aaphlebotomy for nurses

7/28/2019 Aaphlebotomy for Nurses

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Objectives

Describe and perform the venipunctureprocess including:

1. Proper patient identification procedures.

2. Proper equipment selection and use.

3. Proper labeling procedures and completion oflaboratory requisitions.

4. Order of draw for multiple tube phlebotomy.

5. Preferred venous access sites, and factors to considerin site selection, and ability to differentiate between

the feel of a vein, tendon and artery.6. Patient care following completion of venipuncture.

7. Safety and infection control procedures.

8. Quality assurance issues.


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Objectives

Identify the additive, additive function,volume, and specimen considerations tobe followed for each of the various colorcoded tubes.

List six areas to be avoided whenperforming venipuncture and the reasonsfor the restrictions.

Summarize the problems that may beencountered in accessing a vein,

including the procedure to follow when aspecimen is not obtained.

List several effects of exercise, posture,and tourniquet application uponlaboratory values.


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VENIPUNCTURE PROCEDURE

The venipuncture procedure is complex, requiring bothknowledge and skill to perform. Each phlebotomistgenerally establishes a routine that is comfortable for

her or him. Several essential steps are required forevery successful collection procedure:


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ORDER FORM / REQUISITIONA requisition form must accompany each sample submitted

to the laboratory. This requisition form must contain theproper information in order to process the specimen. Theessential elements of the requisition form are:

1. Patient's surname, first name, and middle initial.

2. Patient's ID number.

3. Patient's date of birth and sex.

4. Requesting physician's complete name.

5. Source of specimen. This information must be givenwhen requesting microbiology, cytology, fluid

analysis, or other testing where analysis and reportingis site specific.

6. Date and time of collection.

7. Initials of phlebotomist.

8. Indicating the test(s) requested.


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Identify the patient.

Assess the patient's physical disposition (i.e. diet,exercise, stress, basal state).

Check the requisition form for requested tests, patientinformation, and any special requirements.

Select a suitable site for venipuncture.

Prepare the equipment, the patient and the puncture site.

Perform the venipuncture.Collect the sample in the appropriate container.

Recognize complications associated with the phlebotomyprocedure.

Assess the need for sample recollection and/or rejection.

Label the collection tubes at the bedside or drawing area.

Promptly send the specimens with the requisition to thelaboratory.


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An example of a simple requisitionform with the essential elements is

shown below:


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LABELING THE SAMPLE

A properly labeled sample is essential so that the resultsof the test match the patient. The key elements inlabeling are:

Patient's surname, first and middle.

Patient's ID number.

NOTE: Both of the above MUST match the same on therequisition form.

Date, time and initials of the phlebotomist must be on the

label of EACH tube.

Automated systems may include labels with bar codes


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Examples of labeledcollection tubes are

shown below:


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EQUIPMENT:

Alcohol Wipes - 70% isopropylalcohol.

Povidone-iodine wipes/swabs -Used if blood culture is to bedrawn.Gauze sponges - for application onthe site from which the needle iswithdrawn.

Adhesive bandages / tape -protects the venipuncture siteafter collection.

Needle disposal unit - needlesshould NEVER be broken, bent, orrecapped. Needles should be

placed in a proper disposal unitIMMEDIATELY after their use.


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EQUIPMENT:

Gloves - can be made of latex, rubber,vinyl, etc.; worn to protect the patientand the phlebotomist.

Syringes - may be used in place of theevacuated collection tube for specialcircumstances.


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ORDER OF DRAW:


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ORDER OF DRAW:

3. Third - non-additive tube (red top)

4. Last draw - additive tubes in this order:

SST (red-gray or gold top). Contains a gel

separator and clot activator. Sodium heparin (dark green top)

PST (light green top). Contains lithiumheparin anticoagulant and a gel separator.

EDTA (lavender top)

ACDA or ACDB (pale yellow top). Containsacid citrate dextrose.

Oxalate/fluoride (light gray top)


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Plastic Tube(Stopper Color)

Additive Laboratory Use

3. SST (Red-Gray, orGold stopper)

Gel separator +clot activator

Iron, TIBC, PSA, B12

4a. Dark Green

Sodium Heparin BMP, CMP Lipid

4b. PST

Light Green Lithium Heparin +gel separator

LAP, Drug Screen,Alcohol


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Plastic Tube(Stopper Color)

Additive Laboratory Use

Lavender

EDTA CBC, A1C, Retic, H&H

Pale Yellow (ACDA orACDB)

Acid citratedextrose

Basic Immune Profile,HLA tissue typing,paternity testing, DNAstudies

Light Gray

Oxalate/fluoride Lactic Acid


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Certain areas are to be avoidedwhen choosing a site:

Hematoma - may cause erroneous testresults. If another site is not available,collect the specimen distal to the

hematoma.

