Phlebotomy Essentials: Blood Collection Equipment, Additives, and Order of Draw PDF

CHAPTER 7 Blood Collection Equipment, Additives, and Order of Draw Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Objectives 1.List, describe, and explain the purpose of the equipment and supplies needed...

CHAPTER 7 Blood Collection Equipment, Additives, and Order of Draw Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Objectives 1.List, describe, and explain the purpose of the equipment and supplies needed Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com to collect blood specimens by venipuncture, and define associated terms and abbreviations. 2.List and describe evacuated tube system (ETS) and syringe system components, explain how each system works, and tell how to determine which system and components to use. Objectives (cont.) 3.Demonstrate knowledge of the types of blood collection additives, identify the Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com chemical composition of the specific additives within each type, and describe how each additive works. 4.Describe ETS tube stopper color coding used to identify the presence or absence of an additive, connect additives and stopper colors with laboratory departments and tests, and list the order of draw and explain its importance. General Blood Collection Equipment and Supplies ▪ Blood-Drawing Station ▪ Table for supplies Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Special chair ▪ Bed or reclining chair ▪ Phlebotomy Chairs ▪ Comfortable ▪ Adjustable armrests ▪ Prevent falling if a patient faints ▪ Some can recline ▪ Adjustable height Figure 7-1 Two styles of phlebotomy chairs. A. Chair with adjustable arms and hydraulic height adjustment. ▪ Can be helpful for ergonomics B. Reclinable chair. ▪ Available in bariatric models © Wolters Kluwer. General Blood Collection Equipment and Supplies (cont.) In a busy environment like a hospital, phlebotomists must Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com often go to their patients ▪ Some patients may be bed-bound and unable to come to the lab to have their blood drawn ▪ This necessitates finding ways to easily bring all the needed equipment to each patient's bedside ▪ When beginning a shift, it is important to be sure you have all the equipment you may need ready to go before beginning to be sure you are ready for any situation that may arise General Blood Collection Equipment and Supplies (cont.) ▪ Handheld phlebotomy equipment carriers Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Come in multiple sizes ▪ Contain supplies for multiple draws ▪ Great for STAT or emergencies ▪ Best for when we don’t need to collect many samples Figure 7-2 Two types of handheld phlebotomy equipment carriers. © Wolters Kluwer. General Blood Collection Equipment and Supplies (cont.) ▪ Phlebotomy carts ▪ Contain more supplies Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Better for collecting many samples ▪ Used for “Sweeps” ▪ Easy to maneuver ▪ Can be bulky ▪ Potential source of nosocomial infection ▪ Best practice is to leave them outside the room ▪ Bring in only needed equipment using a small tray Keeping carts and trays adequately stocked with supplies Figure 7-3 A phlebotomist is an important duty with a phlebotomy cart. of the phlebotomist. © Wolters Kluwer. General Blood Collection Equipment and Supplies (cont.) ▪ Gloves and Glove Liners Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Required by CDC/HICPAC and OSHA when performing phlebotomy ▪ New pair must be used for each patient ▪ Nonsterile, disposable latex, nitrile, neoprene, polyethylene, and vinyl are acceptable ▪ Due to latex allergies latex is no longer commonly used and is not recommended ▪ Good fit is essential, it is hard to feel with poorly fitting gloves ▪ Glove liners or barrier hand creams may be used if gloves cause allergies or dermatitis ▪ Gloves with powder not recommended ▪ Associated with lung problems, allergies and hypersensitivities Figure 7-4 Half-finger glove liners. Courtesy Gloves-Online.com, Cary, NC. General Blood Collection Equipment and Supplies (cont.) Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Always remember to decontaminate your hands!!! Before putting on your gloves After removing your gloves Both hand washing and alcohol-based hand sanitizers are acceptable Only use hand sanitizers if your hands are not visibly soiled! If your hands are visibly soiled always wash with soap and water General Blood Collection Equipment and Supplies (cont.) ▪ Antiseptics Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Prevents or inhibits the growth of microorganisms, but does not necessarily kill them ▪ Prevents sepsis (microorganisms or their toxins in the blood) ▪ 70% isopropyl alcohol most common for routine blood collection ▪ Iodine, benzalkonium chloride, Chlorohexidine gluconate, hydrogen peroxide are also sometimes used ▪ Safe on human skin ▪ Disinfectants ▪ Remove or kill microorganisms on surfaces and instruments ▪ Disinfectants do not kill spores, reusable medical equipment must be sterilized ▪ Not safe on human skin General Blood Collection Equipment and Supplies (cont.) ▪ Hand Sanitizers Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Alcohol-based rinses, gels, and foams ▪ Can replace handwashing if hands are not visibly soiled ▪ Both handwashing and hand sanitizers are important tools in maintaining asepsis https://navigate2.jblearning.com/mod/page/view.php?id=37841505 General Blood Collection Equipment and Supplies (cont.) ▪ A personal-size bottle of hand sanitizer (A) and a wall-mounted hand sanitizer dispenser (B) Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Decontamination of hands after glove removal is essential. Any type of glove may contain defects, and some studies suggest that vinyl gloves may not provide A an adequate barrier to viruses. B Figure 7-6 A. A personal- size bottle of hand sanitizer. Figure 7-6 B. A wall-mounted A. © yurakrasil/Shutterstock. hand sanitizer dispenser. B. © Paul Velgos/Shutterstock. General Blood Collection Equipment and Supplies (cont.) ▪ Gauze Pads or Cotton Balls ▪ Clean 2 × 2-in gauze pads are used to hold pressure over site following blood Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com collection ▪ Some pads have fluid-proof backing to prevent contamination ▪ Avoid using cotton balls, as they tend to stick ▪ Still standardly used in many facilities ▪ Bandages ▪ Used over blood collection site once bleeding has stopped ▪ Can also use paper, cloth, or knitted tape over folded gauze ▪ Always check for patient allergies to adhesives Never use self-adhesive bandages on infants under 2. They can be a choking hazard!! General Blood Collection Equipment and Supplies (cont.) ▪ Slides ▪ If needed to prepare blood smears Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Pen ▪ Permanent and no smearing ▪ For labelling tubes and initialing forms ▪ Watch ▪ Digital or with second hand or portable clock ▪ Make sure it is easy to disinfect ▪ Many phlebotomists prefer a nurses watch that pins to their scrubs ▪ Patient identification equipment ▪ Many facilities use barcode readers to print the correct labels at the patient’s bedside  General Blood Collection Equipment and Supplies (cont.) ▪ Needle and sharps disposal containers ▪ Any needle, lancet or other sharp object must be disposed of in a Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com sharps container immediately after use ▪ Even if they have other safety features ▪ Come in many sizes, shapes and colors ▪ All are rigid, puncture resistant leakproof, disposable and clearly labelled with the biohazard symbol and have locking lids Never overfill a sharps container!!! Sharps containers should be disposed of once they are 2/3 full to prevent biohazard exposure. Figure 7-7 Several styles of sharps containers. Courtesy and © Becton, Dickinson and Company. General Blood Collection Equipment and Supplies (cont.) ▪ Biohazard bags Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Leakproof bags used to transport blood and other specimens ▪ Marked with a biohazard label ▪ Often have an external pouch for any needed paperwork ▪ Keeps paperwork free of