1.A. Blood Collection

Tubes

Gold - Clot activator and gel for serum separation. Used for serum determinations in chemistry and for routine blood donor screening and diagnostic testing of serum for infectious disease.

Light Green - Lithium heparin and gel for plasma separation. Used for plasma determinations in chemistry.

Red - Silicone coated (glass), Clot activator, Silicone coated (plastic). Used for serum determinations in chemistry and for routine blood donor screening and diagnostic testing of serum for infectious disease.

Orange - Thrombin-based clot activator with gel for serum separation. Used for stat serum determinations in chemistry.

Royal Blue - Clot activator (plastic serum), K2EDTA (plastic). Used for trace-element, toxicology, and nutritional-chemistry determinations.

Green - Sodium heparin or Lithium heparin. Used for plasma determinations in chemistry.

Gray - Potassium oxalate/sodium fluoride, Sodium fluoride/Na2EDTA, Sodium fluoride (serum tube). Used for glucose determinations. Oxalate and EDTA anticoagulants will give plasma samples. Sodium

fluoride is the antiglycolytic agent.

Tan - K2EDTA (plastic). Used for lead determinations. This tube is certified to contain less than .01 μg/mL(ppm) lead.

Lavender - Liquid K3EDTA (glass), Spray-coated K2EDTA (plastic). K2EDTA and K3EDTA for whole blood hematology determinations. K2EDTA may be used for routine immunohematology testing, and blood donor screening.

White - K2EDTA and gel for plasma separation. used in molecular diagnostic test methods (such as, but not limited to, polymerase chain reaction [PCR] and/or branched DNA [bDNA] amplification techniques.)

Pink - Spray-coated K2EDTA (plastic). used for whole blood hematology determinations. May be used for routine immunohematology testing and blood donor screening.

Light Blue - Buffered sodium citrate 0.105 M (≈3.2%) glass0.109 M (3.2%) plastic. Citrate, theophylline, adenosine, dipyridamole (CTAD).

Clear – None (plastic). Used as a discard tube or secondary specimen tube

B. Complete Venipuncture and Skin Puncture Equipment and their uses or functions.

I. Venipuncture

Tourniquet – used to provide a barrier against venous blood flow to help locate a vein. It must not be applied 2-4 inches above puncture site left no longer than 1 minute prior to drawing of blood.

Collection tubes – evacuated tube system is commonly used. Plastic tubes are recommended, while glass tubes are coated with silicone inside to prevent hemolysis and cell adherence.

Needles – in selecting needle gauge for phlebotomy always use the appropriate size for the vein diameter to prevent vein collapse and hemolysis. Needles are made to be screwed into the evacuated tube holder or to be attached to the tips of syringes. The needle gauges for drawing blood range from 20 to 25 gauge. The most common needle size for adult venipuncture is 21 gauge with a length of 1 inch.

Needle holder – prevents the possibility of needle sticks. They are disposable and must be discarded after

single use with the needle attached.

Winged infusion sets (butterfly) – an intravenous device with short needle and a thin tube with attached plastic wings. Useful in difficult blood draws especially in children and difficult veins.

Syringes – useful in drawing blood from pediatric, geriatric or other patients with tiny, fragile or “rolling” veins that would not be able to withstand vacuum pressure from evacuated tubes.

Solutions for Skin preparation – 70% isopropyl alcohol is commonly used. It is used to clean the site.

II.Skin Puncture

Capillary tubes – with or without heparin added.

Microcollection tubes – available with or without additives, and the cap colors on the tubes correspond with the colors on vacuum tubes.

C. Collection sites for Venipuncture and Skin Puncture (both for adults and children)

I. Venipuncture

Median cubital vein is the first choice.

Cephalic vein – most prominent in obese patients Basilic veins can also be used.

II. Capillary Puncutre

Heel or finger can be used. In infants, only the heel is

used – the lateral or medial surface of the plantar side of the heel.

In older children and adult – the palmar surface of the distal portion of the third and fourth finger on the non-dominant hand may be used.

D. Complications encountered during blood collection.

Ecchymosis (Bruise) – caused by leakage of a small amount of fluid around the tissue.

Syncope (Fainting) – it is the second most common complication. Remove the

needle immediately if the patient starts to faint.

Hematoma – a leakage of a large amount of fluid around the puncture site causes the area to swell. If the area starts to swell, remove the needle and apply pressure for several minutes.

Failure to draw blood – the major reason is the vein is missed, often because of improper needle positioning. The needle should be inserted completely into the vein with the slanted side (bevel) up, at an angle of 15 to 30 degrees. Other reasons are device malfunction and vacuum loss in evacuated tubes.

Petechiae – small red spots indicating small amounts of blood that have escaped into the epithelium. It indicates a coagulation problem and should alert the phlebotomist for prolonged bleeding.

Edema – it is an abnormal accumulation of fluid in the intercellular spaces of the tissues. Edematous sites should be avoided for venipuncture.

Obesity – the cephalic vein is often the only vein that can be felt in obese patients. When palpating do not depress the area so much because you might miss the vein suspended in the fatty tissue. Usually the error in palpating obese patients is thinking that the vein is

buried deep below fat, this is not always the case.