Intravenous therapy (IV) / bloodtransfusions - fluid may dilute thespecimen, so collect from the opposite

arm if possible. Otherwise, satisfactorysamples may be drawn below the IV byfollowing these procedures:


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PROCEDURE FOR VEINSELECTION:

Palpate and trace the path of veinswith the index finger. Arteries pulsate,are most elastic, and have a thickwall. Thrombosed veins lackresilience, feel cord-like, and rolleasily.

If superficial veins are not readilyapparent, you can force blood into the

vein by massaging the arm from wristto elbow, tap the site with index andsecond finger, apply a warm, dampwashcloth to the site for 5 minutes, orlower the extremity over the bedsideto allow the veins to fill.


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PERFORMANCE OF AVENIPUNCTURE:

Approach the patient in a friendly,calm manner. Provide for theircomfort as much as possible, andgain the patient's cooperation.

Identify the patient correctly.

Properly fill out appropriaterequisition forms, indicating thetest(s) ordered.

Verify the patient's condition.Fasting, dietary restrictions,medications, timing, and medicaltreatment are all of concern andshould be noted on the lab

requisition.


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Check for any allergies to antiseptics, adhesives,or latex by observing for armbands and/or byasking the patient.

Position the patient. The patient should either sit

in a chair, lie down or sit up in bed. Hyperextendthe patient's arm.

Apply the tourniquet 3-4 inches above theselected puncture site. Do not place too tightly orleave on more than 2 minutes.

The patient should make a fist without pumpingthe hand.

Select the venipuncture site.

Prepare the patient's arm using an alcohol prep.


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When the last tube to be drawn is filling,remove the tourniquet.

Remove the needle from the patient'sarm using a swift backward motion.

Press down on the gauze once the needleis out of the arm, applying adequatepressure to avoid formation of ahematoma.

Dispose of contaminatedmaterials/supplies in designatedcontainers.

Mix and label all appropriate tubes at thepatient bedside.

Deliver specimens promptly to thelaboratory


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The first step is always to identify the patient.Outpatient phlebotomy, as shown here, shouldtake place with the patient seated.


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The tourniquet is applied and the phlebotomist palpatesfor a suitable vein for drawing blood.


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The area of skin is cleaned with a disinfectant, here analcohol swab.


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The vein is anchored and the needle is inserted.


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The vacutainer tube is depressed into the needle to begindrawing blood. Additional vacutainer tubes can be utilized.Determine what tests are ordered and what tubes will benecessary BEFORE you begin to draw blood, anddetermine the order of draw for the tubes.


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When the final tube is being drawn, release thetourniquet. Then remove the tube, and remove theneedle


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After the needle is removed from the vein, apply firmpressure over the site to achieve hemostasis.


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Apply a bandage to the area.


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Dispose of the needle into a sharps container that isclose by.


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PERFORMANCE OF AFINGERSTICK:

Follow the procedure as outlined abovefor greeting and identifying the patient.As always, properly fill out appropriate

requisition forms, indicating the test(s)ordered.

Verify the patient's condition. Fasting,dietary restrictions, medications, timing,

and medical treatment are all of concernand should be noted on the labrequisition.


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Position the patient. The patient shouldeither sit in a chair, lie down or sit up inbed. Hyperextend the patient's arm.

The best locations for fingersticks arethe 3rd (middle) and 4th (ring) fingersof the non-dominant hand. Do not usethe tip of the finger or the center of thefinger. Avoid the side of the fingerwhere there is less soft tissue, wherevessels and nerves are located, and

where the bone is closer to the surface.The 2nd (index) finger tends to havethicker, callused skin. The fifth fingertends to have less soft tissue overlyingthe bone. Avoid puncturing a fingerthat is cold or cyanotic, swollen,scarred, or covered with a rash.


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Cap, rotate and invert the collectiondevice to mix the blood collected.

Have the patient hold a small gauze pad

over the puncture site for a couple ofminutes to stop the bleeding.

Dispose of contaminatedmaterials/supplies in designatedcontainers.

Label all appropriate tubes at the patientbedside.

Deliver specimens promptly to thelaboratory.


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Here is the equipment for fingersticks (heelsticks). Thelancets come in different lengths. There are severalstandard microtainers utilized to collect fingerstick (or babyheelstick) blood. The purple cap is for hematologyspecimens and the green cap is for chemistry specimens.The dark brown-red microtainer protects a neonatal

bilirubin sample from the light.