contamination ▪ Keeps paperwork and sample together in transit Figure 7-8 A specimen in a biohazard bag. © Wolters Kluwer. Venipuncture Equipment ▪ Vein-Locating Devices ▪ Transillumination: shine Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com high-intensity LED or infrared light ▪ Highlight veins in patient’s subcutaneous tissue ▪ Hemoglobin absorbs the light highlighting the veins ▪ Can be helpful for hard to find veins Don’t forget that you can test your B equipment knowledge with the questions in the EXAM REVIEW. Figure 7-9 B. A vein appears as a dark line between the light-emitting arms of the Venoscope II. B. Venoscope II, LLC, Lafayette, LA. Venipuncture Equipment (cont.) ▪ Tourniquet Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Device applied or tied around patient’s arm to restrict blood flow ▪ Should restrict venous flow to inflate veins, but not arterial flow ▪ Never leave for over 1 min, it can alter blood components and lead to false results ▪ Most common type: stretchable disposable straps ▪ https://navigate2.jblearning.com/mod/page/view.php?id=37841523 Figure 7-10 Stretchable nonlatex Figure 7-11 Single-use strap touriquets. latex-free tourniquets. © Wolters Kluwer. n Courtesy and © Becton, Dickinson and Company. Venipuncture Equipment (cont.) ▪ Needles Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Sterile, disposable, designed for single use only ▪ Types ▪ Multisample Figure 7-27 C. BD Vacutainer® ▪ Hypodermic UltraTouch push button blood ▪ Winged infusion (butterfly) collection set. C. Courtesy and © Becton, Dickinson and Company. ▪ Parts ▪ Bevel ▪ Shaft ▪ Hub ▪ Lumen A Venipuncture Equipment (cont.) ▪ Needles (cont.) ▪ Gauge Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Diameter of lumen (hollow space within the needle) ▪ Higher the gauge, the smaller the diameter of needle ▪ Needles color coded by gauge (25, 23, 22, 21) are the most used for phlebotomy ▪ The most commonly used needle for phlebotomy is a 21 gauge 1 ¼ inch needle ▪ Length ▪ 1- and 1.5-in lengths are most common for venipuncture Selecting the correct needle for each phlebotomy is an important part of your job. Too big of a needle might collapse a vein but too small of a needle could hemolyze a sample. Venipuncture Equipment (cont.) ▪ Safety features on tube holder (hub) or attached to needle Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Figure 7-16 Tube holders with needles attached. A. Traditional tube holder with safety needle attached. B. Venipuncture Needle-Pro safety tube holder with needle resheathing device attached to a traditional nonsafety needle. © Wolters Kluwer. Venipuncture Equipment (cont.) ▪ Evacuated Tube System (ETS) Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Closed system in which blood flows through a needle inserted into a vein and then directly into a collection tube ▪ Prevents exposure to air or outside contaminants ▪ Allows numerous tubes to be collected with a single venipuncture ▪ Components ▪ Multisample needle ▪ Tube holders ▪ Needle and holder units with Figure 7-13 Evacuated tube system (ETS) safety attached to needle components. B. Safety needle and traditional ▪ Evacuated tubes tube holder. © Wolters Kluwer. Venipuncture Equipment (cont.) ▪ Multisample Needles ▪ Allow multiple tubes to be collected in a Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com single venipuncture ▪ Double-pointed and have threaded part that screws into holder ▪ Tube end of needle has retractable sleeve to prevent leakage ▪ Available with and without safety features ▪ If no safety feature: use with safety holder Figure 7-13 Evacuated tube system (ETS) components. A. Traditional needle and safety tube holder. © Wolters Kluwer. Needle and Holder Units ▪ Needle and Holder Units Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Needle and holder permanently OSHA regulations attached require that the tube ▪ Evacuated Tubes holder with needle attached be ▪ Used with both ETS and syringe method disposed of as a unit ▪ Available in different sizes and volumes after use and never ▪ Size used depends on: be removed from ▪ Age of patient the needle and reused. ▪ Volume of blood needed for test ▪ Size and condition of patient’s vein ▪ Available in glass and plastic (plastic preferred for safety) Needle and Holder Units (cont.) ▪ Evacuated Tubes (cont.) Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Vacuum ▪ Negative pressure artificially created by pulling air from tube ▪ Designed to draw an exact volume of blood into tube ▪ Additive tubes: substance added to tube (e.g., anticoagulant) ▪ Nonadditive tubes: no substance added to tube (rare) ▪ Stoppers: rubber or rubber with plastic covering ▪ Color coding: color of stopper usually indicates type of additive ▪ Expiration dates: for additive and vacuum, printed on tube label NAACLS Entry Level Competencies Met in This Chapter ▪ 5.00 Demonstrate knowledge of collection equipment, various types of additives Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com used, special precautions necessary, and substances that can interfere in clinical analysis of blood constituents. ▪ 5.5 List and select the types of equipment needed to collect blood by venipuncture and capillary (dermal) puncture. ▪ 5.6 Identify special precautions necessary during blood CHAPTER 7 Blood Collection Equipment, Additives, and Order of Draw Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Objectives 1.List, describe, and explain the purpose of the equipment and supplies needed Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com to collect blood specimens by venipuncture, and define associated terms and abbreviations. 2.List and describe evacuated tube system (ETS) and syringe system components, explain how each system works, and tell how to determine which system and components to use. Objectives (cont.) 3.Demonstrate knowledge of the types of blood collection additives, identify the Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com chemical composition of the specific additives within each type, and describe how each additive works. 4.Describe ETS tube stopper color coding used to identify the presence or absence of an additive, connect additives and stopper colors with laboratory departments and tests, and list the order of draw and explain its importance. Needle and Holder Units (cont.) ▪ Evacuated Tubes Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Vacuum ▪ Negative pressure artificially created by pulling air from tube ▪ Designed to draw an exact volume of blood into tube ▪ Additive tubes: substance added to tube (e.g., anticoagulant) ▪ Nonadditive tubes: no substance added to tube (rare) ▪ Stoppers: rubber or rubber with plastic covering ▪ Color coding: color of stopper usually indicates type of additive ▪ Expiration dates: for additive and vacuum, printed on tube label ▪ Always check before you begin collecting Needle and Holder Units (cont.) ▪ Evacuated tubes Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Color-coded by additive for easy use ▪ Allow us to easily collect multiple samples from a patient without needing to poke them again ▪ Commonly used for most routine phlebotomy testing ▪ Originally made of glass now mostly A B plastic ▪ Multiple sizes depending on the volume Figure 7-18 Evacuated tubes. A. needed Vacutainer® Plus plastic brand evacuated tubes. B. Vacuette® evacuated tubes. ▪ Manufactured by a number of different A. Courtesy and © Becton, Dickinson and Company; B. Courtesy of Greiner Bio-One companies International AG, Kremsmünster, Austria. Needle and Holder Units (cont.) If a tube loses its vacuum blood will no Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com longer flow into the tube, this can occur for many reasons ▪ Incorrect storage ▪ Dropped or opened tube ▪ Needle position ▪ Not allowing tubes to fill fully A B The vacuum in ETS tubes is pre- Figure 7-18 Evacuated tubes. A. measured to ensure the correct ratio of Vacutainer® Plus plastic brand evacuated blood to additive. tubes. B. Vacuette® evacuated tubes. A. Courtesy and © Becton, Dickinson and Company; B. Courtesy of Greiner Bio-One International AG, Kremsmünster, Austria. Needle and Holder Units (cont.) ▪ Syringe