Intravenous therapy – drawing blood from an arm with IV catheter should be avoided if possible. If not possible, apply tourniquet below the IV site and draw blood below the IV site. Have the nurse stop the infusion 2 minutes before drawing blood. Discard the first 5mL of blood collected before obtaining samples for testing. Note: the problem with this is that the IV catheter might be dislodged, as much as possible find another site.

Hemoconcentration – increased concentration of larger molecules and analytes in the blood as a result of a shift in water balance. Caused by leaving the tourniquet on the arm for too long. It should not take more than 1 minute, if the vein is not located within 1 minute it should be removed for 2 minutes and reapplied before the venipuncture.

Hemolysis – can cause the plasma or serum to appear pink or red due to the rupture of RBCs with the consequent escape of hemoglobin. Can occur if small gauge needle is used in difficult draws; pulling back the plunger too quickly; forces blood from syringe into a tube; shakes the tube; or if the sample is contaminated with alcohol or water

Burned, Damaged, Scarred and Occluded Veins – should be avoided because blood does not flow freely in these sites.

Seizures and tremors – remove needle immediately to prevent injury. Preventing injury from nearby objects should ensure the patient’s safety.

Vomiting and choking – the patient’s head is positioned so that he/she does not aspirate any vomit. Keep the patient from hitting his/her head.

Allergies – some patients may be allergic to skin antiseptic substances other than alcohol, adhesive bandages and tape. Sensitivity to latex should be determined.

Mastectomy patients – requires physician permission before blood is drawn from the same side as a prior mastectomy even in the case of bilateral mastectomies. The pressure on the arm with the tourniquet can lead to pain or lymphostasis.

Inability to Obtain a Blood Specimen – if two unsuccessful attempts at collection have been made, it is recommended that the phlebotomist seek the assistance of another caregiver with blood collection expertise. The patient has the right to refuse to give a blood specimen.

E. Venipuncture Procedure in Adults.

1. ID the patient and look for the doctor’s order.

2. Wash hands, wear gloves and choose a comfortable place to set up the biological sampling station.

3. Lay out a clean disposable mat with all the equipment necessary to collect blood samples.

4. Examine both arms to find the best vein. Locate the puncture site; apply the tourniquet(less than 2 minutes).

5. Cleanse the area with an alcohol wipe. Wipe the area in a circular motion making sure the area is thoroughly cleaned.

6. If it is necessary to feel the vein again, do so, but cleanse the area again with an alcohol wipe.

7. Fix the vein by pressing down on the vein about 1 inch below the proposed point of entry and pull the skin taut.

8. Remove the needle shield.9. Approach the vein in the

same direction the vein is running, holding the needle so that it is at an approximately 15° angle with the participant's arm.

10.Push the needle, with bevel facing up, firmly and deliberately into the vein, If the needle is in the vein, blood will enter the syringe and you can start pulling the plunger

11.For collection, loosen the tourniquet immediately after blood flow is established.

12.When you have the desired volume of blood, slowly removed the syringe and apply the dry gauze.

13.Ask the patient to apply pressure for 10 minutes.

14.Properly label the specimen.15.Dispose the used material

properly (if possible cut the needle using a needle cutter to avoid accidental prick).

F. Venipuncture Procedure in Children and Infants.

1. Wash hands and place on gloves.

2. Identify the patient. 3. Prepare and organize

venipuncture equipment. A 23g butterfly attached to a pediatric vacutainer holder. Pediatric vacuum tubes can be used on prominent veins.

For smaller veins use a 23g butterfly attached to a 3-5 ml syringe.

4. Restrain the child if necessary according to the recommendations (roll the infant in a blanket exposing only the puncture site).

5. Place a pediatric size tourniquet around the bicep muscle in the upper arm. Palpate for a vein in the antecubital fossa.

6. Once the vein has been located cleanse site in concentric circles with 70% isopropyl alcohol. Let air dry.

7. Anchor the vein by pulling skin down with thumb or index finger.

8. Make sure to keep needle out of sight from child. Enter vein with butterfly needle at a 15 to 30 degree angle. Check for “flash” of blood in the tubing. If no blood appears, gently redirect until “flash” appears. As soon as blood appears in the tubing of the butterfly, pull the syringe plunger to fill with blood (butterfly/syringe method) or engage vacuum tubes into holder (vacutainer method) and fill to capacity. Make sure not to exceed maximum daily blood volume. (See volume chart) After collection is completed activate the safety mechanism on the Butterfly device. Hold direct pressure on the puncture site with 2 x 2 gauze sponges until bleeding has stopped. Apply

a clean 2 x 2 gauze sponge folded into fourths and apply paper tape.

9. Discard the entire assembly device in an approved sharps disposal container.

10.Gently invert additive tubes and label tubes with: a. Patient’s name b. Medical record number c. Date d. Time of draw e. Blood collector’s initials and notify the infant’s nurse of the total blood volume collected, or record in appropriate log.