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The proper location on the 3rd or 4th finger of the non-

dominant hand for performing a fingerstick is outlined herebetween the green lines. The puncture should be made justoff center and perpendicular to the fingerprint ridges. (Apuncture parallel to the ridges tends to make the blood run

down the ridges and hamper collection.)


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The lancet is placed over the proper location on thefinger and the puncture is made quickly.


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A drop of blood appears at the puncture site.


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The first drop of blood that may contain tissue fluid iswiped away.


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The finger is gently massaged from base to tip and theblood drops are collected into the proper collectiondevice.


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The blood is mixed in microtainers with an additive.


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To prevent a hematoma:

Puncture only the uppermost wall of thevein

Remove the tourniquet before removing

the needle

Use the major superficial veins

Make sure the needle fully penetrates the

upper most wall of the vein. (Partialpenetration may allow blood to leak intothe soft tissue surrounding the vein byway of the needle bevel)

A l ressure to the veni uncture site


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To prevent hemolysis

Mix tubes with anticoagulant additivesgently 5-10 times

Avoid drawing blood from a hematoma

Avoid drawing the plunger back tooforcefully, if using a needle and syringe,and avoid frothing of the sample

Make sure the venipuncture site is dry

Avoid a probing, traumatic venipuncture

Ind elling Lines or


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Indwelling Lines orCatheters

Potential source of test error

Most lines are flushed with a solution ofheparin to reduce the risk of thrombosis

Discard a sample at least three times thevolume of the line before a specimen isobtained for analysis


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Hemoconcentration: An increasedconcentration of larger molecules and formedelements in the blood may be due to several

factors:

Prolonged tourniquet application (no more than 2minutes)

Massaging, squeezing, or probing a site

Long-term IV therapySclerosed or occluded veins

P l d T i t


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Prolonged TourniquetApplication:

Primary effect is hemoconcentration ofnon-filterable elements (i.e. proteins). Thehydrostatic pressure causes some water

and filterable elements to leave theextracellular space.

Significant increases can be found in total

protein, aspartate aminotransferase (AST),total lipids, cholesterol, iron

Affects packed cell volume and othercellular elements


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Patient Preparation Factors

Therapeutic Drug Monitoring: differentpharmacologic agents have patterns ofadministration, body distribution,

metabolism, and elimination that affectthe drug concentration as measured inthe blood. Many drugs will have "peak"and "trough" levels that vary according todosage levels and intervals. Check for

timing instructions for drawing theappropriate samples.


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Effects of Exercise: Muscular activity hasboth transient and longer lasting effects.

The creatine kinase (CK), aspartate

aminotransferase (AST), lactatedehydrogenase (LDH), and platelet countmay increase.


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Stress: May cause transient elevation inwhite blood cells (WBC's) and elevatedadrenal hormone values (cortisol and

catecholamines). Anxiety that results inhyperventilation may cause acid-baseimbalances, and increased lactate.


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Diurnal Rhythms: Diurnal rhythms arebody fluid and analyte fluctuations duringthe day. For example, serum cortisol

levels are highest in early morning butare decreased in the afternoon. Serumiron levels tend to drop during the day.

You must check the timing of thesevariations for the desired collection point.


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Posture: Postural changes (supine to sitting etc.) areknown to vary lab results of some analytes. Certainlarger molecules are not filterable into the tissue,

therefore they are more concentrated in the blood.Enzymes, proteins, lipids, iron, and calcium aresignificantly increased with changes in position.

Other Factors: Age, gender, and pregnancy have an

influence on laboratory testing. Normal referenceranges are often noted according to age.

SAFETY AND INFECTION


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SAFETY AND INFECTIONCONTROL



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Dispose of needles immediately uponremoval from the patient's vein. Do notbend, break, recap, or resheath needles

to avoid accidental needle puncture orsplashing of contents.

Clean up any blood spills with adisinfectant such as freshly made 10%bleach.



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If you stick yourself with a contaminatedneedle:

1. Remove your gloves and dispose of themproperly.

2. Squeeze puncture site to promote bleeding.

3. Wash the area well with soap and water.

4. Record the patient's name and ID number.5. Follow institution's guidelines regarding

treatment and follow-up.

6. NOTE: The use of prophylactic zidovudine

following blood exposure to HIV has shown


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PROTECT THE PATIENT

Place blood collection equipment awayfrom patients, especially children andpsychiatric patients.

Practice hygiene for the patient'sprotection. When wearing gloves, changethem between each patient and washyour hands frequently. Always wear aclean lab coat or gown.

TROUBLESHOOTING


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TROUBLESHOOTING

GUIDELINES: Change the position of the needle.Move it forward (it may not be in the

lumen)


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or move it backward (it may havepenetrated too far).