System ▪ Alternative for patients with small or Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com difficult veins ▪ No longer typically used for phlebotomy ▪ Syringe needles ▪ 1- to 1.5-in long ▪ Must have resheathing feature if used to draw blood ▪ Syringes ▪ Barrel ▪ Plunger Figure 7-23 Syringe system components. © Wolters Kluwer. Needle and Holder Units (cont.) ▪ Syringe transfer device: allows safe transfer of blood into tubes without Never transfer blood from a syringe to a tube using a syringe needle or removing Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com without a transfer device!!!! tube stopper ▪ Syringes do not contain any additives so blood must be promptly transferred to the correct tube ▪ Transfer devices greatly reduce the chance of a needle sticks Figure 7-25 Syringe transfer devices. B. Transfer device B attached to a syringe. Courtesy and © Becton, Dickinson and Company. Needle and Holder Units (cont.) ▪ Blood Collection Sets Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Winged infusion set ▪ Commonly referred to as a butterfly ▪ Currently all butterfly needles require automated in-vein retraction ▪ Effective for small or difficult veins (hands; elderly and pediatric) ▪ Can be attached to an evacuated tube holder (left) or syringe (right) ▪ The shorter length allows for a shallower angle ▪ Common gauges range from 25-21 gauge Figure 7-26 Winged infusion sets ▪ Nonwinged blood collection Set attached to a syringe (right) and an evacuated tube holder by means of ▪ VANISHPOINT: automated in-vein a Luer adapter (left). retraction to eliminate exposure © Wolters Kluwer. Needle and Holder Units (cont.) ▪ Combination Systems ▪ Complete system for blood Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com collection ▪ Blood collection tube and collection apparatus are combined in single B unit ▪ Specimen can be collected by evacuated tube or syringe ▪ Available with regular or butterfly- style needles A C ▪ Safety devices are available Figure 7-29 Sarstedt S-Monovette venous blood collection system. A. System with needle attached. B. System used with a syringe-style technique. C. System used as ETS. Courtesy of Sarstedt AG & Co. KG. Blood Collection Additives ▪ Additives are anything that is added to a tube other than the tube stopper or a Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com silicone coating ▪ Most tubes contain an additive to prevent or encourage clotting or preserve certain blood components ▪ Additives are not interchangeable and it is very important to select the correct tube for every test ▪ If an anticoagulant is added the result is whole blood ▪ Some whole blood samples are used as is and some are centrifuged to obtain plasma for testing ▪ If the additive is a clot activator the blood will clot and the tube must be centrifuged to obtain serum for testing Courtesy of Greiner Bio-One International AG, Kremsmünster, Austria. Blood Collection Additives ▪ Anticoagulants Because the cells are free ▪ Substances that prevent blood flowing and not clotted, a Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com specimen collected in from clotting anticoagulant can ▪ Required for any whole blood or plasma sample separate through settling ▪ Two methods of preventing or centrifugation and can clotting: be resuspended by ▪ Precipitating calcium intentional or inadvertent mixing of the specimen. ▪ Inhibiting formation of thrombin ▪ Types ▪ Ethylenediaminetetraacetic acid (EDTA) ▪ Citrates ▪ Oxalates ▪ Heparin Courtesy of Greiner Bio-One International AG, Kremsmünster, Austria. Blood Collection Additives ▪ Ethylenediaminetetraacetic acid (EDTA) ▪ Comes in 2 types k2 and k2 Because the cells are free ▪ Binds with calcium flowing and not clotted, a Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Lavender or purple tube most common specimen collected in ▪ Pink, tan, royal blue and white specialty tubes available anticoagulant can ▪ Used for hematology and blood banking separate through settling ▪ Preserves cell morphology or centrifugation and can ▪ Citrates be resuspended by ▪ Binds with calcium intentional or inadvertent ▪ Preserves clotting factors mixing of the specimen. ▪ Light blue tube or blue and black ▪ Used in coagualtion ▪ Oxalates ▪ Binds to calcium ▪ Grey top ▪ Often found with an antiglycolytic ▪ Heparin ▪ Inhibits thrombin ▪ Used for blood chemistry and tests requiring faster TAT ▪ Green top tube most common Courtesy of Greiner Bio-One International AG, Kremsmünster, Austria. ▪ Green and grey, royal blue, grey and black less common Blood Collection Additives (cont.) ▪ Anticoagulant specimens: ▪ Must be mixed immediately Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Gentle mixing prevents hemolysis ▪ No shaking! ▪ Recommended number of inversions required ▪ Usually 3-10 depending on additive ▪ Numbers vary by manufacturer; consult manufacturer instructions Figure 7-30 One complete tube inversion. © Wolters Kluwer. Blood Collection Additives (cont.) ▪ Light blue–top tubes: Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Used for coagulation testing ▪ Contain a 9:1 ratio of blood ▪ Contains Sodium Citrate ▪ Must be filled to within 90% of that volume for accurate results ▪ Vacuette® sodium citrate tubes have arrows that are used to identify correct fill volume. Figure 7-31 Guide showing fill levels for sodium citrate tubes. © Wolters Kluwer. Blood Collection Additives (cont.) ▪ Special-Use Anticoagulants Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Acid citrate dextrose (ACD): blood bank, paternity, transplants ▪ 2 types A and B ▪ Citrate phosphate dextrose (CPD): blood bank ▪ Sodium polyanethol sulfonate (SPS): microbiology, blood cultures © Wolters Kluwer. ▪ Antiglycolytic Agents ▪ Substances that prevent glycolysis (breakdown of glucose by blood cells) ▪ Sodium fluoride (most common) ▪ Preserves glucose for up to 3 days and inhibits bacterial growth ▪ Used with potassium oxalate (anticoagulant) for rapid response © Wolters Kluwer. Blood Collection Additives (cont.) ▪ Clot Activators ▪ Substances that enhance Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com coagulation in serum-separator tubes (SSTs) ▪ Types ▪ Substances that provide more surface for platelet activation Blood in an SST tube will 1. Glass (silica) particles eventually clot without 2. Inert clays (Celite) ▪ Clotting factors (thrombin) mixing; however, when it is not mixed, glass particles may become suspended in the serum and could interfere in the testing process, as glass particles have been known to plug the small-diameter tubing in some analyzers. Courtesy and © Becton, Dickinson and Company; Blood Collection Additives (cont.) ▪ Serum or Plasma Separator Tubes Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Thixotropic gel separator ▪ PST Plasma Separator Tube ▪ SST Serum Separator Tube ▪ Has density between that of cells and serum or plasma ▪ When centrifuged, gel moves between cells and serum or plasma ▪ Prevents cells from continuing to metabolize substances ▪ Trace element-free tubes ▪ Tubes made of materials free of trace element Courtesy and © Becton, Dickinson and Company; contamination ▪ Used for trace element tests, toxicology studies, WORKBOOK Matching 7-2 can help you and nutrient determinations learn the additives and their functions. ▪ Feature royal-blue stoppers ▪ Always check the label for additive Blood Collection Additives (cont.) ▪ Serum or Plasma Separator Tubes Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Non gel separator tubes ▪ BD Barricore ▪ Uses a flexible elastomer as opposed to a gel ▪ Able to be used for more tests than those with gel ▪ Slowly becoming more common, particularly in hospitals CLSI Order of Draw 1.Blood culture tube or bottles Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com 2.Sodium citrate tube 3.Serum tube with or without gel 4.Heparin tube with or without gel 5.EDTA tube with or without gel separator 6.Sodium fluoride/potassium oxalate glycolic inhibitor *FYI: The Memory Jogger for the order of draw places the red top before the SST and the PST before the green top only for convenience in memorization." Order of Draw ▪ Carryover/Cross-Contamination Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Transfer of additive from one tube to the next ▪ Can occur when: ▪ Blood in additive tube touches needle during ETS collection ▪ Blood is transferred from a syringe into ETS tubes ▪ Order of draw presents sequence of collection that minimizes risk for interference should carryover occur ▪ Filling specimen tubes from bottom up minimizes carryover Grab some colored pencils and have some fun with the order of draw with WORKBOOK Labeling Exercise 7-2. Order of Draw (cont.) ▪ Tissue Thromboplastin Contamination Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Tissue thromboplastin, present in tissue fluid: ▪ Activates extrinsic coagulation pathway ▪ Can interfere with coagulation tests ▪ For coagulation tests (other than PT or PTT), draw a few millimeters of blood into another tube before collecting coagulation specimen ▪ Microbial Contamination ▪ Microorganisms found on skin can contaminate blood specimens ▪ Blood cultures are collected first in order of draw, when Courtesy of Greiner Bio-One International sterility of site is optimal and to prevent contamination of AG, Kremsmünster, Austria. needle NAACLS Entry Level Competencies Met in This Chapter ▪ 5.00 Demonstrate knowledge of collection equipment, various types of additives Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com used, special precautions necessary, and substances that can interfere in clinical analysis of blood constituents. ▪ 5.1 Identify the various types of additives used in blood collection, and explain the reasons for their use. ▪ 5.2 Identify the evacuated tube color codes associated with the additives. ▪ 5.3 Describe the proper order of draw for specimen collections. NAACLS Entry Level Competencies Met in This Chapter (cont.) ▪ 5.4 Describe substances that can interfere in clinical analysis of blood Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com constituents and ways in which the phlebotomist can help to avoid these occurrences. ▪ 5.5 List and select the types of equipment needed to collect blood by venipuncture and capillary (dermal) puncture. ▪ 5.6 Identify special precautions necessary during blood collections by venipuncture and capillary (dermal) puncture. CHAPTER 8 Venipuncture Procedures Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com. Objectives 1. Demonstrate knowledge of each venipuncture step from the time the test Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com request is received until the specimen is delivered to the lab, and define associated terminology. 2. Describe how to perform a venipuncture using evacuated tube system (ETS), syringe, or butterfly needle; list required patient and specimen identification information; describe how to handle patient ID discrepancies; and state the acceptable reasons for inability to collect a specimen. Objectives (cont.) 3. Identify challenges and unique aspects associated with collecting specimens Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com from pediatric and geriatric patients. 4. Describe why a patient would require dialysis and how it is performed, and exhibit an awareness of the type of care provided for long-term care, home care, and hospice patients. Overview ▪ Venipuncture Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ The process of collecting or “drawing” blood from a vein ▪ Covered in this chapter: ▪ How to correctly identify all types of patients ▪ How to safely obtain high-quality blood specimens ▪ Venipuncture procedures: ETS, butterfly, needle, and syringe procedures on arm and hand veins ▪ Challenges and issues unique to pediatric, geriatric, dialysis, long-term care, home care, and hospice patients Patient Registration ▪ Patient must be registered before specimen collection can take place Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Patient’s identity (ID) includes full name, DOB, sex, address, and proof of ID ▪ Patient-specific identifier is typically assigned and will appear on test requests and specimen labels Requests for Testing ▪ Laboratory testing typically requested by a physician or other qualified HCW Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Nurse Practitioner, Midwife, Naturopathic Dr ▪ Certain rapid tests can be purchased and performed at home by consumers ▪ Pregnancy tests, Urinalysis strips, Blood glucose monitors, Covid tests ▪ Blood specimens may be requested by law enforcement officials ▪ Direct access testing (DAT) Not common in Canada Photo courtesy of Sharon Whetten Figure 11-22 Accu-Chek® Inform II System kit. Courtesy Roche Diagnostics Corporation, Indianapolis, IN. The Test Requisition ▪ Manual Requisitions Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Declining with increased use of computer systems ▪ Computer-Generated Requisitions ▪ Typically contain specimen labels ▪ Barcode Requisitions ▪ One- or two-dimensional ▪ Used with manual or computer- generated requisitions Figure 8-2 A computer- Figure 8-1 A manual generated requisition requisition. with a one-dimensional © Wolters Kluwer. barcode. © Wolters Kluwer. The Test Requisition LifeLabs Requisition Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com The front of a requisition contains the patient’s identifying information as well as the Drs ordering information, tests ordered, diagnosis, test priority and special collection instructions The back of a requisition has answers to many frequently asked questions like how do I need to prepare and do I need an appt as well as contact information The Test Requisition Hospital Requisition Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com Drs can use standard requisitions from a lab or hospital or create their own Some Provinces like Ontario have moved to 1 standardized requisition to reduce confusion and make data entry easier for phlebotomists BC does not have a standard requisition Venipuncture Steps Overview ▪ Overview WORKBOOK Skills Drill 8-3 Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com 1. Receive, review, and accession test request can help you commit these 2. Approach, greet, and identify the patient steps to memory. 3. Explain the procedure and obtain consent 4. Verify collection requirements, and identify sensitivities and potential problems 5. Sanitize hands and put on gloves 6. Position patient, apply tourniquet, and ask patient to make a fist 7. Select vein, release tourniquet, and ask patient to open fist 8. Clean and air-dry the site 9. Prepare collection equipment 10.Reapply tourniquet, uncap and inspect needle 11.Ask patient to remake a fist, anchor vein, and insert needle Venipuncture Steps Overview (cont.) 12. Establish blood flow, release tourniquet, and ask patient to open fist Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com 13. Fill, remove, and mix tubes in order of draw, or fill syringe 14. Withdraw needle, place gauze, activate needle safety feature, and apply pressure 15. ETS: Discard blood collection unit in sharps container immediately Syringe system: Discard needle in sharps, attach transfer device, transfer blood, discard syringe and transfer device in sharps 16. Label and prepare tubes for handling and transport 17. Check patient’s arm and apply bandage 18. Dispose of used materials, and reposition moved items 19. Thank patient, remove gloves, and sanitize hands 20. Transport specimen to the lab promptly © Wolters Kluwer. Venipuncture Steps ▪ Step 1: Receive, Review, and Accession Test Request ▪ Receive the test request Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Review the requisition ▪ Check to see that all required info is present and complete ▪ Make certain request matches labels ▪ Resolve any problems or discrepancies with provider ▪ Verify tests to be collected and time and date of collection ▪ Identify diet restrictions or other special circumstances ▪ Fasting, Timed collection ect ▪ Determine test status and collection priority ▪ Accession the test request © Wolters Kluwer. ▪ Accessioning is the process of entering the requisition into the lab’s computer system. ▪ This process connects a particular specimen to an individual and generates a unique identifying number for this interaction ▪ Some newer inpatient facilities have Direct