Phlebotomy for Healthcare Providers 2012

7/28/2019 Phlebotomy for Healthcare Providers 2012

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PHLEBOTOMYFOR

HEALTHCARE

PROVIDERS

By

KLINS B. OLIVER, RP-RN,KU-RN,UAE-RN,IVTN CCRN, CRNS, CPS



By the end of this training, we are to:

Ю To learn the foundation of

Phlebotomy practice.-History

-Anatomy and Physiology

Ю To know what specific skills

and ability we are to have in the

course of our practice.

Ю Indications and Limitations of

Phlebotomy Practice



By the end of this training, we are to:Ю To learn the 4 Basic

Procedural Approaches inPhlebotomy and their Scopes

-Venipuncture

-Finger Prick

-Heel Prick-Arterial Blood Gas Sampling-Smearing – Microscopical Scope-Order of the Draw

Ю To learn and master Safetyand Infection Protocols along

with the Legal Aspects of the

Practice



Overview of

Phlebotomy



• Phlebotomists – they draw blood for

laboratory analysis and monitoring. They

also handle a wide range of specimens

from blood – other body fluids.

• An allied collaborative health

provision.



Skills Required

• Ability to insert needles quickly and

accurately

• Maintain sterility of the sample

• Adheres to safety standards anddeals with different emergent

situations

• Good bedside attitude

• Maintains good and accurate

records.



History of Phlebotomy

-An in-depth view of the

foundations of practice



5th Century B.C.

HIPPOCRATES

4 HUMORS

• Blood,

• Phlegm,

• Yellow Bile

(Chole)

• Black Bile(Melan Chole)



Middle Ages

• Surgeons and

Barbers are

sought after for

Blood Lettingservices

whenever they

feel something

not good in their body.



18th to 19th Century

• Mayflower ,

Bloodletting was

introduced in US.

George

Washington wasthe first patient.

Drained 16-20oz

of blood. Fainting

is a sign of affectivity and

efficacy of

treatment.



1875 – 1900’s Dark Ages

• phlebotomy

was declared

witchcraft and

quackery.• Collection and

draining of

blood was

considered as agrave offense

payable with

life.





ANATOMY AND PHYSIOLOGY



Vein and Artery

Anatomy and Physiology

• Veins are unlike arteriesin that they are• 1)superficial,

• 2) display dark red blood at

skin surface and• 3) have no pulsation

• Vein Anatomy

-Tunica Adventitia

- Tunica Media

- Tunica Intima

- Valves



Tunica Adventitia

-the outer layer of the vessel

• Connective tissue

• Contains the arteries

and veins supplyingblood to vessel wall



Tunica Media

-the middle layer of the vessel

• Contains nerve

endings and muscle

fibers

• The vasoconstrictive

response occurs at

this layer



Tunica Intima

the inner layer of the vessel

One layer of endothelial

No nerve endings

Surface for plateletaggregation w/traumaand recognition of foreign object at thislevel



Valves

present in MOST veins

• Prevent backflow and

pooling

• More in lower extremities and longer

vessels

• Vein dilates at valve

attachment



Arteries

• Walls contains

smooth and hard

muscles that

withstand bloodpressure.

• Transports clean

blood away from the

heart.(in exemption tothe function of the

pulmonary artery.



Vein and Artery Cross-section





Vein and Artery

ARTERIES

• Transport blood away

from the heart.

• Have relativelynarrow lumens and

more muscle elastic

tissue.

• Transports blood at

higher pressure.

• Do not have valves.

VEINS

• Transports blood

towards the heart.

• Have relatively widelumens and less

muscle elastic tissue.

• Transports blood atlower pressure.

• Contains valves.



BLOOD AND

COMPARTMENTALIZATION



FUNCTIONS OF THE BLOOD

• Transportation of gases, nutrients and

waste products

• Transport of processed molecules

• Transport of regulatory molecules

• Regulation of Ph and osmosis

• Maintenance of body temperature• Protection against foreign substances

• Clot formation



THE SYSTEMIC CIRCULATION



COMPOSITION AND COMPONMENTS

PLASMAIs a pale yellow fluid that consists of about 91% water,

7% proteins and 2% other substances.

Water – acts as solvent, medium of suspension

Proteins – maintains osmotic pressure

Ions – maintains acid-base balance




PLASMAIons – maintains acid-base balance

Nutrients – source of energy and “the building blocks” of

more complex moleculesGases – involves in aerobic respiration

Waste products –breakdown of protein metabolism

(UREA/AMMONIA SALTS) erythrocytes (BILIRUBIN) and

anaerobic respiration (LACTIC ACID)Regulatory substances – catalyze chemical reactions.




