Phlebotomy

Objectives
Theory and practice of phlebotomy
How to interact professionally with patients
Occupational health hazards and appropriate
precautions
Related anatomy and physiology
Phlebotomy equipment and supplies
Phlebotomy procedures
Complications of venipuncture and how to
handle them.

Theory and Practice of Phlebotomy

What 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

Who is a phlebotomist
Other medical professionals, including
doctors, nurses, technologists, and
medical assistants must also be trained to
collect blood specimens.

Confidentiality
All employees are responsible for
maintaining confidentiality of medical
information

Attitude
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 facility’s dress code and
personal appearance policies.

Blood-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.

Blood-Borne Pathogens
Diagram of
Hepatitis C
Virus

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 act

Standard Precautions
Standard Precautions means treating all
body fluids and substances as if they were
infectious.

Standard Precautions
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.

Hand washing
Remove rings
Stand by the sink but do not touch it
Apply soap and rub hands together
Both sides of the hand, between fingers,
around knuckles, under fingernails
Rinse hands in a downward motion
Dry hands with a clean paper towel
Turn off water with another paper towel

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.

Needle sticks and prevention act
Safety Devices should always be
encouraged

Anatomy & Physiology
Anatomy is the branch of science
concerned with the study of the structure
of the body.
Physiology is the branch of science
concerned with the study of the function of
the body.

Anatomy & Physiology
The cardiovascular
system consists of the
Heart, and Blood
Vessels.
Its main function is
circulate oxygenated
blood from the lungs to
various organs, and
return blood depleted of
oxygen to the lungs,
where it is reoxygenated.

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.

Trays
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.

Blood collection tubes
Rubber stoppers of
blood collection tubes
are color coded.
Each type of stopper
indicates a different
additive or a different
tube type.

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

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

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

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

GRAY
Inhibitor for glycolysis
+ anticoagulant
Sodium Fluride
+potassium oxalate.
glucose levels.

YELLOW
Acid citrate dextrose
Inactivates
complements
DNA studies,
paternity testing

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

Blood Culture Bottles
Different blood culture
bottles are used for
aerobic, anaerobic,
and pediatric
collections.

Blood collection tubes: Safety
The rubber stopper is
positioned inside the
plastic shield

Sizes
Adult:3 - 10 ml
Pediatric 2 - 4 ml.
Tubes for fingersticks
or heelsticks ½ or
less

Holders
A plastic holder must
be used with the
evacuated tube
system.

Needle holders with built-in protection
devices

Syringes with built-in safety devices

Needles
Different sizes.
size =gauge.
The larger the needle, the smaller the
gauge number.
21 or 22 gauge needle is mostly used.

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.

Butterflies with built-in safety features
number-one cause of needlestick
injuries, so proper use of their safety
devices is critical.

Butterflies with built-in safety features

Lancets
Lancets are used for
difficult
venipunctures,
including pediatric
draws.

Tourniquets
Vein easier to SEE,
FEEL, and
PUNCTURE

Gloves
Gloves must be worn
for all procedures
requiring vascular
access.
Non-powdered latex
gloves are most
commonly used;

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 patient’s 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.
Technical Tip

Good verbal, listening, and nonverbal
skills are very important for patient
reassurance
Technical Tip

Patient Identification
Make sure the name, medical record
number, and date of birth on your
order/requisition match those on the
patient’s armband.
Verify the patient’s 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.
Technical Tip

Patients are often reassured that proper
safety measures are being followed when
gloves are put on in their presence.
Technical Tip

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 patient’s arm, do not
hyperextend the elbow. This may make
vein palpation difficult.
Technical Tip

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
Technical Tip

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.
Technical Tip

Scarred, abraded, or inflamed skin
Arms containing IV catheters
Edematous arms
Occluded Veins
Shunts
draw from these areasNever

Cleansing the site
Isopropyl alcohol swab
Outward expanding spiral starting with the
actual venipuncture site.
Allow the alcohol to dry:-
1-disinfect the site
2-prevent a burning sensation

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.
Technical Tip

Insert needle
the needle bevel up

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.
Technical Tip

Blood won’t 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.

Incomplete collection or no blood is
obtained:

obtained:
Change the position of the needle. Move it
forward (it may not be in the lumen)

obtained:
or move it backward (it may have
penetrated too far).

obtained:
Adjust the angle (the bevel may be
against the vein wall).

obtained:
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.

Other Problems
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.

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
movement

Apply Pressure
Quickly place clean gauze over the site,
and apply pressure.
You may ask the patient to continue
applying pressure until bleeding stops.

The practice of quickly applying tape over
the gauze without checking the puncture
site frequently produces a hematoma
Technical Tip

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.

Specimen Labeling
Label specimens at the bedside according
to your institution’s standard procedures,
or apply preprinted labels.
Proper labeling is the single most critical
task you are asked to perform.

Proper labeling generally includes:
Patient’s first and last name
Hospital identification number
Date & time
Phlebotomist initials
Your institution may provide bar coded
computer generated labels that contain
this information.

1. 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.
Summary Of Venipuncture Technique

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 patient’s arm.
28.Bandage the patient’s 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.

Finger stick
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.

Finger stick
Select a safety lancet
appropriate for the size of
the patient’s finger.
You may warm the finger
prior to puncture to
increase blood flow.
Make the puncture
perpendicular, rather than
parallel, to the finger
print.

Finger stick
Wipe away the first
drop of blood using
gauze to remove
tissue fluid
contamination.

Finger stick
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
Veins of small
children and infants
are too small for
venipuncture;
Butterfly needles may
be used to collect
venous blood in older
children.

Heel stick neonatal blood collection
These devices are
designed to control
the depth of incision,
since going too deep
into an infant’s heel
could injure the heel
bone, and cause
osteomyelitis (bone
infection).

Heel stick
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.

Heel stick
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.

Heel stick
Collect the blood into
the appropriate tube.
Do not: Squeeze the
infant’s foot too tightly
and wipe with alcohol
during the collection.

Heel stick
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 infant’s 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
Butterfly needles
come attached to a
small tube which may
be connected to:
An evacuated tube
holder, or A syringe.

Patients 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 refusal

Fainting
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 won’t hurt themselves.
self-limited

Fainting; what to do?
Gently remove the tourniquet and needle from
the patients arm, apply gauze and pressure to
the skin puncture site.
Call for help.
If the patient is seated, place his head between
his knees.
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

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.

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.

Hemolysis
Hemolysis can cause falsely increased
potassium, magnesium, iron, and
ammonia levels, and other aberrant lab
results.

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

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.

Labeling Errorrs
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
patient’s care.

Causes
Failure to follow proper patient identification
procedure.
Failure to label the specimen completely
and immediately after collection.

Ten Commandments

I. Thou shalt protect thyself from injury
II. Thou shalt identify thy patients
III. Thou shalt stretch the skin at the puncture site
IV. Thou shalt puncture the skin at about a 15 degree angle
V. Thou shalt glorify the median vein
VI. Thou shalt invert tubes containing anticoagulants immediately
after collection
VII. Thou shalt attempt to collect specimens only from an acceptable
site
VIII. Thou shalt label specimens at the bedside
IX. Thou shalt know when to quit
X.Thou shalt treat patient's like they are family

Healthcare in the new millennium

Phlebotomy

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