Provider Entry systems that allow health practitioners to enter tests directly into this system bypassing the majority of this step and reducing data entry for phlebotomists Venipuncture Steps (cont.) ▪ Manual Requisition Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Common issues include ▪ Hard to read handwriting ▪ Tests that are not clearly marked With any type of requisition, it is essential for the information to be transcribed or entered correctly. Figure 8-1 A manual requisition. © Wolters Kluwer. Venipuncture Steps (cont.) ▪ Computer Requisition Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ These are commonly entered as a batch at the beginning of a shift When a computer- generated label is used, the phlebotomist is typically required to write the time of collection and his or her initials on the label after collecting Figure 8-2 A computer-generated requisition the specimen. with a one-dimensional barcode. © Wolters Kluwer. Venipuncture Steps (cont.) ▪ Step 2: Approach, Greet, and Identify the Patient Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ https://navigate2.jblearning.com/mod/page/view.ph p?id=37841509 ▪ Approaching the patient in a hospital setting ▪ Look for signs containing patient info: for example, DNR, Isolation, Purple Dot ▪ When entering a patient’s room, knock lightly, make your presence known, and respect privacy A ▪ Scan the room for sharps containers, obstacles, hazards and IVs ▪ Don’t interrupt physicians and clergy Figure 8-4 Three examples of warning signs. A. No blood pressures or ▪ Ask family and visitors to step out, but use venipuncture in right arm. your discretion while following facility protocol A. Courtesy Brevis Corp., Salt Lake City, UT. if they wish to stay ▪ Document if patient is unavailable ▪ Use bedside manner to gain the patient’s trust and confidence to put them at ease Venipuncture Steps (cont.) ▪ Step 2: Approach, Greet, and Identify the Patient Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com (cont.) ▪ Greeting the patient and identifying yourself ▪ Verify name and date of birth ▪ Check ID band for inpatient ▪ Be aware of bands from other facilities or for other purposes ▪ Use three-way ID: patient’s verbal ID statements, ID band, and visual comparison of label with ID band ▪ Be aware of ID situations requiring extra care, for example, common names ▪ Notify nurse of ID discrepancies Figure 8-8 A phlebotomist with a ▪ If missing ID, check ankle, avoid using bands manual requisition verifying an found elsewhere in the room, follow institutional outpatient’s ID. protocol © Jones & Bartlett Learning. Venipuncture Steps (cont.) ▪ Step 2: Approach, Greet, and Identify the Patient (cont.) Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Greeting the inpatient and identifying yourself (cont.) ▪ Wake sleeping patients gently to obtain identification and consent ▪ Ask relative or nurse to identify unconscious patients, be aware they may hear you and feel pain ▪ Unidentified ER patients: follow CLSI standards and AABB guidelines ▪ Identification of young, mentally incompetent, or non-English-speaking patients can be aided by friends, relative, or HCW ▪ Always follow your facilities protocol and document any special considerations ▪ Neonates/infants: ID bands may be on lower leg ▪ Outpatient ID: may have ID card rather than band Venipuncture Steps (cont.) ▪ Step 3: Explain the Procedure and Obtain Consent Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Explain the procedure ▪ Address patient inquiries ▪ Handle patient objections ▪ Address difficult patients ▪ Handle cognitively impaired or combative patients ▪ Handle patients in altered mental states ▪ Address needle phobia Regardless of the difficulties involved, you must always determine that the patient understands what is about to take place and obtain permission before proceeding. This is part of informed consent. Venipuncture Steps (cont.) Step 4: Verify Collection Requirements, and Identify Sensitivities and Potential Problems Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com Verify diet restrictions Fasting (Nothing but water) NPO (Nothing by mouth including water) If the patient has eaten Address sensitivities and you are told to proceed with specimen Latex allergies, Iodine ect collection, it is Identify previous problems important to write “nonfasting” on the Address objects in patient’s mouth requisition and the specimen label. Can pose a choking hazard CHAPTER 8 Venipuncture Procedures Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com. Objectives 1. Demonstrate knowledge of each venipuncture step from the time the test request is received until the specimen is delivered to the lab, and define associated terminology. 2. Describe how to perform a venipuncture using evacuated tube system (ETS), syringe, or butterfly needle; list required patient and specimen identification information; describe how to handle patient ID discrepancies; and state the acceptable reasons for inability to collect a specimen. Venipuncture Steps Overview Overview WORKBOOK Skills Drill 8-3 1. Receive, review, and accession test request can help you commit these steps to memory. 2. Approach, greet, and identify the patient 3. Explain the procedure and obtain consent 4. Verify collection requirements, and identify sensitivities and potential problems 5. Sanitize hands and put on gloves 6. Position patient, apply tourniquet, and ask patient to make a fist 7. Select vein, release tourniquet, and ask patient to open fist 8. Clean and air-dry the site 9. Prepare collection equipment 10.Reapply tourniquet, uncap and inspect needle 11.Ask patient to remake a fist, anchor vein, and insert needle Venipuncture Steps Overview (cont.) 12. Establish blood flow, release tourniquet, and ask patient to open fist 13. Fill, remove, and mix tubes in order of draw, or fill syringe 14. Withdraw needle, place gauze, activate needle safety feature, and apply pressure 15. ETS: Discard blood collection unit in sharps container immediately Syringe system: Discard needle in sharps, attach transfer device, transfer blood, discard syringe and transfer device in sharps 16. Label and prepare tubes for handling and transport 17. Check patient’s arm and apply bandage 18. Dispose of used materials, and reposition moved items 19. Thank patient, remove gloves, and sanitize hands 20. Transport specimen to the lab promptly https://navigate2.jblearning.com/mod/page/view.php?id=37841529 © Wolters Kluwer. Venipuncture Steps (cont.) Step 5: Sanitize Hands and Put on Gloves https://navigate2.jblearning.com/mod/page/vie w.php?id=37841520 Figure 8-9 A phlebotomist applying hand sanitizer. © Wolters Kluwer. Venipuncture Steps (cont.) Step 6: Position Patient, Apply Tourniquet, and Ask Patient to Make a Fist Positioning patient Hand well supported Avoid bending at elbow for AC venipuncture Seated patients: typically outpatients Recumbent patients: typically inpatients Venipuncture Steps (cont.) Step 6: Position Patient, Apply Tourniquet, and Ask Patient to Make a Fist (cont.) Apply tourniquet (see Procedure 8-1) Apply tourniquet snugly 3 to 4 in above intended site, assuring ends or tails of tourniquet are above the AC area. Never apply over open sore Apply over a dry washcloth or gauze if patient has sensitive skin Ask patient to make a fist—no pumping https://navigate2.jblearning.com/mod/page/view.php?id=37841523 A tourniquet has a greater tendency to roll or twist on the arms of obese patients. Bariatric tourniquets are available from manufacturers. However, if one is not available, two tourniquets placed on top of each other and used together will sometimes be sturdy enough to prevent this © Wolters Kluwer. problem. Venipuncture Steps (cont.) Step 7: Select Vein, Release Tourniquet, and Ask Patient to Open Fist Preferred site is antecubital area of arm First choices are median cubital and median veins Palpate patient’s dominant arm with index finger Roll finger side to side while pressing against vein to judge size Avoid veins that feel hard and cord-like or lack resilience Figure 8-13 A phlebotomist Release tourniquet and have patient open fist palpating the antecubital area for a vein. © Wolters