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Adjust the angle (the bevel may be

against the vein wall)

TROUBLESHOOTING


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Loosen the tourniquet. It may be

obstructing blood flow.

Try another tube. There may be novacuum in the one being used.

Re-anchor the vein. Veins sometimes

roll away from the point of the needleand puncture site.

TROUBLESHOOTING

GUIDELINES

IF BLOOD STOPS


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FLOWING INTO THE

TUBE: The vein may have collapsed; resecurethe tourniquet to increase venous filling.If this is not successful, remove the

needle, take care of the puncture site,and redraw


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PROBLEMS OTHER THAN


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AN INCOMPLETE

COLLECTION: A hematoma forms under the skin

adjacent to the puncture site -

release the tourniquet immediatelyand withdraw the needle. Apply firmpressure.

TROUBLESHOOTING


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TROUBLESHOOTING

GUIDELINES The blood is bright red (arterial)rather than venous. Apply firm

pressure for more than 5 minutes.


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In the view above, there has been moreextensive subcutaneous hemorrhage, andeven tearing of the skin from adhesivetape applied with a bandage, in a patient

on corticosteroid therapy


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In older patients with thin, loose skin and

less subcutaneous tissue, the minortrauma of venipuncture is more likely toproduce local hemorrhage. Note the smallhematomas in the view above.

BLOOD COLLECTION


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BLOOD COLLECTION

ON BABIES: The recommended location for bloodcollection on a newborn baby or infant isthe heel. The diagram below indicates in

green the proper area to use for heelpunctures for blood collection:


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Heel Stick Procedure

Prewarming the infant's heel (42 Cfor 3 to 5 minutes) is important toobtain capillary blood gas samplesand warming also greatly increasesthe flow of blood for collection ofother specimens. However, do notuse too high a temperaturewarmer, because baby's skin isthin and susceptible to thermal

injury.

Clean the site to be punctured withan alcohol sponge. Dry the cleanedarea with a dry cotton sponge.

Hold the baby's foot firmly to avoid


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Using a sterile blood lancet, puncture theside of the heel in the appropriate regionsshown above in green. Do not use the

central portion of the heel because youmight injure the underlying bone, whichis close to the skin surface. Do not use aprevious puncture site. Make the cutacross the heelprint lines so that a drop

of blood can well up and not run downalong the lines.


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Wipe away the first drop of blood with apiece of clean, dry cotton. Sincenewborns do not often bleed

immediately, use gentle pressure toproduce a rounded drop of blood. Do notuse excessive pressure or heavymassaging because the blood maybecome diluted with tissue fluid.

l i k d


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Fill the capillary tube(s) or microcollection device(s) as needed.

When finished, elevate the heel,

place a piece of clean, dry cottonon the puncture site, and hold it inplace until the bleeding hasstopped.

Be sure to dispose of the lancet inthe appropriate sharps container.Dispose of contaminated materialsin appropriate waste receptacles.Remove your gloves and wash

your hands.


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Two heelsticks have been performed onthis baby. One of them has beenperformed correctly. One was performedimproperly.


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Blood SmearingBlood Smearing

1. A single smear can be made per slide (smearrunning the length of the slide) or two (or eventhree) smears can share a slide, with the

smears running the width of the slide. Puttingtwo smears per slide saves on weight (glass isheavy) for field trips, and storage space.

2. It is easiest to use microscope slides with afrosted end, so that identifying information can

be written there with pencil. Comparedifferent pencils to find one that does not yieldlabels that rub off or wash off in the methanoldip.

Warning:


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Why do ABGs


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Why do ABGs

Precise measurement of acid base balance of the blood

Check lungs ability to oxygenate

blood and to remove CO2Assess respiratory function

O2 and CO2 levels determined primarily bythe lungs


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Puncture Procedure


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Puncture Procedure

Check for Ordersa. Check for indications and

contraindications Indications can be wide and varied

No absolute contraindications,mostly just extraprecautions and hazards

i. Dialysis shunt choose

another siteii. Mastectomy use oppositeside

iii. Pt on anticoagulant therapy MAY have to hold pressure on puncture

Puncture Procedure


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Puncture Procedure

Introduce yourself and explain what isordered

a. Patient cooperation needed to

help simplify andminimize pain

b. if patient refuses, notify physician

Make positive patient I.D.

a. Ask patient their name

b. Check patient I.D. wristband

Put on gloves

Puncture Procedure


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Puncture Procedure

Assemble needle to syringea. keep needle sterile

b. eject excess heparin and air

bubbles, if using syringewith liquid heparin

c. pull back syringe plunger to atleast 1cc to give room for

blood to fill

syringe when puncture is made

d. NEVER recap needle

Puncture Procedure


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Puncture Procedure

Select SiteA. Palpate the right and left radials arterial

pulse and visualize the course ofthe artery.

