Unit 1 - 4 Phlebotomy(throughout)- 1.0.ppt

Phlebotomy 1 Objectives Phlebotomy 3.1,3.1.2,3.1.3,3.1.4,3.1.5,3.1.6,3.1.7 Objectives 1. Objectives: Parts of the Vacuum Tube System. 1.1. Comprehensive Understanding of Vacuum Tube System Components: - Identify and describe each component of the vacuum tube system, including needles, vacuum tubes, holders or adapters, and the vacuum mechanism. 2. Objectives: Different Types of Additives 2.1. Familiarity with Additives in Blood Collection Tubes: - Recognize and differentiate between various additives used in blood collection tubes, such as anticoagulants, clot activators, and preservatives. 2.2. Understanding the Purpose of Additives: - Explain the role and significance of different additives in maintaining blood sample integrity and facilitating specific laboratory tests. 3 Objectives 3. Objectives: Difference between serum and plasma: 3.1. Clear Distinction Between Serum and Plasma: - Articulate the biological dissimilarities between serum and plasma, emphasizing their distinct compositions, formation processes, and clinical implications. 4. Objectives: Types of anticoagulants 4.1. Thorough Understanding of Anticoagulants: - Describe common types of anticoagulants used in blood collection, including their mechanisms of action, indications for use, and potential interactions with laboratory tests. 4 Objectives 5. Objectives: The Color of Tubes 5.1. Precise Recognition of Tube Colors and Corresponding Additives: - Identify tube colors and associate them with their respective additives or anticoagulants, ensuring accurate sample collection and processing. 5.2. Understanding the Significance of Tube Color Coding: - Explain the importance of standardized tube color coding in minimizing errors and streamlining laboratory workflow. 6. Objectives: Which department the tubes go to 6.1. Knowledge of Laboratory Departments and Specimen Distribution: Understand the organizational structure of laboratory departments and their respective areas of specialization. 6.2. Knowledge in Specimen Handling and Distribution: - Knowledge in correctly routing collected specimens to the appropriate laboratory departments for analysis and processing. 5 Objectives 7. Objectives: Tube Selection for Various Laboratory Tests 7.1. Understanding Tube Selection for Various Laboratory Tests: - Determine the appropriate types of tubes to use for specific laboratory tests based on test requirements, compatibility with additives, and sample volume needs. 8.Objectives: Common Sites for Venipuncture 8.1 Comprehension of Anatomical Knowledge: Comprehensive knowledge of common sites for venipuncture, including the antecubital fossa, dorsal hand veins, and forearm veins. 8.2 Proficiency in Site Selection: Knowledge to assess and select appropriate venipuncture sites based on factors such as vein visibility, accessibility, and patient comfort. 6 Objectives 9. Objectives: Identifying a Good Vein 9.1 Adept Vein Assessment Skills: Knowledge to identify and assess characteristics of a good vein, such as palpable, visible, resilient, and easily compressible. 9.2 Understanding Patient Factors: Recognize how patient factors such as age, hydration status, and medical history can affect vein quality and suitability for venipuncture. 10. Objectives: Inappropriate Sites for Venipuncture 10.1 Risk Identification: Develop the ability to recognize and avoid inappropriate venipuncture sites, such as areas with compromised circulation, scarring, or inflammation. 10.2 Patient Safety Awareness: Understand the potential risks associated with venipuncture in inappropriate sites, including pain, hematoma formation, and nerve damage. 7 Objectives 11. Objectives: Order of Draw 11.1 Sequential Process : Master the correct sequence for drawing multiple blood samples to minimize the risk of cross-contamination and sample integrity compromise. 12. Objectives: Addressing Difficulty in Finding a Vein 12.1 Problem-Solving Skills Development: Develop strategies to overcome challenges in locating veins, such as adjusting patient positioning, applying warm compresses, or utilizing vein visualization technologies. 12.2 Patient Comfort and Safety: Ensure patient comfort and safety while attempting venipuncture by employing gentle techniques and effective communication. 8 Objectives 13. Objectives: Managing Unsuccessful Venipuncture 13.1 Response Protocol Proficiency: Demonstrate proficiency in responding to unsuccessful venipuncture attempts, including proper wound care, documentation, and notification of appropriate medical personnel. 13.2 Patient Support and Communication: Provide empathetic support and clear communication to patients following unsuccessful venipuncture, addressing concerns and ensuring a positive patient experience. 14. Objectives: Understanding Complications of Phlebotomy 14.1 Comprehensive Complication Awareness: Develop a thorough understanding of potential complications associated with phlebotomy, such as hematoma, nerve injury, and infection. 