unit 1 phlebotomy

Patient Identification and Verification

• Verify patient identification by matching the patient's first and last name, date of birth, and PHIN number (or other unique identifier) with the information on their Manitoba Health Card or hospital arm band.
• Ask the patient to spell their name and provide their birth date to ensure accuracy.
• Make sure all necessary information is correct before proceeding.

Importance of Accurate Patient Identification

• Accurate patient identification is crucial to prevent lab errors.
• The patient must be positively identified to ensure the correct test results.
• If any information is incorrect or missing, do not perform the procedure. Get the information corrected before continuing.

Pre-Procedure Preparation

• Make sure the patient has followed dietary instructions if required for a specific test.
• Wash hands and put on gloves as a standard precaution.
• Position the patient for venipuncture with their arm straight and slightly downward.

Venipuncture Procedure

• Apply the tourniquet 3-4 inches above the intended venipuncture site.
• Palpate a vein to determine its depth and patency.
• Assemble all necessary supplies and equipment, including the needle and syringe.
• Position the equipment and pop the barrel of the syringe to remove any air.
• Reapply the tourniquet and re-palpate the vein before inserting the needle.
• Cleanse the site with alcohol and let it dry before inserting the needle.
• Anchor the vein and insert the needle at a 15° angle with the bevel up, following the direction of the vein.

Importance of Proper Venipuncture Technique

• Use a proper venipuncture technique to prevent rolling of the vein.
• Do not use the two-finger technique (also called the "C" hold) for safety reasons.
• Do not depress the skin by pushing down on the needle as it is inserted, as this can cause pain to the patient and increase the risk of blood leakage.

Post-Procedure Care

• Remove the needle cover and put the needle into the holder.
• Smoothly push the tube into the holder without moving the needle.
• Release the tourniquet when blood begins to flow.
• Fill the tubes according to the correct order of draw and invert additive tubes to mix.

Inappropriate Sites for Venipuncture

• Avoid using arms with mastectomy, edematous areas, hematomas, or sites above an IV cannula.
• Do not use arms with fistulas or vascular grafts, or those that are being transfused.
• Avoid using sclerosed veins, as they are hardened due to numerous punctures and may lead to errors in lab results.
• Avoid using arms with paralysis, as it increases the chance of thrombosis.

Phlebotomy Procedure

• Release the tourniquet once there is evidence of blood in the hub of the needle.
• Fill the syringe by slowly and firmly pulling on the plunger with the non-drawing hand to prevent hemolysis and vein collapse.
• Withdraw the needle and immediately apply pressure for 3-5 minutes with a clean gauze.
• Apply needle safety guard and place needle in a sharp container.

Syringe Transfer Device

• Attach the transfer device to the syringe.
• Place a vacuum tube in the transfer device in the order of draw.
• Push the tube onto the internal needle until the stopper is pierced.
• Blood from the syringe is drawn into the tube without pushing the plunger.

Labeling and Disposal

• Label all tubes immediately with patient's name, identification number, date, time of collection, and initials.
• Dispose of syringe assembly immediately in one piece in a sharps container to reduce the chance of a needle stick injury.
• Dispose of contaminated items into a biohazard container, wiping up any spills with 1:10 bleach solution.

Patient Care

• Examine the patient's arm 5-10 seconds before applying a bandage to prevent hematoma.
• Thank the patient and say goodbye for customer satisfaction.
• Remove and discard all contaminated items into a biohazard container, wiping up any spills with 1:10 bleach solution.

Heel Stick

• Recommended for children less than 1 year old.
• Be careful not to puncture a bone, as it may cause osteomyelitis or osteochondritis.

Butterfly Method

• Used for fragile veins, hands, elderly, or children, when a small volume of blood is sufficient.
• 23-gauge needle is the most common.
• If a coagulation tube is the first tube drawn, a discard tube should be drawn first to fill up the dead space and maintain blood/anticoagulant ratio (9:1).

Patient Complications

• If a patient faints, allow them to rest, offer a glass of water or juice, and do not leave them alone until fully recovered.
• If a patient has a seizure, remove the needle, call for help, ease them to the floor, and do not restrict movement.

Petechiae

• Tiny non-raised red spots that appear on the skin when a tourniquet is applied.
• May be due to coagulation problems or abnormalities.
• Phlebotomist must be aware that the patient may bleed excessively after blood collection and ensure bleeding stops prior to leaving the patient.

