Theory and Practice of PhlebotomyWhat is phlebotomy? The term phlebotomy refers to the ancient practice of bloodletting Now the term phlebotomy is used for the withdrawal of blood from a vein, artery, or the capillary bed for lab analysis or blood transfusion.Who is a phlebotomist? Collects blood and other specimens Prepares specimens for testing Interacts with patients & health care professionals plays a vital role in any health care system Other medical professionals, including doctors, nurses, technologists, and medical assistants must also be trained to collect blood specimens. ProfessionalismConfidentiality All employees are responsible for maintaining confidentiality of medical informationAttitude Tone of voice and facial expression will determine how patients respond to you. Always be polite, friendly, calm, and considerate. Appearance Your personal appearance will also affect the impression you make. Comply with your facilitys dress code and personal appearance policies. SafetyBlood-Borne Pathogens Infectious micro-organisms which live in the bloodstream. You can be exposed to bloodborne pathogens if you are injured with a contaminated needle. You can also be exposed if your mucous membranes, including eyes, mouth, or the inside of your nose come into contact with contaminated body fluids. Occupational Health and Safety Administration of the federal government has mandated bloodborne pathogen training for all workers who are at risk of exposure. OSHA Training Standard Precautions Personal Protective Equipment Hand Washing Hazardous waste disposal Needle sticks and prevention actStandard Precautions Standard Precautions means treating all body fluids and substances as if they were infectious. Potentially infectious body fluids include: Blood, Semen, Vaginal Secretion, Peritoneal, pericardial and pleural fluids, and Saliva Sweat and tears are not generally considered infectious. Personal Protective Equipment lab coat Gloves Face masks ( certain types of isolation)Hand Washing Hand washing is the single most important infection control measure. Wash hands thoroughly before, after, and between all patient contacts. Be sure to turn off faucets using a paper towel to avoid contamination. Hazardous waste disposal All needles & other sharps must be disposed of in approved sharps disposal containers. Other contaminated waste must be discarded in an appropriate biohazard bag or waste receptacle.

Blood Components Circulating whole blood is a mixture of: Plasma (which contains fluid, proteins, and lipids), and formed elements, consisting of red cells, white cells, and platelets. Blood Clot When a blood sample is left standing without anticoagulant, it forms a coagulum or blood clot. The clot contains coagulation proteins, platelets, and entrapped red and white blood cells. Serum Serum contains all the same substances as plasma, except for the coagulation proteins, which are left behind in the blood clot. EquipmentTrays Trays should be sanitized daily using appropriate disinfectant Kept Organized and well-stocked. Blood Collection tubes glass or plastic tube with a rubber stopper. It has a vacuum so that blood will flow into the tube. anticoagulants and/or other chemical additives. Rubber stoppers of blood collection tubes are color coded. Each type of stopper indicates a different additive or a different tube type.

1. LAVENDER EDTA to prevent clotting hematology studies. Should be completely filled Must be inverted after filling

2. LIGHT BLUE sodium citrate. coagulation (clotting) studies. must be completely filled must be inverted immediately after filling

3. GREEN sodium or lithium heparin for tests requiring whole blood or plasma such as ammonia

4. RED No additives Blood bank tests, toxicology, serology Must not be inverted after filing

5. GRAY Inhibitor for glycolysis + anticoagulant Sodium Fluoride +potassium oxalate. glucose levels.

6. YELLOW Acid citrate dextrose Inactivates complements DNA studies, paternity testing

7. ROYAL BLUE heparin or Na EDTA anticoagulants Tube is designed to contain no contaminating metals Trace element and toxicology studies

Holders A plastic holder must be used with the evacuated tube system. Needles Different sizes. size =gauge. The larger the needle, the smaller the gauge number. 21 or 22 gauge needle is mostly used. Needle Components Tip Bevel Barrel

Single Draw Needle Single draw needles are of the type that fit on a syringe, and can be used only to fill the syringe to which they are connected. Multiple Draw Needle Used with vacuum collection tubes. They have a retractable sheath over the portion of the needle that penetrates the blood tube. Needles with built-in safety devices An internal blunt needle that is activated with forward pressure on the final blood tube prior to withdrawal of the needle from the vein.Butterfly Needle Winged infusion set Difficult venipunctures including pediatric draws with a syringe or a holder and vacuum collection tube system. 21, 23, or 25 gauge. number-one cause of needlestick injuries, so proper use of their safety devices is critical.

Lancets Lancets are used for difficult venipunctures, including pediatric draws. Tourniquets Vein easier to SEE, FEEL, and PUNCTURESterilization 70% AlcoholGloves Gloves must be worn for all procedures requiring vascular access. Non-powdered latex gloves are most commonly used;

Collecting Blood1. Greeting Always greet patient in a professional, friendly manner. A good initial impression will earn the patients trust, and make it easier and more pleasant to draw a good specimen. Knock on the patients door before entering. Identify yourself by name and department. Explain the reason for your presence. The more relaxed and trusting your patient, the greater chance of a successful atraumatic venipuncture. Good verbal, listening, and nonverbal skills are very important for patient reassurance

2. Patient Identification Make sure the name, medical record number, and date of birth on your order/requisition match those on the patients armband. Verify the patients identity by politely asking them to state their full name. Properly identifying patients and specimens is probably the single most critical part of your job. The consequences of misidentifying a specimen can be life threatening. Never rely on the patient name on the door or above the bed. Patients are frequently moved from room to room. A hospitalized patient must always be correctly identified by an ID band that is attached to the patient.