B. Pick strongest pulse1. Radial artery is always the first choice

and should be used becauseof it provides collateralcirculation

i. if radial pulse weak on right,move to left

ii. if pulse on left weak, then trybrachial2. Brachial used as alternative site3. Femoral is the last choice in normal

situations almost every related

complication has been

Other Puncture Sites:


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Other Puncture Sites:

Puncture Procedure: Allens


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Test

When using radials, perform Allen's Test forcollateral circulation

A. In a conscious and cooperative patient:

1. compress ulnar and radial arteries at wrist to

obliterate pulse2. have patient clench and release pulse until handblanches

3. with radial still compressed, release pressure onulnar artery

4. watch for pinkness to return should pink upwithin 10 15 second

Puncture Procedure: AllensT


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Test

B. In an unconscious:

1. compress ulnar and radials

2. elevate hand above head, squeeze hard

3. release ulnar and lower hand below heart Palpate left and right radial arteries noting

maximal pulse. The one with the strongerpulse will be your site of entry.

Performing Allens Test


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Performing Allen s Test

The idea here is to figure out if there is adequate collateralcirculation from the ulnar artery to perfuse the hand.

Puncture Procedure


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Puncture Procedure

Drape the bed and stabilize the wrist in theposition that gives maximal pulse

(hyper-extended, using a rolled up towel ifnecessary)

Prepare the site Cleanse the chosen area with a alcohol and/or

iodine

Secure needle to syringe and remove cap

from needle

Puncture Procedure


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Puncture Procedure

Puncture Procedure


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Puncture Procedure

Pierce the skin at puncture site keep needle angle constant

Bevel of needle up, or into the arterial flow(Bevel faces the heart)

Angle of Entry


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Angle of Entry

Angles of Entry


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Angles of Entry

Puncture Procedure


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Puncture Procedure

Slowly advance in one plane When the artery is punctured, blood will

enter the syringe flash

Puncture Procedure


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Puncture Procedure

Slowly allow blood to fill syringe if no blood appears, remove, change needles,

and start again

Puncture Procedure


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Puncture Procedure

Upon removal of the needle, hold pressureon the puncture site for at least 5 minutes.

Pressure may need to be held longer (> 5mins) if the patient is on anticoagulant therapy

Puncture Procedure


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u c u e ocedu e

Check for: Bleeding

movement of fingers and tingling

sensation pulse distal to puncture

if pulse not palpable, notify physician STAT

Post Puncture Procedure


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Remove any air bubbles from sample and capsyringe Dispose of needle in sharps container

Roll syringe to mix heparin with sample Immerse in ice On lab slip indicate:

a. FIO2 b. patient temperature c. ventilator parameters

Deliver to lab

Post Puncture Procedure


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Complications of ArterialPunctures:


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Punctures:

Complications of ArterialPunctures:


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Punctures:

Technical Causes ofAbnormal Results:


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Abnormal Results:

Delay in running sample O2 consumption will continue as will CO2

production pH does what CO2 tells it to do

Iced, sample will last an hour without a change inthe results

un-iced, ABG's can be significantly changed after 10min

Venous sample drawn

Usually this in shocky patient that you expect low

pressures and dark blood Should doubt when PO2 is significantly lower

than expecteddraw venous blood to check comparison or

redraw sample



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Abnormal Results:

Capillary samples From infants warmed heel

CAUTION pay attention to puncture site andsample type

ONLY diagnostic values are pH and PaCO2 PaO2 value is NOT diagnostic

Heparin

Sodium Heparin 1% solution should be useammonium heparin will alter pH dry lithiumheparin is OK

All unnecessary heparin should be ejectedfrom syringe, excess can effect results



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Abnormal Results:

Patient pain a. Can cause hyperventilation or breath holding

b. An anesthetic may be injected prior to stick forpain, although this hurts probably as much

Usually 2% lidocaine

CAUTION some people allergic to caines

Machine errors

a. Improper calibration

b. Air bubbles in electrodes

c. Torn membranes

Quality Control/PerformanceImprovement


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Improvement

Quality control levels (high, normal, low) arerun every 8 hours to check performance ofmachine

Levey-Jennings chart assesses whether controlvalue falls within acceptable limits.

i. trend 6 or more results in an increasing ordecreasing pattern

ii. shift 6 or more results falling on the sameside of the mean


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aaphlebotomy for nurses

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