14.2 Preventive Measures Implementation: Implement preventive measures and best practices to minimize the risk of complications during venipuncture, ensuring patient safety and quality care. 9 Objectives 15. Objectives: Age-Specific Care Considerations 15.1 Comprehensive Understanding of Age-Related Factors: Develop a thorough understanding of how age influences venipuncture procedures, considering anatomical differences, developmental stages, and age-specific health considerations. 16. Objectives: Correct Procedure - Venipuncture by Vacutainer System 16.1 Mastery of Vacutainer System Operations: Demonstrate mastery of the correct procedures for venipuncture using the vacutainer system, including proper assembly of equipment, vein selection, needle insertion, and sample collection. 16.2 Adherence to Safety Protocols: Ensure strict adherence to safety protocols and best practices throughout the venipuncture process, including infection control measures, patient identification, and specimen labeling. 10 Objectives 17.Objectives: Correct Procedure - Butterfly Method  17.1 Knowledge in Butterfly Method Utilization: Knowledge when to perform venipuncture using the butterfly method, including proper butterfly needle selection, vein stabilization, and sample collection techniques. 18.Objectives: Correct Procedure - Capillary Method  18.1 Understanding of Capillary Blood Collection Principles: Acquire a comprehensive understanding of the principles and techniques involved in capillary blood collection, including site selection, skin preparation, and sample handling. 19.Objectives: Correct Procedure - The Syringe System  19.1 Knowledge in Syringe System Utilization: Knowledge in when to perform venipuncture using the syringe system, including proper syringe selection, vein palpation, needle insertion, and sample aspiration techniques. 11 Preparing for blood collection Introduction 12 The primary duty of a medical lab assistant/ phlebotomist is to collect specimens for laboratory analysis. The vacuum tube system is the most efficient, safest, and easiest method of collecting a venous blood sample, especially when multiple tests are ordered. 13 The vacuum tube system A multiple sample needle Evacuated tubes Vacutainer holder/adapter 14 Multiple sample needle 1- 1 ½ inches long Needle gauge between 20 and 23( most common gauge for venipuncture is 21) Both ends are beveled ( an angular cut on the needle for a smoother entry into the skin) Rubber sleeve on the inside needle prevents the blood from leaking into the tube holder 15 Multiple Sample Needle 16 Safety Needle After collection the shield is activated immediately after the needle is removed from the vein. When the thumb pushes forward on the shield, a click is heard. This indicates that the safety shield is in place. This provides immediate containment of a needle 17 Safety Needle 18 Evacuated tubes Fills to the precise volume because of the vacuum in the tubes. Sizes vary from 2 – 15 ml. May or may not have additives Rubber stoppers on each tube indicates the contents of the tube. 19 20 Needle into vein Electron Microscope 21 Different types of tubes 22 No anticoagulant tubes No anticoagulant is added to enable blood to clot. The liquid part of the blood is called serum Stoppers are typically red or gold Specimens collected in non additive tubes must be allowed to stand for 30 min. in order to allow clotting Also Tiger top ( Stripped) is included in this group 23 No anticoagulant tubes Clot activator This is a substance that enhances coagulation in tubes that use serum These substances provide more surface for platelet activation. Example glass( silica) particles in serum separator tubes (SST) And clotting activators such as thrombin 24 No anticoagulant tubes Serum separator In certain tubes there is gel in it. This gel is called Thixotropic gel This gel is an inert substance. The density is different from the cells and plasma/serum. When the specimen is centrifuged, the gel undergoes a change in thickness ( viscosity) 25 This change in thickness causes the gel to move between the cells and plasma/serum. It forms a physical barrier between them. These tube are called These are called SST( serum separator tube) or PST ( plasma separator tube) tubes. Specimens collected in SST tubes must stand for 30 min. in order to allow clotting. 26 Anticoagulant Tubes Contain additives that play a specific role in specimen collection These can be gels, or chemicals called anticoagulants. 27 Other additive tubes Contain anticoagulants - Chemicals that prevent blood from clotting. When blood is spun down it will produce plasma. These tubes can be spun immediately 28 Blood 29 Plasma Plasma is composed of 90% water and 10% dissolved solutes Cellular portion of the specimen contains WBCs, platelets and RBCs. If the specimen is centrifuged, the RBCs will sink to the bottom of the tube. The WBCs and platelets form a thin white layer above the RBCs called the buffy coat 30 Serum If a blood specimen is allowed to clot(Fibrinogen is all used up), the result is serum plus blood cells meshed in a fibrin clot. Serum contains essentially the same chemical constituents as plasma, except the clotting factors and the blood cells are contained within the fibrin clot. 31 Anticoagulant Definition of an anticoagulant – These Are substances that prevent the blood from clotting. There are 2 methods to prevent clotting 1) Binding or precipitation of Calcium 2) Inhibiting the formation of Thrombin 32 Examples of Anticoagulants Ethylenediaminetetraacetic acid (EDTA) Citrates Heparin Oxalates 33 Commonly used anticoagulants 34 EDTA Ethylenediaminetetraacetic acid Used for whole blood hematology studies ( ex; CBC Retic, sedimentation rate) Also, can be used in Immunohematology Used for Ammonia Used for HgbA1C Lavender/purple stopper Binds with Ca and therefore interrupts the coagulation process. 