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• NB 3172 covers general phlebotomy procedures in adults

Introduction

• Phlebotomy is cutting into a vein
• A phlebotomist's primary role is to obtain blood specimens for testing

Requirement for Phlebotomists

• Caring & kind demeanor is a needed requirement
• Willing to be hands-on with patients
• Able to put patients at ease, as they might be anxious about giving blood
• Follow instructions and procedures accurately
• Work in a team but use initiative
• Explain procedures clearly and methodically
• Need good communication and listening skills
• Treat others as you would want to be treated

Responsibilities for Phlebotomists

• Do no harm to the patient
• Do not disturb patient nursing care
• Take the blood correctly to enable accurate testing
• Accurately label all samples
• Correctly store the blood samples
• Promptly deliver the samples to the lab

Roles and Responsibilities

• Identification of the patient is vital for blood samples
• Proper identification is a three-step process
• Ask, compare, and validate

Safety and Infection Control

• Contact transmission of infectious agents happens through direct or indirect contact
• Direct contact requires transfer of pathogens from reservoir to susceptible host like person to person
• Indirect contact happens when a contaminated item is handled prior to contact with a susceptible host, like from person to contaminated item to person
• Prevention of Nosocomial Infections prevents disease originating from a hospital

How to Prevent Infection

• Combines good hand hygiene and glove use by workers exposed to contaminated products
• Handwashing should last 15 seconds, including soap and friction
• Handwashing is the primary way of preventing infection spread, especially nosocomial
• Wash hands before and after each blood draw
• Use alcohol-based hand rub
• Exposure to blood borne pathogens, such as hepatitis and HIV, need personal protective equipment to prevent exposure, like a lab coat, gloves, and mask

Needle Stick Injury, Safety, and Prevention

• Using safety devices on needles is mandated to prevent exposure to blood borne pathogens
• Phlebotomy devices should be equipped with needlestick prevention features
• Needles should never be recapped, bent, or broken

Summary of Phlebotomy

• Phlebotomists collect, process, and transport blood specimens
• Professionalism involves a positive attitude and appearance, proper communication, and quality customer service
• Phlebotomists are employed at hospitals, rehabilitation centers, nursing homes, clinics, physician's offices, ambulatory care centers, blood banks, and reference labs
• Infection control and safety practices include hand hygiene and Standard and Isolation Precautions

Blood Function

• Supplies nutrients to tissues such as O2, hormones, and glucose
• Removes end-products of metabolism such as CO2, urea, and creatinine
• Provides a defense mechanism via WBC and antibodies
• Prevents blood loss using platelets and coagulation proteins

Blood Composition

• Blood has formed elements making up ~45%, including:
• RBC
• WBC
• Platelets
• The plasma makes up ~55%, including:
• Water (~92%)
• Protein (~7%)
• Antibodies
• Salts
• Enzymes

Blood Samples

• A blood sample left standing with no anticoagulant forms a coagulum or blood clot
• The clot has coagulation proteins, platelets, and entrapped red and white blood cells

Order of Draw Chart

• Blood is collected into different tubes for different tests and analyses
• Tubes are drawn in a specific order to prevent cross-contamination of additives

Safety Information

• When using a winged blood collection for venipuncture and a coagulation tube is the first drawn, use a discard tube first
• A discard tube fills the collection set tubing's "dead space" with blood, but does not have to be completely filled
• This ensures proper blood-to-additive ratio

Blue Top Tubes For Blood Collection

• Used for coagulation studies
• Sodium citrate is the anticoagulant used
• Fill light blue tubes as far as the vacuum allows
• Mix by gentle inversion
• Transport should occur within one hour of collection
• If the sample does not mix well, the anticoagulant cannot remove calcium and the sample clots.
• Digging around for a vein can cause activation, but not enough sodium citrate can overcome this

Purple Top Tubes For Blood Collection

• Used for hematology studies such as FBC and FBP
• Contains an anticoagulant called EDTA (ethylene diamine tetra acetic)
• The tubes should be inverted 8-10 times

Grey Top Tubes For Collection

• Contains an anticoagulant: potassium oxalate
• Contains an antiglycolytic agent: sodium fluoride
• Maintains plasma glucose levels
• Used for glucose and lactic acid tests
• Tubes should be inverted 8-10 times

Red Top Tubes For Blood Collection

• Have no additives
• Tubes should be inverted 3-5 times
• Used for blood bank tests, toxicology, and serology

Yellow Top Tubes For Blood Collection

• Invert 5-6 times
• Contain sodium polyanethol sulfonate (SPS)
• Used for blood bank studies, HLA phenotyping, and paternity testing

