PHLEBOTOMY BASICS Marjorie Moreau,RN

PHLEBOTOMY BASICS Marjorie Moreau,RN

OBJECTIVES After completing this unit the student will be able to: o Define the terms o List the components of blood o Describe how to prepare a patient for a venipuncture. o Describe how to collect a specimen via venipuncture. o Describe how to process blood specimens for testing

TERMINOLOGY Anticoagulant:substance that prevents clotting (EDTA and Heparin) Hematocrit: the % of RBC in blood Hemoglobin: iron containing protein of blood that carries oxygen Hemolysis: breakdown of blood cells Lumen: the diameter of . e.g. needle or vein Phlebotomy: blood collection using venipuncture Venipuncture: process of withdrawing blood from a vein

Phlebotomy Whys? Webster’s – the act of bloodletting as a therapeutic measure To aid in diagnosis of illness Monitor effectiveness of treatment Screening for absence of illness

What is Blood? Thick red fluid flowing through circulatory system consisting of liquid components and cellular components Plasma: Liquid part of blood Serum: Liquid part of blood after clotting (minus fibrin) Cells: erythrocytes, leukocytes and platelets Volume: approx.10 pints in average adult

Blood’s Function Carries O2 and nutrients to tissue Artery Carries CO2 and waste from tissue Vein Capillary tiny blood vessels connecting arterioles and venules RBC’s composed of Hemoglobin O2/CO2 carrier WBC’s fight infection Platelets – Hemostasis/coagulation

To Spin or Not to Spin?

TUBES

TUBE ORDER Choice of tube depends on lack of additive or additive. Blood Culture Red or Marbled Blue Gold Green Lavendar Gray

Test Requisition Computerized Paper Must include: – Patient Name, – Physician Name – Date – Patient ID/age/birthdate – Test request, – Your initials

Patient Identification The most critical step in phlebotomy Inpatients – Must have correct wristband prior to collection Ask patient to state their full name and birth date. Match wristband information with test req.

Technology & patient identification

NEEDLES Needles vary in length and diameter Diameter is measure in gauge The smaller the gauge the LARGER the needle. The manufactures use colors to differentiate the gauges.

Basic Phlebotomy Supplies Requisition Gloves Tourniquet Needle Barrel or Syringe Tubes Alcohol Cotton or Gauze Bandage or Tape

Standard Precautions Always wear gloves Keep needle sterile Use proper protective equipment – PPE’s Remove tourniquet prior to removing needle Never recap needles Wear gloves Wash hands after every patient Dispose of equipment properly

The integrity of the specimen THE RIGHT PATIENT THE RIGHT CONTAINER THE RIGHT TIME USE CORRECT TECHNIQUE/SITE LABEL CORRECTLY AND COMPELETLY AVOID HEMOLYSIS

To begin the phlebotomy procedure: 1. Explain “This will not hurt” 2. Ask, “Are you Mr Perez?” 3. Ask the patient to spell his last name 4. Apply the tourniquet 88% 12% 0% hi “T 1 2 3 4 5 6 7 8 9 10 11 s ill w n . ot u yo 0% . r. e rP M e n e Ar i “ a th l , p sk sk Ex A A 12 13 14 15 16 pa nt it e to el sp A 17 pp . ly 18 e th t ue q i rn u to

What do you want to puncture during a venipuncture? A pulsating artery A small capillary A stringy tendon A spongy vein A hard vein 94% 6% 2 3 4 5 6 7 8 9 10 11 12 15 16 n rd A ha gy on A 14 17 ve i ve in on 0% A st sp rin g al l sm A 13 0% y ca g ls at in pu A 1 pi ll ar te ry ar y 0% te nd 1. 2. 3. 4. 5. 18

A needle’s colored cap indicates: Gauge Length Type Recommended use 59% 35% e us pe ng 0% R ec om m en de d Ty G Le au th 6% ge 1. 2. 3. 4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Which size needle is best used for a venipuncture? 1. 2. 3. 4. 5. 18 19 22 25 27 53% 24% 12% 5 6 7 8 9 10 11 12 13 14 15 16 17 18 27 4 25 3 6% 22 2 19 1 18 6%

What is serum? 1. 2. 3. 4. White blood cells Red blood bells Platelets Liquid part of blood before clotting 5. Liquid part of blood after clotting 82% 18% 2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 af . bl oo of Li qu i d pa rt of 15 d d bl oo Pl pa rt d qu i Li 1 b. . le ts at e lls be d bl oo ed R W hi te bl oo d ce lls 0% 0% 0% 18

Technique 1.Identify patient 2.Reassure patient and position arm 3.Assemble equipment 4.Verify order and paperwork 5.Select vein site 6.Apply tourniquet (NO MORE THAN 1 min) 7.Vigorously alcohol site/dry with gauze 8.Perform venipuncture

Puncture at 15 degree angle

Veins feel soft and bouncy. Blood is dark red Veins are more superficial than arteries Arteries have a pulse and blood is bright or scarlet red Damage to an artery can endanger distal tissue

Technique continued 9. Release the tourniquet 10. Remove needle 11. Gently agitate tube 12. Correctly label the tubes 13. Bandage arm 14. Dispose of vacutainer/tube & trash 15. Deliver sample to lab or prepare specimen for lab pickup.