FORMED

ELEMENTS





SITES FOR PHLEBOTOMY

Digital Vessels

-Along lateral aspects

fingers, infiltrate easily,

painful, difficult toimmobilize and should be

your LAST RESORT

Metacarpal Vessels

-Located between joints &metacarpal bones (act as

natural splint). Formed by

union of digital veins.




• Cephalic (Intern’s Vein)

-Starts at radial aspect of

wrist

-Access anywhere along

entire length (BEWAREof radial artery/nerve)

• Medial Cephalic (“On

ramp” to Cephalic Vein)

-Joins the Cephalic belowthe elbow bend

-Accepts larger gauge

catheters, but may be a

difficult angle to hit and

maintain






• Medial Basilic

- Empties into the Basilic

vein running parallel to

tendons, so it is not

always well defined. Accepts larger gauge

catheters.

- BEWARE of Brachial

Artery/Nerve



Certain areas are to be avoided when

choosing a site:

Extensive scars fromburns and surgery - itis difficult to puncturethe scar tissue and

obtain a specimen.The upper extremity

on the side of aprevious mastectomy

- test results may beaffected because of lymphedema.





Certain areas are to be avoided when

choosing a site:

Cannula/fistula/heparinlock - hospitals havespecial policies regardingthese devices. In general,

blood should not bedrawn from an arm with afistula or cannula withoutconsulting the attendingphysician.

Edematous extremities -tissue fluid accumulationalters test results.



INDICATIONS FOR PHLEBOTOMY



INDICATIONS

CBC

To differentiate bacterial or viral infection

LFT’s: to determine liver function

: to differentiate between diagnosis of cholecystitis & pancreatitis

Renal function

BUN Creatinine: before giving drugs. Ex. Contrast

dye, Gentamycin Cultures

To assess Coagulation status

Blood typing/RH status



FOUR BASIC PROCEDURAL

APPROACHES IN PHLEBOTOMY

-Venipuncture

-Finger Pricking

-Heel Pricking

-Arterial Blood Gas Sampling



Venipuncture



• Other name: Blood-Draw/ Phlebotomy

• is the process of obtaining intravenous access for the

purpose of intravenous therapy or obtaining a sample

of venous blood.

• is one of the most routinely performed invasive

procedures and is carried out for two reasons, to obtain

blood for diagnostic purposes or to monitor levels of

blood components







Needles - The gaugenumber indicates the boresize: the larger the gaugenumber, the smaller theneedle bore. Needles areavailable for evacuated

systems and for use witha syringe, single draw or butterfly system.

Holder/Adapter - usewith the evacuatedcollection system.

Tourniquet - Wipe off with alcohol and replacefrequently



Gloves - can be

made of latex, rubber,

vinyl, etc.; worn to

protect the patient andthe phlebotomist.

Syringes - may be

used in place of the

evacuated collectiontube for special

circumstances.



ORDER FORM / REQUISITION A requisition form must accompany each sample

submitted to the laboratory. This requisition form mustcontain the proper information in order to process thespecimen. The essential elements of the requisition formare:

1. Patient's surname, first name, and middle initial.2. Patient's ID number.

3. Patient's date of birth and sex. (NOTE NEWGUIDELINES)

4. Requesting physician's complete name.5. Source of specimen. This information must be given

when requesting microbiology, cytology, fluid analysis,

or other testing where analysis and reporting is sitespecific.6. Date and time of collection.7. Initials of phlebotomist.8. Indicating the test(s) requested.



An example of a simple requisition form with

the essential elements is shown below:





Collect the sample in the appropriate

container. Recognize complications associated

with the phlebotomy procedure.

Assess the need for samplerecollection and/or rejection.

Label the collection tubes at thebedside or drawing area.

Promptly send the specimens with therequisition to the laboratory.







PROCEDURE FOR SITE SELECTION

Palpate and trace the path of veins with the

index finger . Arteries pulsate, are most elastic, and

have a thick wall. Thrombosed veins lack resilience,

feel cord-like, and roll easily.

If superficial veins are not readily apparent, youcan force blood into the vein by massaging the

arm from wrist to elbow, tap the site with index

and second finger, apply a warm, damp washcloth

to the site for 5 minutes, or lower the extremity over the bedside to allow the veins to fill.



PERFORMANCE OF A VENIPUNCTURE

Approach the patient in a friendly, calm manner.Provide for their comfort as much as possible, andgain the patient's cooperation.