Kluwer. Venipuncture Steps (cont.) Step 8: Clean and Air-Dry the Site Clean site with an antiseptic, like 70% isopropyl alcohol, to avoid infection or contamination May clean using circular motion, moving outward in widening concentric circles for an area 2–3 inches in diameter Allow area to air dry (no fanning/blowing/or wiping) 30 seconds to 1 minute. Do not retouch site after cleaning, but if necessary, the site must be cleaned and air dried again C Figure 8-14 Marking the site with an alcohol pad before Leave an alcohol cleaning the site. C. Alcohol pad pointing in the pad pointing in the direction of direction of the the vein. vein, if needed for © Wolters Kluwer. marking the site Venipuncture Steps (cont.) Step 9: Prepare Collection Equipment ETS equipment preparation Blood collection set preparation Syringe equipment preparation Positioning equipment for use Venipuncture Steps (cont.) Step 10: Reapply Tourniquet, Uncap and Inspect Needle According to the CLSI, when a tourniquet has been in place for longer than 1 minute, it should be released and reapplied after 2 minutes. © Wolters Kluwer. Venipuncture Steps (cont.) Step 11: Ask Patient to Remake a Fist, Anchor Vein, and Insert Needle Anchoring Use nondominant hand to anchor (secure firmly) the vein Place thumb at least 1 to 2 in below and slightly to side of site Pull skin toward wrist NEVER place fingers above puncture site! Figure 8-16 Proper placement of thumb and fingers in anchoring a vein. © Wolters Kluwer. Venipuncture Steps (cont.) Needle insertion Hold collection device or butterfly needle in dominant hand With bevel facing up, position needle above insertion site Insert at 30-degree angle or less in smooth, steady forward motion Rest fingers on patient’s arm https://navigate2.jblearning.com/mod/page/view.php?id=37841501 Figure © Wolters 8-17Kluwer. A. Illustration of a 30-degree angle of needle insertion. Figure 8-17 A. Illustration of a 30-degree angle of needle insertion. © Wolters Kluwer. A Venipuncture Steps (cont.) Step 12: Establish Blood Flow, Release Tourniquet, and Ask Patient to Open Fist Advance collection tube into tube holder until stopper is completely penetrated by needle Push tube with thumb while index and middle fingers straddle and grasp flanges of tube holder, pulling back slightly Blood will begin to flow into tube Release tourniquet Have patient release fist https://navigate2.jblearning.com/mod/page/view.php?id=37841520 Venipuncture Steps (cont.) Step 13: Fill, Remove, and Mix Tubes in Order of Draw, or Fill Syringe Figure 8-19 A phlebotomist mixing a heparin tube. © Wolters Kluwer. Venipuncture Steps (cont.) Step 14: Place Gauze Over and Just to the Side of Needle, Withdraw Needle, Immediately Slide Gauze Over Puncture Site and Apply Pressure with Your Nondominated Hand While Activating Safety Feature Step 15 (ETS): Discard Blood Collection Unit in Sharps Step 15 (Syringe System): Discard Needle in Sharps, Attach Transfer Device, Transfer Blood, and Discard Syringe and Transfer Device Unit in Sharps Venipuncture Steps (cont.) Step 16: Label and Prepare Tubes for Handling and Transport Patient’s first and last names Patient’s identification number (if applicable) or date of birth Date and time of collection Phlebotomist’s initials or code Pertinent additional information, such as “fasting” Compare information on each labeled tube with the patient’s wristband and the requisition Figure 8-21 A phlebotomist https://navigate2.jblearning.com/mod/page/vi comparing a labeled tube with the ew.php?id=37841521 patient’s ID band. © Wolters Kluwer. Venipuncture Steps (cont.) Step 17: Check Patient’s Arm, and Apply Bandage Step 18: Dispose of Used Materials, and Reposition Moved Items Step 19: Thank Patient, Remove Gloves, and Sanitize Hands Step 20: Transport Specimen to the Lab Promptly See how well you know the Key Points and Cautions in this chapter with WORKBOOK Knowledge Drill 8-1. Pediatric Venipuncture Overview Challenges Small, undeveloped veins Children 5 minutes, notify appropriate personnel Caution: Never apply a pressure bandage instead of maintaining pressure until bleeding has stopped, and do not dismiss an outpatient or leave an inpatient until bleeding has stopped or the appropriate personnel have taken charge of the situation. Patient Complications and Conditions (cont.) https://navigate2.jblearning.com/mod/page/view. php?id=37841508 Fainting (Syncope) A loss of consciousness and postural tone Caused by insufficient blood flow to brain Have patients with history of fainting lie down during venipuncture Lower patient’s head and apply cold compress to back of neck (See text Procedure 9-9) Figure 9-12 Phlebotomist caring for a patient who feels faint. © Wolters Kluwer. Patient Complications and Conditions (cont.) Nausea and Vomiting Discontinue blood draw until feeling subsides Give patient emesis basin or wastebasket Apply cold, damp washcloth to forehead Pain Warn patient before needle insertion Avoid excessive, deep, blind, or lateral redirection of needle Extreme pain or numbness indicates nerve involvement; remove needle immediately, apply ice, document incident if pain persists Patient Complications and Conditions (cont.) Petechiae Tiny, nonraised red spots Appear on arm when tourniquet is applied Figure 9-13 Petechiae. A. Adult arm. B. Hand of a child with low platelet count. A. Used with permission from medtraining.org; B. Reprinted with permission from McConnell TH. The Nature of Disease Pathology for the Health Professions. Lippincott Williams & Wilkins; 2007. Patient Complications and Conditions (cont.) Seizures/Convulsions Discontinue draw immediately Hold pressure over site without restricting patient’s movement Do not put anything in patient’s mouth Protect patient from self-injury Notify first-aid personnel Procedural Error Risks Hematoma Formation and Bruising Discontinue draw immediately and hold pressure over site 2 minutes Offer cold compress or ice pack if it is large and swollen Iatrogenic Anemia Anemia brought about by blood loss from blood draws Life is threatened if >10% of blood volume is removed at once Collect only minimum required specimen volumes Inadvertent Arterial Puncture Signs: rapidly forming hematoma, bright red blood filling tube quickly or spurting into tube Procedural Error Risks (cont.) Infection Avoid by doing the following: Don’t open tape or bandages ahead of time Don’t preload needles onto tube holders ahead of time Don’t touch needle insertion site after sterilizing it Minimize time between needle cap removal and venipuncture Remind patient to keep bandage on at least 15 minutes Procedural Error Risks (cont.) Nerve Injury Caused by: Improper site or vein selection Inserting needle too deeply or quickly Excessive lateral redirection of needle Blind probing Figure 9-14 Abnormal hand position If initial vein entry is unsuccessful: called “claw hand” caused by ulnar Use slight forward or backward nerve injury. redirection of needle © Wolters Kluwer. Remove needle and try an alternate site Procedural Error Risks (cont.) Reflux of Additive https://navigate2.jblearning.com/mod/page/view.php?id=37841 520 Blood flows back into vein from collection tube Tube additives (e.g., EDTA) may cause adverse reaction Keep arm in downward position and tube below venipuncture site Vein Damage Avoid numerous venipunctures in the same area over time Avoid blind probing and improper technique Match risks to procedural errors in the WORKBOOK activity Matching 9-5. Procedural Error and Specimen Quality Concerns Hemoconcentration A decrease in fluid content of blood An increase in nonfilterable large molecules Caused by stagnation of normal venous flow due to tourniquet Hemolysis https://navigate2.jblearning.com/mod/page/view.php?id=37841506 Damage to or destruction of RBCs Hemoglobin escapes into fluid part of specimen Partially Filled Tubes (short draw) Blood-to-additive ratio may be incorrect Procedural Error and Specimen Quality Concerns (cont.) Specimen Contamination Allowing alcohol residue, fingerprints, glove powder, baby powder, urine on newborn screening samples Getting glove powder on blood films or capillary specimens Dripping perspiration into capillary