3. Wash hands

4. Apply gloves Patients are often reassured that proper safety measures are being followed when gloves are put on in their presence. Position the Patient Comfortable position Turn the arm so that the wrist and palm face upward, and the antecubital area is accessible When supporting the patients arm, do not hyperextend the elbow. This may make vein palpation difficult.

5. Applying the tourniquet Tie the tourniquet just above the elbow. The tourniquet should be tight enough to stop venous blood flow in the superficial arm veins. The tourniquet should be applied a maximum of 1 2 minutes. After applying the tourniquet, you may ask the patient to make a fist to further distend the arm veins. Patients often think they are helping by pumping their fists This is an acceptable practice when donating blood, but not in sample collection as this can lead to hemoconcentration

6. Choose a site The median cubital vein If not accessible: Cephalic vein, or the Basilic vein. If not accessible: veins on the back of the hand. Use a much smaller needle for these hand veins. Using the nondominant hand routinely for palpation may be helpful when additional palpation is required immediately before performing the puncture. Often, a patient has veins that are more prominent in the dominant arm.Never Draw from these Areas: Scarred, abraded, or inflamed skin Arms containing IV catheters Edematous arms Occluded Veins Shunts

7. Cleansing the site Isopropyl alcohol swab Outward expanding spiral starting with the actual venipuncture site. Allow the alcohol to dry

8. Cleansing the site Patients are quick to complain about a painful venipuncture. The stinging sensation caused by undry alcohol is a frequent, yet easily avoided, cause of complaints.

9. Attach needle to holder10. Place tube into holder11. Hold vein in place12. Insert needle

13. Push tube into holder Gently push the tube onto the needle holder so that the catheter inside the needle holder penetrates the tube. Blood flow should be visible at this point. Allow tubes to fill until the vacuum is exhausted to ensure the correct blood to anticoagulant ratio.Blood wont flow If you do not see blood flow, the tip of the needle:1. May not yet be within the vein.2. May have already passed through the vein.3. May have missed the vein entirely.4. May be pushed up against the inside wall of the vein.TROUBLESHOOTINGIncomplete collection or no blood is obtained: Change the position of the needle. Move it forward (it may not be in the lumen) Incomplete collection or no blood is obtained: or move it backward (it may have penetrated too far). Incomplete collection or no blood is obtained: Adjust the angle (the bevel may be against the vein wall). Loosen the tourniquet. It may be obstructing blood flow. Try another tube. There may be no vacuum in the one being used. Re-anchor the vein. Veins sometimes roll away from the point of the needle and puncture site.Other Problems A hematoma forms under the skin adjacent to the puncture site - release the tourniquet immediately and withdraw the needle. Apply firm pressure. The blood is bright red (arterial) rather than venous. Apply firm pressure for more than 5 minutes Multiple Tube Collection If you are drawing more than one tube: Keep a firm grip in the needle holder while pressing down on the patients arm. Use your other arm to interchange tubes.

14. Removing the Needle Gently release the tourniquet before the last tube of blood is filled Remove the last tube from the needle Withdraw the needle in a single quick movement15. Apply Pressure Quickly place clean gauze over the site, and apply pressure. You may ask the patient to continue applying pressure until bleeding stops.16. Apply Adhesive bandage The practice of quickly applying tape over the gauze without checking the puncture site frequently produces a hematoma17. Needle disposal Remove the needle from the holder if appropriate, and properly discard it in an approved sharps disposal container. Discard all waste and gloves in the appropriate biohazardous waste container. Wash hands.