Identify the patient correctly.

Properly fill out appropriate requisition forms,indicating the test(s) ordered.

Verify the patient's condition. Fasting, dietaryrestrictions, medications, timing, and medicaltreatment are all of concern and should be noted on

the lab requisition.



Check for any allergies to antiseptics, adhesives,or latex by observing for armbands and/or byasking the patient.

Position the patient. The patient should either sitin a chair, lie down or sit up in bed. Hyperextend

the patient's arm.Apply the tourniquet 3-4 inches above the

selected puncture site. Do not place too tightly or leave on more than 2 minutes.





When the last tube to be drawn is filling, removethe tourniquet.

Remove the needle from the patient's arm usinga swift backward motion.

Press down on the gauze once the needle is outof the arm, applying adequate pressure to avoidformation of a hematoma.

Dispose of contaminated materials/supplies indesignated containers.

Mix and label all appropriate tubes at the patientbedside.

Deliver specimens promptly to the laboratory



FINGERSTICK



WHY PERFORM FINGER PRICKS?

• Fingersticks (or fingerpricks) are small

superficial wounds that provide venous blood for

some blood tests. Various methods are used to open the

wound, which produces no more than a few drops

of blood. The procedure can be painful, but is typicallyquicker and less distressing than venipuncture.

• After a droplet has formed, venous blood is sucked up in

a capillary tube, usually relying on surface tension, butsometimes by indirect suction.

http://en.wikipedia.org/wiki/Wound

http://en.wikipedia.org/wiki/Venous_blood

http://en.wikipedia.org/wiki/Blood_test

http://en.wikipedia.org/wiki/Blood

http://en.wikipedia.org/wiki/Pain

http://en.wikipedia.org/wiki/Venipuncture

http://en.wikipedia.org/wiki/Capillary_tube

http://en.wikipedia.org/wiki/Surface_tension

http://en.wikipedia.org/wiki/Surface_tension

http://en.wikipedia.org/wiki/Capillary_tube

http://en.wikipedia.org/wiki/Venipuncture

http://en.wikipedia.org/wiki/Pain


http://en.wikipedia.org/wiki/Blood_test

http://en.wikipedia.org/wiki/Venous_blood

http://en.wikipedia.org/wiki/Wound







EQUIPMENT

Lancets – for pricking

either manually or

automatically.

Lancing Device –

automatic pricking.

Gauze/Cotton balls

Gloves

Capillary tubes or micro containers



PERFORMANCE OF A

FINGERSTICK:Follow the procedure as outlined above for

greeting and identifying the patient. As always,

properly fill out appropriate requisition forms,

indicating the test(s) ordered.

Verify the patient's condition. Fasting, dietaryrestrictions, medications, timing, and medical

treatment are all of concern and should be noted on

the lab requisition.







PERFORMANCE OF A FINGERSTICK:

Collect drops of blood into the collection

device by gently massaging the finger .

Avoid excessive pressure that may squeeze

tissue fluid into the drop of blood.

PERFORMANCE OF A



PERFORMANCE OF A

FINGERSTICK:Cap, rotate and invert the collection device to

mix the blood collected.

Have the patient hold a small gauze pad

over the puncture site for a couple of minutes

to stop the bleeding.

Dispose of contaminated materials/supplies

in designated containers.

Label all appropriate tubes at the patientbedside.

Deliver specimens promptly to the laboratory.



HEEL PRICKING







CONTRAINDICATION

Edema – Notify physician for medical treatment

Injury or anomalies that preclude putting pressure

on the foot – May cause osteomyelitis

Areas that are bruised or injured by multiple

previous heel sticks – Do not attempt to extract

Poor perfusion – Use heel warmer

Local infection – Notify physician for antibiotic

treatment



MATERIALS

Stillete ( lancet

device)

Alcohol swabsCotton wool balls

Capillary blood

tubes

Blood spot card

Gloves

PERFORMANCE OF A HEEL




STICK: Check physician’s order. Ensure the correct

specimen obtained for correct children.

Check if child allergic to any material usesuch as to iodine.

Prepare the child and the family by explainabout the procedure. We could ask for assistant to comfort the child.





STICK:

Stimulate the feet by using feet warmer an hour

before procedure.

Prepare the materials or equipment.

Wash hands and wear gloves.

Select site.

Remove the warmer.

Wash site with soap and water or antisepticsolution.

Let the area dry completely before puncture.





STICK: Using dominant hand puncture the site with 90°

angel with quick and forceful motion.

Remove the lancet immediately.

Apply pressure to leg with counter pressure toball of foot and allow blood drop to form.