35 EDTA There is a Pink Stopper tube. Has EDTA Used for Immunohematology ( Blood Banking) 36 EDTA Also used with the Royal Blue Tube This is for trace metals Example; Lead, zinc, copper – Note: Lead testing is whole blood Zinc is just plasma - Chemistry Department 37 Heparin Green stopper Contain either sodium or lithium heparin Inhibits thrombin Most common anticoagulant used in the chemistry department Examples of tests done on heparin are – Electrolytes – Cholesterol – Glucose 38 Sodium Citrate Blue stopper ( light blue) Binds with Ca and therefore interrupts the coagulation process. Used for coagulation studies Common tests are – Prothrombin time ( PT) – Partial thromboplastin time ( PTT) – D- dimer – Fibrinogen – Factor studies 39 Sodium Citrate Light blue top contains 9:1 ratio blood to anticoagulant It is very important to fill the light blues to the stated volume. 40 Sodium Fluoride/Potassium Oxalate Gray stopper 41 Sodium Fluoride/Potassium Oxalate Sodium fluoride is an antiglycolytic agent. – This prevents the breakdown of glucose by red blood cells. ( called glycolysis ) – Perseveres glucose for up to 3 days – Inhibits bacterial growth 42 Sodium Fluoride/Potassium Oxalate Potassium Oxalate – is the anticoagulant Binds with Ca and therefore interrupts the coagulation process. 43 Sodium Fluoride/Potassium Oxalate Used for Lactate or glucose testing Collect blood without using tourniquet when collecting for lactate. Gray top tubes must be used if glucose samples from older children and adults cannot be delivered to the lab within 2 hours. Chemistry Department 44 ACD Acid Citrate Dextrose Yellow stopper Binds with Ca and therefore interrupts the coagulation process. Maintains red cell integrity Tube of choice for Canadian blood services for HLA typing, DNA testing. 45 SPS Sodium Polyanethol Sulfonate Binds with Ca and therefore interrupts the coagulation process. Tube of choice for blood culture collections Blue bottle, burgundy bottle, yellow bottle 46 Blood Culture Bottle 47 The vacuum tube adapter/holder Is the device that has the multiple sample needle screwed into one end of the holder and the vacuum tube placed inside the other end. 48 49 Blood Drawing Tray should be stocked with: Vacuum collection system components gauze Alcohol Paper tape or band aids A few butterfly systems A few syringe needles Glass slides 50 Blood Drawing Tray should be stocked with: Marking pen for labeling A tourniquet Gloves Sharps container Capillary stick equipment ( lancets and microtainers) Blood drawing trays must be clean, neat, and well organized! 51 Blood Drawing Tray should be stocked with: Note: Because of the prevalence of MRSA and other pathogens, tourniquets should be single use to prevent healthcare acquitted infections. 52 Venipuncture veins Antecubital veins: Are superficial veins found in the antecubital fossa (in front of). They include; - Median cubital vein - Cephalic vein - Basilic vein 53 Common Sites for venipuncture 1. Median cubital vein - A superficial vein, most commonly used for venipuncture, it is between the cephalic and basilic veins. 2. Cephalic vein -, Shown in both forearm and arm, it, can be followed proximally where it empties into the axillary vein. ( Thumb Side) 3. Basilic vein - Shown in the forearm and arm, it divides to join the brachial vein. ( Baby Finger side) 54 55 What is a good vein To locate a vein, palpate the vein. This is done by touching the vein with the index finger. Do not use thumb. Thumb has a pulse. It should feel spongy 56 What is a good vein When you have found the vein, roll your finger from side to side while pressing against it. This will help to determine the depth and patency of the vein 57 What is a good vein Depth is determined by degree of pressure required to feel it. Patency is distended and a bouncy or spongy feeling. DO NOT USE A VEIN THAT HAS A PULSE. IT IS AN ARTERY 58 What is a good vein Trace the path of the vein. This is to determine a proper entry point. This is done by palpating above and below where you first felt the vein. 59 Inappropriate Sites for Venipuncture Arm on side of mastectomy - secondary lymphedema Edematous areas - tissue fluid accumulation alters test results. Hematomas - may cause discomfort for the patient and may also affect the quality of the blood sample. Sites above an IV cannula 60 Inappropriate Sites for Venipuncture Arm in which blood is being transfused – contamination from the blood being transfused Sclerosed veins- these are veins that are hardened due to numerous punctures. Should be avoided because of impaired blood flow. This might lead to errors lab results. 