specimens Following improper antiseptic procedure Using wrong antiseptic Wrong or Expired Collection Tube Routinely check expiration dates Additives in expired tubes may not work properly Troubleshooting Failed Venipuncture Tube Position Needle Position Improper seating Needle not inserted far enough Needle fails to penetrate stopper Bevel partially out of skin Bevel partially into vein Bevel partially through vein Bevel completely through vein Bevel against vein wall Remember, Bevel in valve the important steps Needle beside vein to trouble shoot Undetermined position venipuncture: STOP, ASSESS, and CORRECT. Needle Position A. Correct needle position; blood can flow freely into the needle. https://navigate2.jblearning.com/mod/page/view.php?id=378415 01 Figure 9-19 Needle position. A. Correct needle position; blood can flow freely into the needle. © Wolters Kluwer. Needle Position (cont.) B: Needle not inserted far enough; needle does not enter the vein. https://navigate2.jblearning.com/mod/page/view.php?id=378415 12 Figure 9-19 Needle position. B. Needle not inserted far enough; needle does not enter the vein. © Wolters Kluwer. Needle Position (cont.) C: Needle bevel partially out of the skin; tube vacuum will be lost. https://navigate2.jblearning.com/mod/page/view.php?id=378414 91 Figure 9-19 Needle position. C. Needle bevel partially out of the skin; tube vacuum will be lost. © Wolters Kluwer. Needle Position (cont.) D: Needle bevel partially into the vein; causes blood leakage into tissue. https://navigate2.jblearning.com/mod/page/view.php?id=378414 90 Figure 9-19 Needle position. D. Needle bevel partially into the vein; causes blood leakage into tissue. © Wolters Kluwer. Needle Position (cont.) E: Needle bevel partially through the vein; causes blood leakage into tissue. https://navigate2.jblearning.com/mod/page/view.php?id=378414 92 Figure 9-19 Needle position. E. Needle bevel partially through the vein; causes blood leakage into tissue. © Wolters Kluwer. Needle Position (cont.) F: Needle bevel completely through the vein; no blood flow obtained. https://navigate2.jblearning.com/mod/page/view.php?id=378414 89 Figure 9-19 Needle position. F. Needle bevel completely through the vein; no blood flow obtained. © Wolters Kluwer. Needle Position (cont.) G: Needle bevel against the upper vein wall prevents blood flow. https://navigate2.jblearning.com/mod/page/view.php?id=378414 88 Figure 9-19 Needle position. G. Needle bevel against the upper vein wall prevents blood flow. © Wolters Kluwer. Needle Position (cont.) H: Needle bevel against the lower vein wall prevents blood flow. https://navigate2.jblearning.com/mod/page/view.php?id=378414 87 Figure 9-19 Needle position. H. Needle bevel against the lower vein wall prevents blood flow. © Wolters Kluwer. Needle Position (cont.) I: Needle bevel penetrating a valve prevents blood flow. Figure 9-19 Needle position. I. Needle bevel penetrating a valve prevents blood flow. © Wolters Kluwer. Needle Position (cont.) J: Needle beside the vein; caused when a vein rolls to the side. https://navigate2.jblearning.com/mod/page/view.php?id=378415 11 Figure 9-19 Needle position. J. Needle beside the vein; caused when a vein rolls to the side, no blood flow obtained. © Wolters Kluwer. Needle Position (cont.) K: Collapsed vein prevents blood flow despite correct needle position. https://navigate2.jblearning.com/mod/page/view.php?id=378414 99 Figure 9-19 Needle position. K. Collapsed vein prevents blood flow despite correct needle position. © Wolters Kluwer. Troubleshooting Failed Venipuncture (cont.) Collapsed Vein Vein walls draw together temporarily, shutting off blood flow Caused by: Vacuum of tube or plunger pressure is too strong for vein Tourniquet is too tight or too close to site There are a lot of new terms Tourniquet is removed during draw (especially with the elderly) in this chapter. See how many you can unscramble in Tube Vacuum the WORKBOOK Loss of vacuum due to bevel Knowledge Drill 9-2 partially out of skin Scrambled Words activity. Loss of vacuum due to damage of tube NAACLS Entry Level Competencies Met in This Chapter 4.0 Demonstrate understanding of the importance of specimen collection and specimen integrity in delivery of patient care. 4.4 List the general criteria for suitability of a specimen for analysis and reasons for specimen rejection or recollection. 4.5 Explain the importance of timed, fasting, and STAT specimens, as related to specimen integrity and patient care. 5.4 Describe substances that can interfere in clinical analysis of blood constituents and ways in which the phlebotomist can help to avoid these occurrences. 5.6 Identify special precautions necessary during blood collection by venipuncture and capillary (dermal) puncture. NAACLS Entry Level Competencies Met in This Chapter (cont.) 6.0 Follow standard procedures to collect specimens. 6.1 Identify potential sites for venipuncture and capillary (dermal) puncture. 6.4 List the effects of tourniquet, hand squeezing, and heating pads on specimens collected by venipuncture and capillary (dermal) puncture. 6.7 Describe the limitations and precautions of alternate collection sites for venipuncture and capillary (dermal) puncture. 6.8 Explain the causes of phlebotomy complications. NAACLS Entry Level Competencies Met in This Chapter (Cont.) 6.9 Describe signs and symptoms of physical problems that may occur during blood collection. 7.0 Demonstrate understanding of requisitioning, specimen transport, and specimen processing. 7.4 Explain methods for processing and transporting specimens for testing at reference laboratories. 7.5 Identify and report potential preanalytical errors that may occur during specimen collection, labeling, transporting, and processing. CHAPTER 10 Capillary Puncture Equipment, Principles, and Procedures Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com. Objectives 1. Define and use capillary puncture terminology; identify capillary puncture Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com equipment; and list the order of draw for capillary specimens and describe the theory behind it. 2. Describe capillary specimen composition; identify differences between capillary, arterial, and venous specimen composition and reference values; decide when capillary puncture is indicated; and demonstrate knowledge of site selection criteria. 3. Name tests that cannot be performed on capillary specimens and explain why. 4. Describe how to collect capillary specimens from adults, infants, and children. Objectives (cont.) 5. Describe specimen collection procedures, and explain the clinical significance Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com of capillary blood gas, neonatal bilirubin, and newborn screening tests. 6. Describe how to prepare both routine and thick blood smears, give reasons why they are sometimes made at the collection site, and identify tests performed on them. 7. Discuss potential complications of capillary puncture. Capillary Puncture ▪ Capillary collections involve collection drops of blood from a Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com small incision in the capillary beds of the dermis ▪ Reference ranges vary for venous and capillary blood ▪ Capillary blood is a mix of venous and arterial blood from the capillary beds and more closely resembles arterial blood in composition ▪ The smaller volume required makes this a good option for individuals for whom removing large quantities of blood is not possible Not all tests can be tested on capillary blood! Always be sure ▪ Pediatric to label tubes appropriately and check to ensure a capillary sample is usable. ▪ Difficult collects ▪ Individuals at risk of iatrogenic anemia Capillary Puncture Equipment ▪ Lancet/Incision Devices Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Sterile, disposable, sharp-pointed or bladed instrument ▪ Punctures or cuts skin to obtain capillary blood specimen ▪ Designed for either finger or heel puncture ▪ Always be sure to select the correct size and type for your patient based on site and age ▪ Must have a safety feature to ensure the blade or needle retracts to reduce chances of injury and blood exposure When you finish the