through which specimens must be obtained, processed and transported for legal purposes Refers to the documentation that must be done when these specimens are obtained, processed and transported Examples; Bld ETOH levels Test for illicit drug Workplace drug testing Specimens that may be part of a crime- ie sexual assault

Chain of Custody The following must be carefully documented
When, how and by whom specimen was collected When, how and by whom specimen was transported Who received the specimen and when; where and how it was stored How and when the specimen was processed When, by whom and to whom the results were reported

Chain of Custody Most labs will have specific forms and a protocol in place to handle chain of custody Refer to handout for more information on Chain of Custody

Communication and Specimen Collection and Processing
Communication during specimen collection and processing is very important Accurate communication is vital The best way to ensure accurate communication is to use repetition and confirmation

Entering and Retrieving Laboratory Values
Lab values must be entered correctly You must pay special attention to the values and the units that are used to report You must also have basic knowledge of normal and abnormal values Entering or retrieving values incorrectly could have serious consequences

Reporting Routine and Critical Values
When you are reporting routine and critical lab values --- use repetition and confirmation You must document to whom you report the values and when Doing this especially when you are reporting critical lab values

Summary Basic venipuncture Proper venipuncture technique Proper
patient ID Preparation Troubleshooting Potential complications Finger stick Heel stick Special collections Processing of specimens

Tubes and Tests Gray top- fbs, gtt, bld etoh, lactic acid
Lavender top- CBC, H&H, ESR, Sickle Cell screening Light Blue top- PT, PTT, Fibrinogen Degradation Product FDP, Red top- Blood bank, immunohematology Red/gray(speckled)- most chemistry tests

Practice Skills The following is a more simply stated order of the draw. Keep in mind that other, less frequently used tubes, will be placed in the order below based on the additive present. MEMORIZE! blood cultures light blue red green purple gray Other.

Basic Principles of Phlebotomy

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