61 Inappropriate Sites for Venipuncture Arms with fistulas or vascular grafts – Only trained medical personnel are allowed to draw blood from an VAD Sites above an IV cannula – contamination from the IV fluid You must do a 2 minute shut down before collecting the blood sample. Paralysis arm – Increase chance of thrombosis 62 Order of draw There is a correct order of collection when there is more than one tube is order. This is to avoid contamination of non additive tubes from additive tubes as well as cross contamination of different types of additive tubes 63 Order of draw – Blood cultures ( always first) – Plain red stopper ( discard) – Blue stopper tube ( coagulation) – Red ( serum) – Gold (serum) ( SST) – Tiger top ( serum) (SST) – Plain green ( heparin ) – Green ( PST ) ( heparin for chemistry) – Lavender stopper tube ( EDTA for hematology) – Royal blue stopper tube( trace metals) – Yellow ( ACD) – Gray stopper tube ( sodium fluoride for glucose) 64 Why Order of Draw Filling the tube in the wrong order can cause cross contamination of the specimen. This can lead to inference in testing. Carry over can be; the anticoagulant, tissue thromboplastin or microorganism. The order of draw to minimize these problems. EDTA has the most carryover problems. Heparin has the least. 65 Phlebotomy chairs 66 67 If You Have Trouble Finding a Vein If you have trouble finding a vein, there are several suggestions; – Look at both arms – Tapping or rubbing the arm can sometimes make veins 'pop'. – A warm towel wrapped around the arm 68 - if available you can use a “ vein finder”. - called a venoscope Venoscope uses an LED light to illuminate the subcutaneous tissue and highlight the veins that absorb the light. 69 Venoscope 70 If all fails you might have to ask for assistance. - example; co worker or supervisor 71 What happens if the venipuncture is Not Successful Sometimes a venipuncture is not successful. Remember, to troubleshoot failed venipuncture, the important steps are: STOP, ASSESS, & CORRECT. This might be solved by by several techniques 72 1) Tube Vacuum Tube Vacuum You will not know this until you put in the tube. Always keep an extra tube close at hand just in case. 73 Loss of vacuum due to bevel partially out of skin Loss of vacuum due to damage of tube 74 2) You might have inserted the needle too far Just reposition the needle, by pulling back slightly 75 3) You might have not penetrated the vein wall Advance the needle slightly farther into the vein 76 4) Tourniquet too tight Sometime the tourniquet is too tight. This can stop blood flow. Try releasing the tourniquet slightly 77 5) 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 Tourniquet is removed during draw (esp. w. elderly) 78 NEVER PROBE Probing is different and repositioning the needle This when the needle is moved back and forth or side to side in effort to try to find a vein. 79 This is very painful. Also it might hemolyzed the specimen. IT IS BETTER TO TRY ANOTHER SITE THAN TO PROBE 80 REMEMBER YOU CAN ONLY ATTEMPT 2 TIMES TO GET A BLOOD SAMPLE. 81 Needle Position Copyright © 2016 Wolters Kluwer All Rights Reserved A: Correct needle position; blood can flow freely into the needle. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved B: Needle not inserted far enough; needle does not enter vein. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved C: Needle bevel partially out of the skin; tube vacuum will be lost. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved D: Needle bevel partially into the vein; causes blood leakage into tissue. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved E: Needle bevel partially through the vein; causes blood leakage into tissue. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved F: Needle bevel completely through the vein; no blood flow obtained. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved G: Needle bevel against the upper vein wall prevents blood flow. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved H: Needle bevel against the lower vein wall prevents blood flow. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved I: Needle bevel penetrating a valve prevents blood flow. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved J: Needle beside the vein; caused when a vein rolls to the side. Needle Position (cont.) Copyright © 2016 Wolters Kluwer All Rights Reserved K: Collapsed vein prevents blood flow despite correct needle position. Complications of Phlebotomy 93 Problem #1 Burns, Scars, & Tattoos – Veins are difficult to palpate here – May have impaired circulation – New burns are painful – Tattoos may be more susceptible to infection; dyes may interfere If you have no choice but to draw in an area with a tattoo, try to insert the needle in a spot that does not contain dye. 94 Problem #2 Damaged Veins – Sclerosed: hardened – Thrombosed: clotted – Difficult to puncture & yield erroneous Results Use another site if possible, or draw below (distal to) damaged veins. 