18. Specimen Labeling Label specimens at the bedside according to your institutions standard procedures, or apply preprinted labels. Proper labeling is the single most critical task you are asked to perform.Proper labeling generally includes: Patients first and last name Hospital identification number Date & time Phlebotomist initials Your institution may provide bar coded computer generated labels that contain this information.Summary Of Venipuncture Technique1. requisition form.2. Greet the patient.3. Identify the patient.4. Reassure the patient and explain the procedure.5. Prepare the patient.6. Select equipment and supplies.7. Wash hands and apply gloves.8. Apply the tourniquet.9. Select the venipuncture site.10. Release the tourniquet.11. Cleanse the site.12. Assemble equipment.13. Reapply the tourniquet.14. Confirm the venipuncture site.15. Examine the needle.16. Anchor the vein.17. Insert the needle.18. Push the evacuated tube completely into adapter.19. Gently invert the specimens, as they are collected.20. Remove the last tube from the adapter.21. Release the tourniquet.22. Place sterile gauze over the needle.23. Remove the needle, and apply pressure.24. Activate needle safety device.25. Dispose of the needle.26. Label the tubes.27. Examine the patients arm.28. Bandage the patients arm.29. Dispose of used supplies.30. Remove and dispose of gloves.31. Wash hands.32. Complete any required paperwork.33. Thank the patient.34. Deliver specimens to appropriate locations.Syringe Specimen Collection Small or delicate veins that might be collapsed by the vacuum of the evacuated tube system. May also be used to collect blood culture specimens.Finger stick-Specimen collection A safety Lancet, which controls the depth of incision Finger-sticks should not be performed on children under one year of age. If possible, use the fourth (ring) finger or the middle finger. Many patients prefer that you use fingers on their nondominant hand. Choose a puncture site near the right or left edge of the finger tip. Clean the site as you would for routine venipuncture. Select a safety lancet appropriate for the size of the patients finger. You may warm the finger prior to puncture to increase blood flow. Make the puncture perpendicular, rather than parallel, to the finger print. Wipe away the first drop of blood using gauze to remove tissue fluid contamination. Collect blood into an appropriate tube. Label specimens appropriately. Make sure bleeding has stopped. Apply an adhesive bandage if necessary. Discard sharps appropriately.Heel stick neonatal blood collection Veins of small children and infants are too small for venipuncture; Butterfly needles may be used to collect venous blood in older children. These devices are designed to control the depth of incision, since going too deep into an infants heel could injure the heel bone, and cause osteomyelitis (bone infection).Heel Stick Procedure Firmly grasp the infants foot. Do not use a tourniquet. The heel may be warmed with a cloth to help increase blood flow. Wipe the collection site with an alcohol prep pad, and allow the alcohol to dry. Wipe the site with sterile cotton or gauze, to be sure all the alcohol has been removed. Puncture the left or right side (outskirt) of the heel, not the bottom of the foot. Wipe away the first drop of blood since it may contain excess tissue fluid or alcohol which could alter test results. Collect the blood into the appropriate tube. Do not: Squeeze the infants foot too tightly and wipe with alcohol during the collection. After collection is completed, apply pressure to the puncture site with a sterile gauze pad until bleeding has stopped. Do not apply an adhesive bandage to an infants foot since it may injure its delicate skin.

Butterfly Butterfly needles (winged infusion set) are available in smaller gauges, and are used to draw venous blood from children, and adults with difficult veins. Butterfly needles come attached to a small tube which may be connected to: An evacuated tube holder, or A syringe.

Special situationsPatients refusing blood work If someone hesitates to let you collect a blood specimen, explain to them that their blood test results are important to their care. Patients have a right to refuse blood tests If the patient still refuses, report and document patient refusalFainting Rarely, patients will faint during venipuncture. It is therefore important that patients are properly seated or lying in such a way during venipuncture so that if they do faint, they wont hurt themselves. Fainting; what to do?1. Gently remove the tourniquet and needle from the patients arm, apply gauze and pressure to the skin puncture site. 2. Call for help. 3. If the patient is seated, place his head between his knees. 4. A cold compress on the back of the neck may help to revive the patient more quickly.Unsatisfactory Specimens They can cause misleading laboratory results Must be rejected by the laboratory. The patient must then undergo another venipuncture to get a better specimen. It costs time & money to redraw the specimen. The credibility of the laboratory is reduced if too many unsatisfactory specimens are drawn. Causes of Unsatisfactory Specimens:1. Hemolysis Hemolysis means the breakup of fragile red blood cells within the specimen, and the release of their hemoglobin and other substances, into the plasma. A hemolyzed specimen can be recognized after it is centrifuged by the red color of the plasma. Hemolysis can cause falsely increased potassium, magnesium, iron, and ammonia levels, and other aberrant lab results. Causes of Hemolysis Using a too small needle for a relatively bigger vein Pulling a syringe plunger too rapidly Expelling blood vigorously into a tube, Shaking a tube of blood too hard.2. Clots Blood clots when the coagulation factors within the plasma are activated. Blood starts to clot almost immediately after it is drawn unless it is exposed to an anticoagulant. Clots within the blood specimen, even if not visible to the naked eye, will yield inaccurate results.Causes of Clots Inadequate mixing of blood and anticoagulant Delay in expelling blood within a syringe into a collection tube

3. Insufficient volume short draws will result in an incorrect ratio of blood to anticoagulant, and yield incorrect test results. Short draws can be caused by: A vein collapsing during phlebotomy. The needle coming out of the vein before the collection tube is full. Loss of collection tube vacuum before the tube is full.4. Labeling Errors Labeling errors are the most common cause of incorrect laboratory results. If detected, the incorrectly labeled specimen will be rejected. If undetected, it will produce incorrect results which might adversely affect your patients care.Causes of Labeling Errors Failure to follow proper patient identification procedure. Failure to label the specimen completely and immediately after collection.