Wipe away the 1st blood using a sterile cottonball.





STICK:

Wipe the puncture site with sterile cotton ball and

apply pressure for 2-3 mins.

If needed apply bandage

Discard equipment in the appropriate container.

Label the specimen and put in appropriate bag

or container along with laboratory form or slip.

Remove gloves and wash hand. Send specimen to laboratory.





S i h dli



Specimen handling

Ensure that blood gas samples are free of air bubbles.

Place the tube horizontally so that the blood is

drawn by capillary action and does not collect air

bubbles that can alter results. Apply caps to ends of

tube.

Capillary blood gas samples should be analyzed

within 10 minutes or should be kept horizontally on

ice for up to 1 hour, and the tube must be rolledprior to analysis.







Why do ABGs

• Precise measurement of acid – base balance of the blood

• Check lungs’ ability to oxygenate blood and to

remove CO2

• Assess respiratory function

• O2 and CO2 levels determined primarily by

the lungs







Puncture Procedure

Introduce yourself and explain what isordered

a. Patient cooperation needed to help

simplify and minimize painb. if patient refuses, notify physician

Make positive patient I.D.

a. Ask patient their name

b. Check patient I.D. wristband

Put on gloves





Oth P t Sit



Other Puncture Sites:



Puncture Procedure: Allen’s Test

• When using radials, perform Allen's Test for collateral circulation

A. In a conscious and cooperative patient:

1. compress ulnar and radial arteries at wrist to

obliterate pulse2. have patient clench and release pulse until hand

blanches

3. with radial still compressed, release pressure onulnar artery

4. watch for pinkness to return should “pink up” within10 – 15 second





Performing Allen’s Test

The idea here is to figure out if there is adequate collateral circulationfrom the ulnar artery to perfuse the hand.



Puncture Procedure

• Drape the bed and stabilize the wrist in theposition that gives maximal pulse

• (hyper -extended, using a rolled up towel if

necessary)

• Prepare the site

• Cleanse the chosen area with a alcohol and/or

iodine

• Secure needle to syringe and remove cap from

needle



Puncture Procedure





Angle of Entry



Puncture Procedure

• Slowly advance in one plane

• When the artery is punctured, blood will enter the

syringe –“flash”



Puncture Procedure

• Slowly allow blood to fill syringe

• if no blood appears, remove, change needles, and start

again



Puncture Procedure

• Upon removal of the needle, hold pressure on thepuncture site for at least 5 minutes.

• • Pressure may need to be held longer (> 5 mins) if the

patient is on anticoagulant therapy



Puncture Procedure

• Check for:

• Bleeding

• movement of fingers and tingling sensation

• pulse distal to puncture• if pulse not palpable, notify physician STAT



Post Puncture Procedure

• Remove any air bubbles from sample and cap syringe• • Dispose of needle in sharps container

• Roll syringe to mix heparin with sample

• Immerse in ice

• On lab slip indicate:

• a. FIO2

• b. patient temperature

• c. ventilator parameters

• Deliver to lab



Complications of Arterial Punctures:



Technical Causes of Abnormal



Results:

• Delay in running sample• O2 consumption will continue as will CO2 production –

pH does what CO2 tells it to do

• Iced, sample will last an hour without a change in the

results – un-iced, ABG's can be significantly changed after 10 min

• Venous sample drawn

• Usually this in shocky patient that you expect lowpressures and dark blood

• Should doubt when PO2 is significantly lower thanexpected

• draw venous blood to check comparison or

• redraw sample




Results:

• Capillary samples• From infants warmed heel

• CAUTION – pay attention to puncture site and sample

type

• ONLY diagnostic values are pH and PaCO2

• PaO2 value is NOT diagnostic

• Heparin

• Sodium Heparin 1% solution should be use ammonium

heparin will alter pH dry lithium heparin is OK• • All unnecessary heparin should be ejected from syringe, excess can

effect results




Results:

Patient pain a. Can cause hyperventilation or breath holding

b. An anesthetic may be injected prior to stick for

pain, although this hurts probably as much

• Usually 2% lidocaine

• CAUTION – some people allergic to “caines”

Machine errors

a. Improper calibration

b. Air bubbles in electrodes

c. Torn membranes



SMEARING

ANDORDER OF THE DRAW



Indication

1. A blood film or peripheral bloodsmear is a thin layer of blood smeared

on a microscope slide and then stained

in such a way to allow the various bloodcells to be examined microscopically.