95 Problem #3 Edema – Swelling caused by abnormal accumulation of fluid in tissues – Results when fluid from IV infiltrates surrounding tissues – Contaminates blood with tissue fluid – Veins are harder to locate, & tissue is fragile 96 Problem #4 Hematoma – A swelling or mass of blood – Caused by blood leaking from vessel during venipuncture – Can be painful, contaminate blood sample, obstruct blood flow 97 Causes of hematomas Failure to remove the tourniquet Applying inadequate pressure Excessive probing Failure to insert the needle in the vein Inserting the needle through the vein Bending the arm after venipucture Veins are too small or fragile for the needle size 98 Hematoma 99 Problem Sites #5 Mastectomy – Surgical breast removal – Lymph flow is obstructed with removal of lymph nodes – Swelling & infection may be present – Applying tourniquet here can cause injury – Can change blood composition – When a mastectomy has been performed on both sides, the patient’s physician should be consulted to determine a suitable site. 100 Problem Sites #6 Obesity – Veins may be deep & hard to find – Use longer tourniquet & try median cubital or cephalic vein 101 Problem Sites #7 Paralysis – Avoid drawing blood from paralyzed arm – Increased chance of thrombosis – Difficulty detecting nerve injury 102 Problem Sites #8 Nerve Damage - There are bundles of nerves close to your major veins, and if one of those nerves are nicked or punctured. Symptoms can be ; Tingling Burning Electric shock sensation Pain up and down the arm Numbness of the arm 103 Nerve Damage Causes of nerve damage Improper vein selection Using jerky movements Inserting the needle too far Movement by the patient while the needle is in the arm Lateral redirection of the needle Blind probing 104 Problem Sites #9 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 & venipuncture Remind patient to keep bandage on at least 15 minutes 105 Problem #10 Reflux of Additive – Blood flows back into vein from collection tube – Tube additives (e.g., EDTA) may cause adverse reaction – Keep arm in downward position & tube below venipuncture site 106 Problem #11 Vein Damage – Avoid numerous venipunctures in the same area over time – Avoid blind probing & improper technique 107 Problem #12 Hemoconcentration – A decrease in fluid content of blood – An increase in nonfilterable large molecules – Caused by stagnation of normal venous flow due to tourniquet 108 Problem #13 Partially Filled Tubes (short draw) – Blood-to-additive ratio may be incorrect 9: 1 ratio light blue tube – Under filled purple tube, excessive EDTA can cause the rbc to shrink – Underfilled grey tube caused hemolysis 109 Problem #14 Wrong or Expired Collection Tube 110 Problem #15 Hemolysis -This is caused the breakdown of RBC and release of hgb. It is detected by a pink or reddish coloring the plasma/serum 111 Hemolysis 112 Tests affected by hemolysis K LD AST CBC Glucose Coagulation tests 113 Causes of hemolysis 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 114 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 115 Problem #16 Icteric Jaundice is caused by a buildup of bilirubin, a waste material, in the blood. An inflamed liver or obstructed bile duct can lead to jaundice, as well as other underlying conditions. Symptoms include a yellow tinge to the skin and whites of the eyes, dark urine, and itchiness. So what does it mean when a blood specimen is Icteric? 116 Icteric Icteric Is a dark yellow to dark brown colour. This normally due almost exclusively to the presence of bilirubin, a hemoglobin waste product from the red blood cells. 117 Icteric 118 Problem #17 Lipemia - is caused by accumulation of lipoprotein particles. - Lipemic samples are patient specimens that have a higher fat content in them, so their blood is a little milkier, and thicker. - The specimen is rejected. - Patient usually ha to fast for 12 hrs 119 Lipemia 120 Problem #18 Contamination Blood collected from an area with edema Blood collected from veins with a hematoma Blood collected from a vein with an IV Site contaminated with alcohol Anticoagulant carryover between tubes 121 Problem #19 Technical problems Tube pops off while blood is being collected Reflux of a tube anticoagulant. ( keep patient’s arm in downward position) Partially filled tubes ( Coag tubes are discarded if not full) 122 Problem #20 Vascular Aid Devices - include a variety of infusion catheters and ports. The most common device is one that is inserted in the arm or hand and used to provide easy access to a patient's circulatory system for administration of fluids and medications. Occasionally, blood specimens are drawn from a VAD, if a direct venipuncture is not feasible. 123 Vascular Aid Devices Only nurses and other specially trained personnel are allowed to draw blood specimens from vascular access devices (VADs). However, the phlebotomist typically assists by supplying the appropriate tubes, and if a syringe is used, transferring the blood to the tubes using a safety syringe transfer device. 