G. Skin Puncture in Adults.

1. Gloves must be worn when performing skin punctures.

2. ID the patient.3. Prepare the puncture

materials.4. If finger is cold, wrap in

warm compress at a temperature no higher than 42° for three to five minutes to warm site.

5. Briskly rubbing the heel or fingertip will improve circulation.

6. Cleanse the area with 70% alcohol pad and let it air dry.

7. Place the puncture device on the patient's skin and activate the release mechanism.

8. Wipe the first drop of blood away with dry gauze (contaminated with tissue fluid).

9. Collect blood using capillary tube action (never put too

much pressure just to force the blood out)

10.Label the specimen and dispose the materials properly.

H. Skin Puncture in Children and infants.

1. Check the computer label or lab requisition to see what test is ordered. Obtain and select appropriate equipment for the heel puncture procedure.

2. Properly identify the infant by matching the computer label with the infant’s identification number located on the bracelet.

3. Place gloves on hands. 4. Infant should be positioned

in the supine position (face up). Allow the foot to hang lower than the torso to improve blood flow.

5. Activate and place a chemical heel warmer on the infant’s heel for 3 to 5 minutes. This will increase the blood flow to the area by 7 fold.

6. Assemble all of your equipment. Do not lay any

equipment in bassinet. Use shelf underneath bed or top of isolette.

7. After stabilizing the infant’s foot, cleanse the foot with a 70% alcohol pad and dry with a piece of sterile gauze. Alcohol residue on the infant’s foot may cause a stinging sensation and hemolysis of the red cells.

8. Place your thumb on the inside bottom of the foot and push the skin across the heel toward the outside of the heel.

9. Puncture the most medial section (outside) of the plantar surface of the heel. Wipe the first drop of blood with a piece of gauze since this blood has been diluted with tissue fluid and may contaminate the specimen.

10.Draw blood by capillary tube action; mix well with the anticoagulant (red band). Dispose properly the materials.

I. Specimen Handling and Quality Assurance in Specimen Collection.

Technical competence

A phlebotomist should be well trained in all phases of blood collection. Continuing education is encouraged.

Collection Procedures

Procedures must be reviewed. Patient preparation and identification are important.

Anticoagulants and Preservatives

The kind of anticoagulant used must be suitable for the test. Proper mixing should be followed following manufacturer’s instructions. Always check the validity and quality of tubes to be used.

Requirements for a Quality Specimen:

Patient properly identified Patient properly prepared for

draw Specimens collected in

correct order and labeled correctly

Correct anticoagulants and preservatives used

Specimens properly mixed Specimens not hemolyzed Specimens requiring fasting

are collected on time Timed specimen drawn at

the correct time

Blood collection attempts

A person may attempt to draw blood only twice. If unsuccessful, another individual must be called to do the job. Inform the physician/nurse if no blood was obtained.

Collection of specimens for blood culture

The rate of contamination for blood culture must be less than 3%. 2-3 blood collections are required depending on the case and must not be collected on the

same site. The 2 remaining samples on the next day will follow the first sample taken. Blood volume for adults: 10-20 mL; Infants: 1-5mL.

Quality control and preventive maintenance on specimen collection instruments:

1. Periodic maintenance should be followed on all instruments using the manufacturer’s advice.

2. The service report on all repairs and periodic maintenance should be kept and filed.

Reasons for specimen rejection:

a. The test request and tube identification do not match

b. The tube is unlabeled.c. Specimen is hemolyzed d. Wrong collection timee. Wrong tube/ anticoagulant

for the specimen/test.f. Clotted specimen for whole

blood examinationsg. Lipemic specimen – case to

case basish. Contaminated with IV fluid

Specimen handling

Preanalytical phase – the pre testing period. Includes the test requisition and all specimens handling before

testing. Each test has their own specimen handling requirements and must be observed carefully.

2.

A. Making of a Peripheral Blood Smear

1. Draw blood from a patient.2. Blood from the syringe or

the blood transferred on a red top tube can be used to make smear.

3. Place a very small drop of blood near the end of the sample slide.

4. Place the end of the spreader slide on the sample slide so that the short sided edge of the spreader is just below the drop of blood (Holding the spreader at an angle of 30o)

5. Quickly drag the spreader along the entire length of the sample slide in one fluid motion. (Factors to be considered: Size of blood drop, angle, speed, etc.)

B. Differential Count

1. Make a peripheral blood smear. 2. Stain using the smear using the

Wright’s stain.3. Examine under the microscope.4. Identify the different white blood

cells.5. Record the results.

C. Hematocrit and Hemoglobin

1. Perform a skin puncture procedure.

2. Seal your capillary tube (red banc) with clay and wax.

3. Centrifuge the tubes.4. Compare it on the chart for

hematocrit and hemoglobin.5. Report your results (use decimal or

percentage form when reporting for hematocrit.)

3.

A. Veins of the forearm

B. Proper and Improper Needle Insertion

C. Areas for Skin Puncture

D. How to Assemble and Use a Multi-sample Needle

Hematology 1 Lab

Assignment

January 9, 2014

Submitted by: Al Glen D. Egarle Mohammad Hattah C.

Macala BSMT-3B

Submitted to: Ma’am Jean Bedia