Blood films are usually examined to

investigate hematological problems(disorders of the blood) and,

occasionally, to look for parasites within

the blood such as malaria and filaria.


http://en.wikipedia.org/wiki/Microscope_slide

http://en.wikipedia.org/wiki/Hematology

http://en.wikipedia.org/wiki/Apicomplexa

http://en.wikipedia.org/wiki/Malaria

http://en.wikipedia.org/wiki/Filariasis

http://en.wikipedia.org/wiki/Filariasis

http://en.wikipedia.org/wiki/Malaria

http://en.wikipedia.org/wiki/Apicomplexa

http://en.wikipedia.org/wiki/Hematology

http://en.wikipedia.org/wiki/Microscope_slide




Indication

• Blood films are made by placing adrop of blood on one end of a

slide, and using a spreader

slide to disperse the blood over

the slide's length. The aim is to get

a region where the cells are

spaced far enough apart to becounted and differentiated.

• The slide is left to air dry, after

which the blood is fixed to the

slide by immersing it briefly

in methanol. The fixative is

essential for good staining and

presentation of cellular detail.

After fixation, the slide

is stained to distinguish the cells

from each other.

http://en.wikipedia.org/wiki/Fixation_(histology)

http://en.wikipedia.org/wiki/Methanol

http://en.wikipedia.org/wiki/Staining_(biology)

http://en.wikipedia.org/wiki/Staining_(biology)

http://en.wikipedia.org/wiki/Methanol

http://en.wikipedia.org/wiki/Fixation_(histology)



Blood Smearing

1. A single smear can be made per slide (smear running

the length of the slide) or two (or even three) smears

can share a slide, with the smears running the width of

the slide. Putting two smears per slide saves on weight

(glass is heavy) for field trips, and storage space.

2. It is easiest to use microscope slides with a frostedend, so that identifying information can be writtenthere with pencil. Compare different pencils

to find one that does not yield labels that rub off orwash off in the methanol dip.

Warning:



3. Place a drop of blood approximately 4 mm in diameter on the slide (near the end if one smear is to be made,



on the slide (near the end if one smear is to be made,or at the proper location if two smears are to share aslide).

4. Spread the drop by using another slide (called here the “spreader”), placing the spreader at a 45° angle andBACKING into the drop of blood. The spreader catchesthe drop and it spreads by capillary action along its

edge. To make a short smear, hold the spreader at asteeper angle, and to make a longer smear, hold itcloser to the drop. Now, push the spreader across theslide; this PULLS the blood across to make the smear.

Do not push the blood by having it ahead of thesmearing slide! It should take about one second tosmear the drop. A smooth action is required, with theedge of the spreader held against the slide. This willyield a nice, even smear.





SAFETY AND

INFECTION CONTROL

LEGAL JURISPRUDENCE

SAFETY AND INFECTION



CONTROL

Because of contacts with sick

patients and their specimens, it is

important to follow safety and

infection control procedures.



SAFETY AND INFECTION CONTROL

PROTECT YOURSELF

Practice universal precautions:

Wear gloves and a lab coat or gown whenhandling blood/body fluids.

Change gloves after each patient or when

contaminated.

Wash hands frequently.

Dispose of items in appropriate

containers.




CONTROL

Dispose of needles immediately uponremoval from the patient's vein. Do not

bend, break, recap, or resheath needles to

avoid accidental needle puncture or

splashing of contents.

Clean up any blood spills with a disinfectant

such as freshly made 10% bleach.




CONTROL

If you stick yourself with a contaminatedneedle:

1. Remove your gloves and dispose of them properly.

2. Squeeze puncture site to promote bleeding.

3. Wash the area well with soap and water.

4. Record the patient's name and ID number.

5. Follow institution's guidelines regarding treatment

and follow-up.6. NOTE: The use of prophylactic zidovudine following

blood exposure to HIV has shown effectiveness (about

79%) in preventing seroconversion



PROTECT THE PATIENT

Place blood collection equipment away from

patients, especially children and psychiatric

patients.

Practice hygiene for the patient's protection.

When wearing gloves, change them between

each patient and wash your hands frequently.

Always wear a clean lab coat or gown.

LEGAL IMPLICATIONS ON



PRACTICE

Maintain principles of Phlebotomy Practice Avoid untoward circumstances that may hover any

untoward implications on both health provider andthe patient.

Maintain adequate health provider – patientinteraction.

Maintain confidentiality.

Defer from any deleterious acts that can

compromise patient, health provider and institution. Follow guidelines set and practiced by the

institution and state/country where you areworking.



THANK YOU

Documents

Phlebotomy for Healthcare Providers 2012