124 Vascular Access Devices (VADs) Only nurses and other specially trained personnel are allowed to draw blood specimens from vascular access devices (VADs). However, the phlebotomist typically assists by supplying the appropriate tubes, and 125 Patient that has an IV Patient that has an IV Every attempt to use another site that does not have an IV 126 Collection below IV site - Find a suitable vein - Ask the nurse to turn off the IV for 2 minutes - After 2 minute shut down , collect specimen - Ask nurse to back on IV - Label specimen” Collection below IV, 2 minute shut down” 127 Collection above IV site This is the last resort - Find a suitable vein - Ask the nurse to turn off the IV for 2 minutes - After 2 minute shut down , collect specimen - Ask nurse to back on IV - Label specimen” Collection above IV, 2 minute shut down” 128 Problem #21 Iatrogenic blood loss –is an adverse condition brought on by the effects of treatment. - Iatrogenic blood loss is the result of blood removal for testing. Large amount of blood collected can lead to Iatrogenic anemia. - This is important to know when you are collecting blood from infants. - Life is threatened if >10% of blood volume is removed at once 129 Problem #22 Patient complications Syncope ( fainting) - A temporarily loss of consciousness - Caused by insufficient blood flow to brain - Have patients w. history of fainting lie down during venipuncture 130 Signs and Symptoms of Syncope Patient’s skin becomes clammy Patient becomes very pale Patient tells you he/she can not see Patient appears woozy ( losing conciousness) 131 What to do if a patient faints Remove the needle from the patients arm immediately. Call for help Place a cold compress on patients forehead and neck Put the patient in a semi prone position if possible. 132 What to do if a patient faints Allow the patient to rest until he/she feels better Offer a glass of water or juice Do not leave the patient alone until they are fully recovered. If the patient has a history of fainting, they must be in the recumbent for the draw. 133 Problem #23 Seizures - A seizure is a sudden, uncontrolled electrical disturbance in the brain. 134 What to do if a patient has a seizure Remove the needle from the patients arm immediately. Call for help Do not panic Ease patient to the floor Do not restrict movement 135 Carefully loose clothing, especially around the neck. Place something soft under the head DO NOT PUT ANYTING IN THE MOUTH. 136 Problem #24 Petechiae -Tiny non-raised red spots that appear on the patient's skin when a tourniquet is applied The are small (1–2 mm) red spots on the skin. - May be due to coagulation problems or abnormalities. 137 Petechiae Tiny blood vessels (capillaries) link the smallest parts of your arteries to the smallest parts of your veins. Petechiae appear when capillaries bleed, leaking blood into the skin. A number of things can cause this bleeding, including: Prolonged straining Certain medical conditions Specific types of injuries Medications Injuries and sunburn Petechiae Phlebotomist must be aware of the fact that the patient may bleed excessively after blood collection. Make sure bleeding stops prior to leaving the patient. Usually is not your technique, UNLESS the tourniquet has been applied to tightly - if this the case reapply tourniquet 139 Petechiae 140 Problem #25 Medications ( aspirin, anticoagulants, etc) - Patient on anticoagulants, on aspirin containing medications or has decreased number of platelets - Do not leave patient until bleeding has stopped 141 142 Age – Specific Care Considerations and Competencies for Phlebotomists 143 0- 6 months Fears and Concerns Totally dependent on and trusts parents and other adults 144 0-6 months Communication & Comfort Introduce yourself to the caregiver Explain the procedure Keep the baby warm ( warm site of puncture if needed) Parent may hold the baby Use of a distraction such as a toy may help 145 0-6 months Safety Keep side rails up during procedure Do not leave any items on the bed Encourage the parent to cuddle the baby after the procedure Use appropriate microcollection supplies Do not use a bandaid on the patients finger 146 0-6 months Parent Behaviour Parent may hold the baby as an aid to the phlebotomist and to provide comfort 147 6-12 months Fears and Concerns Fear of strangers Fear of separation from parent Limited language use 148 6-12 months Safety Do not separate from caregiver Keep rails up Encourage the parent to cuddle the child after the procedure Use appropriate microcollection equipment Do not use a bandaid 149 6-12 months Communication and Comfort Introduce yourself to the caregiver Talk slowly to infant Try to make eye contact with the infant Keep patient warm ( warm site if needed) Allow familiar MLA to perform procedure Allow the parent to be close ( hold child) Allow the child to use pacifier, hold teddy bear, blanket or other items 150 6-12 months Parent Behaviour Parent may assist by holding, explaining to, and comforting the child Parent may help identify comforting toy 151 1-3 years Fears and Concerns Self centered Fear of injury Fear of long separation from parent 152 1-3 years Communication Introduce yourself to the caregiver and to the child Child will understand simple directions and may choose to cooperate Take it slow. The child may need time to process the information Allow the child to touch the supplies Ask the parent to explain the procedure in familiar terms 153 1-3 years Comfort