Phlebotomy Complications

Requisitions

• ER- telephone

• pick up at desk

• ID-ID# might need written on requisition

Greeting the pt.

• Asleep- wake up

• Unconscious- talk to them

• Psychiatric- get RN to help

• Visitors- ask to step out or stay pt. choice

• MD/clergy- wait unless STAT or timed test

• Not in room- check nsg. station

• document

ID

• NO ID-check ankle-not ok if on bed

• NO ID- RN must band

• Nsg. home/pysch might not have, RN to ID

• Unidentified- follow policy

Pt prep

Preanalytical variables

• Basal state- when resting, no activity

• best in AM

• Fasting- nothing to eat/drink x 8-10 hours

Diet

• Fasting ??

• Lipemic- blood milky/cloudy

• high fat diet

• Alcohol, caffeine

• No chewing gum, candy while blood draw= choking

Posture

• Should sit/lay

• If pass out- standing they could fall

• Change in position can affect tests

Other issues

• Stress• Scared-increase

hormones level• Crying child- may

increase levels

• Smoking

• May increase or decrease blood tests

Other issues

• Diurnal:

• Blood levels vary according to time of day

• Medications:

• May affect metabolism

• Meds affect many tests- MD responsibility

• Herbs- affect bleeding• Document meds

Complications of the pt.

• Apprehensive – need help to hold

• Syncope- fainting

• remove needle, pressure, lower to ground

• apply cold compress

• when awake make them stay

• Seizures: take out needle, pressure, help

Complications of the pt.Con’t

• Petichiae- indicates bleeding problem

• hold site longer ( 5 minutes)

• Pt refusal- their right,

• notify MD

• document

Venapuncture

• Equipment:

• Take extra tubes• Check needle

• Tourniquet Application:

• Skin condition: watch for tears

• Don’t leave on more than 1 minute

• Hemolysis- excessive squeezing, long-term IV, sclerosed or occluded veins

Site Selection

• Can’t find veins: palpate• tap veins• massaging• hang down arm• apply heat• use wrist and hand • do not use veins in feet/legs•

Areas to be avoided

• Contain thrombi• Feel hard -sclerosis • Poor circulation• Hematoma• Edema• Burns• Scarred• Mastectomy• IV site-below site

Cannulas and fistulas

Fistula

• Fuse a vein & artery together

Cannula

• special tube in chest

• connects vein and artery to draw blood

Cleaning the site

• Alcohol- routine

• Betadine- sterile

• Soap and water- alcohol tests

Examination of equipment

• Check syringe –does plunger work?

• Needle straight?

• Everything sterile?

Performing venapuncture

• Syringe:• Advantage: blood enters

hub-easy to tell if in vein• Better control of suction• Disadvantage: collapse

vein, needle sticks• Make sure you use small

syringe on small veins

• Winged set (Butterfly)• Use for difficult sticks,

small, fragile veins• Advantage: better control• Lower angle- 10-15

degrees• Collect with vacuatainers• Disadvantage: increase

sticks

Syringe Butterfly

Central Venous Access

• Specific guidelines

• Special training-sterile technique• 4 types: nontunneled- temporary, subclavin

– tunneled-permanent, broviac, hickman– implanted- under skin, port– PICC ( Peripheral lines)- peripheral

PICC Line

Subclavin Line

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Broviac

Causes of failure to obtain blood

1. Resting against wall of vein- rotate needle, pull back, advance some

2. Go through the vein- angle too much

3. Needle rests on top of vein- angle too shallow

4. Vein rolls- vein not anchored

5. Vein collapses- vacutainer too big, to much pressure

2 ATTEMPTS ONLY AFTER THAT REQUEST ANOTHER PHLEBOTOMIST TO DO !!!

Incorrect needle placement

Causes of hemolyzed specimens

• Using a needle with gauge < 23• Using small needle with large tube• Needle not attached to syringe- cause frothing• Pull plunger back too fast• Draw from hematoma* Vigorously mixing tubes*Forcing blood into tube• Failing to allow blood to run down tube• Collect blood from IV lines• Applying tourniquet too close to site

Causes of hematomas

• Failure to take off tourniquet prior to needle removal• Inadequate pressure to site• Bending arm while applying pressure• Excessive probing• Failure to insert needle far enough in vein• Going through the vein• Elderly- decrease vein elasticity• To Treat: remove tourniquet and needle, apply pressure

and ? Ice• Find new site

Label tubes and bandaging arm

• If no preprinted label make one.

• Bandaging:

• anticoagulant meds- hold site x 5 minutes

• If arterial stick- hold x 10 minutes

• Allergies to adhesive: use gauze

• Hairy arms- no bandage

• Children < 2 no bandage

Leaving pt.

• Position as found

• Rails as ordered

• If they need bathroom, drink get RN

Reasons for rejection of specimen

• Unlabeled/mislabeled• QNS• Wrong tube• Hemolysis• Lipemia• Clot in coag tube• No requisition• Contaminated specimen container