chapter, have fun seeing how many types of equipment you can identify from among the crossword clues in the WORKBOOK. Capillary Puncture Equipment (cont.) ▪ Finger Puncture Lancets Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com Figure 10-1 Several types of finger puncture lancets. A. BD Microtainer® contact-activated lancets. C. Capiject® safety lancets. D. ACCU-CHEK® Safe-T-Pro Plus lancet with three depth settings. A. Courtesy and © Becton, Dickinson and Company; C. Courtesy of Terumo Medical Corp., Somerset, NJ; D. Photo by Ruth McCall; lancets appear courtesy of Roche Diagnostics, Indianapolis, IN. ▪ An important OSHA-required lancet safety feature is a permanently retractable blade or needle point to reduce the risk of accidental sharps injury. Capillary Puncture Equipment (cont.) ▪ Heel Puncture Lancets Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com Figure 10-2 Several types of heel puncture lancets. A. BD QuikHeel infant lancet, also available in a preemie version. B. Tenderfoot toddler (pink), newborn (pink/blue), preemie (white), and micro-preemie (blue) heel incision devices. A. Courtesy and © Becton, Dickinson and Company; B. Used with permission from Werfen. Capillary Puncture Equipment (cont.) ▪ Microcollection Containers/Microtubes Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Small plastic tubes used to collect tiny amounts of blood from capillary punctures ▪ Some come with narrow capillary tubes attached ▪ Have color-coded bodies or stoppers and markings for min/max fill levels Figure 10-3 Examples of microcollection containers. C. BD Microtainer® MAP. C. Courtesy and © Becton, Dickinson and Company. Capillary Puncture Equipment (cont.) ▪ Microcollection Containers Capillary specimen Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com collection is especially ▪ Color-coded like ETS useful for pediatric tubes based on additive patients in whom removal of larger ▪ Have a min and max fill quantities of blood by venipuncture can have line for the correct additive serious ratio consequences. ▪ Some have a “scoop” or Figure 10-3 Examples of stray to assist in collection microcollection containers. A. Microtainer®. B. MiniCollect® capillary blood collection tubes. A. Courtesy and © Becton, Dickinson and Company; B. Courtesy of Greiner Bio-One International AG, Kremsmunster, Austria. Capillary Puncture Equipment (cont.) ▪ Hematocrit or packed cell volume Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com measures the percentage of your blood that is red cells ▪ Microhematocrit Tubes and Sealants ▪ Disposable, narrow-bore plastic or plastic-clad glass tubes ▪ Fill by capillary action and hold 50 to 75 L Figure 10-4 Plain (nonadditive) plastic microhematocrit tubes ▪ Used primarily for Hct determinations used to prepare HCTs from EDTA specimens. ▪ One end of tube is sealed with plastic Courtesy of Globe Scientific, Mahwah, NJ. or clay sealant Capillary Puncture Equipment (cont.) Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Often used for child and infant anemia screening ▪ Tubes come in ▪ Heparinized to collect directly from a capillary puncture ▪ Generally, have a red or green band ▪ Non-additive to be filled from an Figure 10-4 Plain (nonadditive) EDTA tube plastic microhematocrit tubes ▪ Blue band used to prepare HCTs from EDTA specimens. Courtesy of Globe Scientific, Mahwah, NJ. Capillary Puncture Equipment (cont.) ▪ Capillary Blood Gas (CBG) Equipment Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ CBG collection tubes: narrow-bore plastic capillary tubes ▪ Stirrers: metal filings or bars inserted into tube to mix ▪ Often called “fleas” ▪ Magnet: used for mixing, in conjunction w. stirrer ▪ Plastic caps: used to seal tubes and maintain anaerobic conditions Capillary Puncture Equipment (cont.) ▪ Capillary Blood Gas Collection Equipment Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com Figure 10-5 Capillary blood gas collection equipment displayed with arterial blood gas syringes. Courtesy of Sarstedt AG & Co. KG. Capillary Puncture Equipment (cont.) ▪ Microscope Slides Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Used for blood films for hematology determinations ▪ Warming Devices ▪ Warming the site increases blood flow up to seven times ▪ Used to increase blood flow for heel pokes in newborns If a commercial warming device is unavailable, a warm damp towel can be used. Always be careful it is too hot as this could scald the patient! Figure 10.F06: An infant heel warmer. Courtesy of Medline Industries, LP Capillary Puncture Principles ▪ Capillary Puncture Risks Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Bruising, hematoma, infection ▪ Puncture site calcification, scarring ▪ Composition of Capillary Specimens ▪ Mixture of arterial, venous, and capillary blood ▪ Interstitial and intracellular fluid ▪ More closely resembles arterial blood than venous ▪ Reference Values ▪ Capillary reference values may differ from venous values ▪ Glucose concentrations are higher in capillary blood ▪ Bilirubin, calcium (Ca2+), chloride, sodium (Na+) and total protein (TP) concentrations are lower in capillary blood Capillary Puncture Principles (cont.) ▪ Indications for Capillary Puncture Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Older children and adults ▪ Available veins are fragile, difficult to access, or must be saved for other procedures ▪ Venipunctures have been unsuccessful and test can be collected by capillary puncture ▪ Venipuncture sites have burns or scars ▪ Patient has clot-forming tendencies ▪ Patient is apprehensive or is needle phobic ▪ Patient is overweight, and veins are difficult to find ▪ No accessible veins (IVs in both arms, scars, burns) ▪ POCT procedures such as glucose monitoring Capillary Puncture Principles (cont.) ▪ Indications for Capillary Puncture (cont.) Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Infants and young children (the preferred method) ▪ Small blood volume presents risk of anemia. (For every 10 mL blood removed, up to 5 mg iron also removed) ▪ Rapid removal of large quantities risks cardiac arrest. (Life threatened if over 10% of blood volume removed at once or in a short period. See Table 10-1) ▪ Venipuncture is difficult and may damage veins and surrounding tissues ▪ Puncturing deep veins can cause hemorrhage, venous thrombosis, infection, and gangrene ▪ Risk of injury due to restraint needed for venipuncture ▪ Capillary blood is preferred specimen for some tests, such as newborn screening  Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com Always consult your facility’s maximum blood draw policy to determine how much blood you can collect Figure 10.T01: Implications of a 10-mL Blood Draw in an Infant Population Reproduced from Bishop ML, Fody EP, Van Siclen C, March Mistler J, Moy M. Clinical Chemistry, Principles, Techniques, and Correlations. 9th ed. Burlington, MA: Jones & Bartlett Learning; 2023:737. Capillary Puncture Principles (cont.) ▪ Tests That Cannot Be Collected by Capillary Puncture Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com ▪ Most erythrocyte sedimentation rate methods ▪ Coagulation studies that require plasma specimens ▪ Although some manufacturers produce light blue microtubes, they are designed for syringe draws of venous blood and are not suitable for capillary specimens ▪ Blood cultures ▪ Tests that require large volumes of serum or plasma Caution: Capillary puncture is generally not appropriate for patients who are dehydrated or have poor circulation to the extremities from other causes, such as shock, because specimens may be hard to obtain and may not be representative of blood elsewhere in the body. Capillary Puncture Principles (cont.) ▪ Order of Draw Copyright © 2024 by Jones & Bartlett Learning, LLC, an Ascend Learning Company. www.jblearning.com Potassium levels may be falsely ▪ Blood gas specimens (CBGs) elevated if there is ▪ To minimize exposure to air tissue fluid contamination or ▪ Usually collected separately hemolysis of the specimen. ▪ EDTA specimens ▪ Affected by the clotting process and any clotting is unacceptable ▪ Other additive specimens ▪ Also affected by clotting If a newborn screening card is requir