Keep patient warm Allow familiar MLA to perform the procedure Allow parent to be in close proximity. ( lap) 154 1-3 years Safety Try not to separate from the parent unless absolutely necessary If necessary, tell the child it will be for a very short time and his parent is right outside the door Keep rails up and do not leave any supplies on the bed Use appropriate equipment ( no bandaid) 155 1-3 years Parent behaviour Parent may assist by holding, explaining to, and comforting the child Parent may help identify comforting toy Encourage parent to praise child after procedure. ( What a brave boy!) Allow child to use a pacifier, hold teddy, blanket, or other comforting items 156 3-5 years Communication Introduce yourself Talk to the child in simple terms Allow the child to touch the equipment Try using familiar cartoon character in the explanation Try to use toys to demonstrate the procedure Provide tokens for bravery 157 3-5 years Fears and Concerns Self- centered Fear of injury Enjoys pretending and role playing 158 3-5 years Comfort Allow the child to have familiar things with him Allow a familiar person to accompany the child Give child time to verbalize fears 159 3-5 years Safety May tolerate separation from the parent Able to recognize danger and obey simple commands Needs close supervision Keep rails up in the bed Do not leave supplies in the bed Ask the parent if it is safe to use a bandaid 160 3-5 years Parent Behaviour Parent may be present to provide emotional support and to assist in obtaining the child’s cooperation Encourage praise for bravery 161 6-12 years Fears and Concerns Less dependent on parents Fears losing self control More willing to participate Tries to be independent Curious 162 6-12 years Communication Introduce yourself Child may be interested in health concepts “why” and “how” Explain why the blood is needed Involve the child in the procedure 163 6-12 years Comfort Try not to embarrass the child but offer them a familiar object or comforting toy Take it slowly. You may have to answer the same questions a few times Allow child to make some decisions, e.g. bandaid color, etc 164 6-12 years Safety Side rails should be left up after the procedure Do not leave items on the bed. Use appropriate equipment 165 6-12 years Parent Behaviour Child may ask the parent to leave the room. 166 13-17 years Fears and Concerns Actively involved in anything that concerns the body More independent Embarrassed to show fear Needs privacy May act hostile to mask fear 167 13-17 years Communication Introduce yourself Use adult vocabulary ( do not talk down) Explain procedure thoroughly Ask if he/she would like to help Ask what might make them more comfortable Allow time for questions or to handle equipment 168 13-17 years Comfort Maintain privacy Take extra time if the patient needs it Offer them the choice of having a parent present Give them time to recover after the procedure if they have cried 169 13-17 years Safety Use same strategies as an adult Use appropriate equipment depending on the size of the patient and the physical and emotional tolerance to the procedure 170 13-17 years Parent Behaviour Child may not want the parent to be present 171 Venipuncture by vacutainer system 172 173 Step 1 Register the patient information and tests into the computer system or log book. Reason – A record must be kept of all information and test results. Also a record of the request 174 Venipuncture Steps (cont.) Manual Requisition With any type of requisition it is essential for the information to be transcribed or entered correctly. Copyright © 2016 Wolters Kluwer All Rights Reserved Venipuncture Steps (cont.) Computer Requisition 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 the specimen. Copyright © 2016 Wolters Kluwer All Rights Reserved Step 1 Look at the status of the request Stat – Immediately Timed- collect at a specific time ASAP – not critical , As soon as possible Fasting – No food or drink 8-12 hrs 177 178 Step 2 Verify the orders for the patient Reason You want to make sure the necessary amount of blood and the correct tubes for the tests ordered are drawn. 179 180 Step 3 Greet and ask the patient his/her name. Introduce yourself and explain what you intend to do. This is PHIA Also ask the patient if they ever had problems with prior draws. Avoid gender terms 181 Explain the procedure Address patient inquiries Handle patient objections Address difficult patients 182 Wake sleeping patients Ask a relative or nurse to identify a patient who is unconscious, young, mentally incompetent, or non-English speaking 183 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 184 Step 4 Verifies patient identification The following must match exactly. – First and Last Name – Ask patient to spell their name – Date of Birth – PHIN Number ( This is the 9 digit number on the Manitoba Health Card) or other unique identifier ( example Hospital Number) 185 Ask patient to spell their name, give birth date. Also ask the patient to show their PHIN number ( or other identifier) If the patient is in the hospital , look at their arm band. Make sure that all the information that you need is correct. ( Name, DOB, Hospital number) 186 Reason The patient must be positively identified to prevent a lab error. The patient is to be made as comfortable as possible 187 You must be 100% accurate when identifying a patient If any information is incorrect or missing, DO NOT PERFORM THE PROCEDURE. Get the information corrected before continuing. 