LABEL THE TUBES Patient name Patient ID (DOB, Age, Bar code) Dr name Date & time Test Your initials

Special Considerations Do not collect above an IV

Avoid Hemolysis GENTLY agitate tube to mix Allow blood to enter tube slowly

To avoid hemolysis you: 1. Do not agitate tube 2. Gently agitate tube 3. Vigorously agitate tube 4. Use sterile technique to acquire specimen 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 . te ch ile st er 17 ni qu e tu be ita se U Vi go ro u sl y ag ag i en tly G te ta te tu tu be ta te gi ta no o D 0% 0% be 0% 18

The best angle of the needle during a venipuncture is: 8-9 degrees 15 degrees 25 degrees 45 degrees 90 degreess 94% 2 3 4 5 6 7 8 9 10 11 12 14 16 ss 0% s re e re e s re e 17 de g 90 de g 15 45 15 13 25 de g re e gr ee s de 9 8- 1 0% s 0% 6% de g 1. 2. 3. 4. 5. 18

What is NOT included on the tube label? 1. 2. 3. 4. Dr. name Your initials Test Patient name and ID 5. Pt blood type 6. Date & times 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 es e D tim at e & d bl oo Pa tie nt n 0% ty p ID d an am e ur Yo 0% Pt Te st 0% in iti a am e r. n D 0% ls 0% 18

If the patient has an IV, your BEST choice is to: Use other arm Stick above the IV Stick below the IV Use the foot Draw directly from the IVs 65% 29% 6% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 di re c t . tly fr om th e se U D ra w St ic k be fo ot IV 0% 0% th e IV lo w th e ab ov e St ic k U se ot he ra rm 1. 2. 3. 4. 5. 18

Which is NOT important for the quality of the blood sample? 1. Use right patient 2. Draw from correct site 3. Use the smallest needle that is possible 4. Label tubes correctly 94% 6% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 ct ly re lt ub es La be sm th e U se co r tn al le s co fr om ra w D 0% ee . . ite rr ec ts at ie nt ht p rig se U 0% 17 18

What is the next step after filling the tubes? 1. Remove the needle 2. Remove the tourniquet 3. Gently agitate the tubes 4. Press down on the needle with gauze pads while removing the needle 71% 18% 2 3 4 5 6 7 8 9 10 11 12 13 16 on w n Pr es s do ag i en tly G 15 th e tu b e th ta te to th e e 14 n. . t ur ni qu e le ne ed th e R em ov em ov e R 1 es 6% 6% 17 18

Geriatric Considerations Treat elderly as if they were your parents Use smaller needles / tubes Use syringe or butterfly instead of Vacutainer Assess hearing acuity Avoid tape – use “Koban” Minimize hematomas – apply pressure longer

Butterfly

Syringe / Butterfly Alternative to Vacutainer Elderly, young, collapsing veins Using the hand or foot Acquire adequate amount of blood as you will be filling tubes after the blood draw Instill blood into tube at angle to prevent hemolysis

Heel Collections

Finger Puncture Puncture across the fingertip Wipe away the first drop Collect in microtubes or capillary tubes

Blood Cultures Aseptic Technique Cleanse site with 2% Chlorhexidine gluconate or Iodine Allow site to dry – do not touch site Fill bottles with appropriate volume of blood

Butterflies are used for blood draws: For the elderly For the young For the hand For the wrist For arterial blood 7 8 9 10 21 22 23 24 25 26 27 28 29 30 11 12 13 14 15 lo od lb t 17 rte ria rt he w r is ha nd rt he 16 ra 6 18 Fo 5 Fo 4 Fo 3 Fo rt he el de rt he 2 Fo 1 yo un g 20% 20% 20% 20% 20% rl y 1. 2. 3. 4. 5. 19 20

Puncture the babies: 1. Center of heel 2. Lateral side of heel 3. Toes 4. Lateral side of foot 5 6 7 8 9 10 21 22 23 24 25 26 27 28 29 30 11 12 14 15 t of fo o es id e To ee of h al s al s 13 16 17 te r 4 La 3 te r 2 La 1 C en id e te ro fh ee l l 25% 25% 25% 25% 18 19 20

When drawing a geriatric patient: 1. Use a large lumen needle 2. Apply pressure for a longer period of time 3. Use small lumen needles or butterfly 4. a & b 5. a & c 6. b & c 21 22 23 24 25 26 27 28 29 30 11 12 13 18 c b & & c b & fo ra ll um . en ne e. . 17 ur e a 10 a 9 sm al 8 14 se 7 U 6 ly 5 pp 4 A 3 se 2 U 1 a la rg e pr es s lu m en n. . 17% 17% 17% 17% 17% 17% 15 16 19 20