Blood Culture Bottles

• Different blood culture bottles are used for aerobic and anaerobic
• The procedure prevents air from entering the anaerobic bottle and altering its environment
• Aerobic bottle should be filled first when using a butterfly needle and needle safety connector because there will likely be air in the tubing
• Anaerobic bottle should be filled first when using a needle and syringe as air is likely to be at the top of the syringe

Type and Amount of Specimen

• Selection depends upon the test
• Whole blood: Use EDTA or heparin?
• Plasma: Use EDTA or heparin?
• Serum: Trace free? Separator gel interference?
• Amount of the sample needed depends on the test to be done
• Multiple labs needing the same specimen at the same time

Preparing What is Needed for Venipuncture

• Have Tourniquets
• They slow venous blood flow
• Tourniquets cause veins to become more prominent
• Tourniquets should never be left on for more than a minute
• Avoid rigorous fist clenching or hand pumping because of the increased potassium and lactic acid
• Be aware of Latex allergy
• Needles should NEVER be reused
• Needles should NEVER be used if the shield is broken
• Needles should NEVER be recapped, cut, or bent
• Drop immediately into sharps container after venipuncture
• Size of needle is indicated by gauge
• A larger gauge number indicates a smaller needle diameter
• 21, 23-gauge needles are routinely used for phlebotomy

Butterfly Needle

• often used with a syringe
• Expensive, less used
• for small fragile veins
• Increased risk of needle stick injury

Vacutainer V Syringe

• Vacutainers are most often used due to being economical and quick
• Vacutainers have the least risk of accidental needle sticks
• Syringes allow for more control
• Syringes allow for a reposition easily
• Syringes allow you to see the 'flash' of blood in the syringe hub when the vein is successfully entered

Troubleshooting vein

• At the puncture site, a vein is bouncy and resilient
• If the artery is accidentally punctured, withdraw the needle and apply firm pressure for 5 minutes
• Instruct the patient not to move and notify a nurse to assist in hematoma prevention

Selecting A Site

• The antecubital area is most often accessed
• Other access areas are hand or wrist
• Always remember each arm is a site to be used
• Use the tip of your index finger on your non-dominant hand to palpate the area to find the vein

Vein Considerations

• The median cubital vein, the cephalic vein, and the basilic vein are potential sites
• The median cubital vein is the first choice
• Femoral, greater saphenous, popliteal, and lesser saphenous veins can be used

Primary Veins Used

• The most commonly used veins for venipuncture are located in the antecubital fossa
• The best vein depends on the patient

Other Sites For Puncture

• Use the hand if the antecubital veins are not able to be used
• Note the veins are smaller and less anchored
• Hand use can be painful for the patient

Needle Insertion

• The vein must be anchored
• Grasp the arm with non-dominant hand
• Use thumb to smooth the skin tight
• Insert the needle smoothly and confidently
• 15-30 degree angle

Precautions

• There should be no needle movement
• The blood-drawing equipment must be anchored on the arm to minimize the chance of injury
• Push the needle no further into the vein when the evacuated tube is engaging
• Pull the needle no further out of the vein when the tube is disengaging
• Do not pull up or press down when the needle is in the vein

After Removal

• Release the tourniquet first when removing the needle
• Disengage the tube
• Place the cotton directly on the needles without pressure
• Withdraw the needle in a swift, smooth motion
• Next, immediately apply pressure to the wound
• The arm is not to be bent

Recheck Draw Site

• Look for bleeding

Failure to Obtain Blood Considerations

Poor Collection Considerations

• Using the wrong anticoagulant
• Venous stasis
• Hemodilution
• Hemolysis

Venipuncture Procedure

• Locate the vein
• Release the tourniquet
• Cleanse the site in outward rotation
• Allow it to air dry
• Then Reapply tourniquet
• Anchor the Vein
• Next Insert needle
• After that fill Tubes
• Quick mix additive tubes
• After the Tubes, release the tourniquet
• Pull out the Needle
• Time to Engage safety device
• Then Dispose of needle immediately
• Time to Apply pressure to the puncture site
• Label Tubes, recheck Puncture site
• Thank the Patient, then Remove Gloves and Wash Hands

Hand Draw

• Sometimes an alternative if the current options are not viable

Skin Puncture Considerations

• Preferred site: Infants/children <1 year old
• Adults: used with scarred, fragile, or hardened veins or those with home glucose monitoring (POCT)
• Hold the finger between the index finger and thumb
• Puncture with a quick, smooth motion
• Wipe away the first drop of blood (may contain tissue fluid/debris