Order of Draw

• Fill vacuum tubes according to the correct order of draw.
• Do not move the hand used to insert the needle, and use the opposite hand to insert each tube into the holder and invert the filled tubes.
• Mix tubes gently to prevent hemolysis and clotting.

Safety Precautions

• Remove gloves and wash hands after the procedure.
• Document any deviations from the approved procedure (SOP – Standard Operating Practices).
• Dispose of all contaminated equipment in a biohazard container.

Hemolysis

• Detected by a pink or reddish coloring of the plasma/serum
• Affects tests such as K, LD, AST, CBC, Glucose, and Coagulation tests
• Causes of hemolysis include:
  • Using a needle with too small a gauge
  • Using a small needle with a large tube
  • Improperly attached needle (frothing)
  • Pulling the plunger back too fast
  • Drawing blood through a hematoma
  • Shaking tubes
  • Forcing blood from a syringe into a tube
  • Collecting blood above an IV
  • Tourniquet too close to puncture site
  • Tourniquet too tight
  • Using fragile hand veins
  • Not allowing alcohol to dry
  • Prolonged contact of plasma to RBCs
  • Centrifuging at too high a speed
  • Underfilled grey stopper tube

Icteric

• Characterized by a dark yellow to dark brown color
• Caused by the presence of bilirubin, a hemoglobin waste product from red blood cells
• Symptoms of jaundice include:
  • Yellow tinge to the skin and whites of the eyes
  • Dark urine
  • Itchiness

Lipemia

• Caused by accumulation of lipoprotein particles
• Lipemic samples have a higher fat content, making them thicker and milkier
• Specimens are rejected if lipemic

Problem Sites

• Obesity: use longer tourniquet and try median cubital or cephalic vein
• Paralysis: avoid drawing blood from paralyzed arm, increased chance of thrombosis and difficulty detecting nerve injury
• Nerve Damage: avoid by selecting proper vein, using smooth movements, not inserting the needle too far, and minimizing patient movement
• Infection: avoid by following proper sterilization and venipuncture procedures

Vein Damage and Reflux

• Vein Damage: avoid numerous venipunctures in the same area over time, and avoid blind probing and improper technique
• Reflux of Additive: blood flows back into the vein from the collection tube, causing adverse reactions; keep the arm in a downward position and the tube below the venipuncture site

Hemoconcentration and Partially Filled Tubes

• Hemoconcentration: a decrease in fluid content of blood, causing an increase in non-filterable large molecules; caused by stagnation of normal venous flow due to tourniquet
• Partially Filled Tubes: incorrect blood-to-additive ratio, causing erroneous results; underfilled tubes can lead to hemolysis or incorrect test results

Collection Tube Issues

• Wrong or Expired Collection Tube: incorrect or outdated tubes can cause erroneous results or contamination

Tube Vacuum

• Loss of Vacuum: due to bevel partially out of skin, damage to the tube, or incorrect insertion
• Solutions: reposition the needle, advance the needle slightly farther into the vein, or release the tourniquet slightly

Needle Position

• Correct Needle Position: blood can flow freely into the needle
• Incorrect Needle Position: needle not inserted far enough, or needle not in the vein

Damaged Veins

• Sclerosed Veins: hardened veins
• Thrombosed Veins: clotted veins
• Solutions: use another site if possible, or draw below (distal to) damaged veins

Edema

• Causes: abnormal accumulation of fluid in tissues, IV infiltration, or swelling
• Effects: veins are harder to locate, and tissue is fragile

Hematoma

• Causes: blood leaking from vessel during venipuncture, failure to remove the tourniquet, applying inadequate pressure, excessive probing, or failure to insert the needle in the vein
• Effects: painful, contaminates blood sample, and obstructs blood flow

Anticoagulants

• Definition: substances that prevent blood from clotting
• Examples: EDTA, citrates, heparin, oxalates
• Methods: binding or precipitation of calcium, or inhibiting the formation of thrombin

Specific Anticoagulants

• EDTA: used for whole blood hematology studies, immunohematology, and ammonia testing; binds with calcium and interrupts the coagulation process
• Heparin: used for chemistry tests, inhibits thrombin, and is the most common anticoagulant used in the chemistry department
• Sodium Citrate: used for coagulation studies, binds with calcium and interrupts the coagulation process

Learn about the importance of accurate patient identification and verification in healthcare. Verify patient information through multiple methods to ensure accuracy.