188 Step 5 Make sure the patient has been following dietary instructions if required for a specific test. Reason If the patient has not followed these restrictions, the lab tests will be inaccurate. You will need to call the patient back when he has followed the dietary instructions 189 Step 6 Wash hands and put on gloves Reason Standard precautions 190 191 Step 7 Position the patient for venipuncture. Make sure the arm is straight and slightly downward Reason The proper positioning of the arm will facilitate a successful blood draw 192 Step 8 Apply the tourniquet. 3 – 4 inches ( 7.6- 10 cm) above the intended venipuncture site. Do not to leave it on for no more than 1 minute. The tourniquet should be tight enough to slow down the flow of blood but not so tight as to stop the flow of blood Reason A tourniquet left on too long can cause hemoconcentration and unnecessary discomfort 193 Reason - A tourniquet left on too long can cause hemoconcentration and unnecessary discomfort – Too close , the vein might collapse as the blood is removed – Too far , the tourniquet might be not effective 194 Step 9 Have the patient to close their hand Select a vein Roll finger side to side while pressing against vein to judge size NEVER go with a vein you "see"!!! Always, palpate for the vein. Eyes tell lies Use you index finger. Do not use your thumb. It has a pulse 195 Do not select a vein that feels hard, cord- like, or lack resilience. This might be a tendon or thrombosed vein. DO NOT SELECT A VEIN IF IT HAS A PULSE. THIS IS AN ATERY Reason A successful venipuncture depends on a well selected vein 196 197 Step 10 Mark the site of the vein. This can be done by visualizing the location of the vein. Use references , such as hair, skin creases, scars, moles, etc. Or mark it with your thumbnail 198 Step 11 Remove tourniquet Reason A tourniquet left on too long can cause hemoconcentration and unnecessary discomfort 199 Step 12 Assembly all supplies and equipment and position them where you can easily reach them Reason You might have to redo the venipuncture if you can’t reach the equipment (such as a tube). 200 Step 13 Reapply tourniquet Re palpate the vein you selected. Make sure that your body is in the right position. 201 Step 14 Clean the area using the friction method, with 70% Isopropyl alcohol Reason: The site must be cleaned to kill any microorganisms. Letting the alcohol dry will prevent stinging. If you touch the site again, you must clean the site again with 70% alcohol 202 203 Step 15 Put needle into the holder. Remove the needle cover from the needle Reason:. The needle cover is to be removed right before the puncture. Be careful when removing the needle cover 204 Step 16 Anchor the vein. This is done by placing your free thumb 1- 2 inches below the venipuncture site. Pull the skin toward the wrist. Reason: The vein must be held in place to prevent rolling 205 For safety reasons, DO NOT use the two – finger technique ( also called the “ C” hold”) If the patient moves their arm , the needle could recoil as it comes out and spring back into your arm 206 “ C “ Hold DO NOT USE 207 Step 17 Stabilize the needle to make sure it does not move. Insert the needle at a 15° - 30 angle with the bevel up, following the direction of the vein. The needle should be ¼ inch within the vein Reason: This position is best for adequate penetration into the vein without going through the vein 208 209 210 DO NOT depress the skin by pushing down on the needle as it is inserted. This causes pain to the patient. It does enlarge the vein openings, but it increases the risk blood leakage at the site 211 Step 18 Smoothly push tube into holder without moving the needle Release the tourniquet when blood begins to flow. Ask the patient to open their hand once the first tube starts to fill. Reason: The tourniquet should be not be left on for more than 1 minute. This to prevent hemoconcentration. 212 Step 19 Fill the vacuum tubes according to the correct order of draw. Do not move the hand used to insert the needle. Use the opposite hand to insert each tube into the holder and to invert the filled tubes. Reason: Using the correct order of draw prevents contamination. It is NB to mix the tubes with your free hand to avoid repositioning the needle and to prevent clotting. 213 214 215 Step 20 Mix tube 5- 8 times Except Light blue tubes invert 3 – 4 times 216 Make sure to invert tubes gently 217 Vigorous mixing may cause hemolysis. Vigorous mixing or excessive number of inversions may activate platelets 218 Step 21 Remove last tube before you withdraw needle. Withdraw the needle carefully. Applying gauze to the puncture with pressure for 3 -5 minutes Cotton balls not recommended. Reason: to help prevent a hematoma 219 Step 22 Engage needle safety guard. Dispose of the needle and holder immediately into a sharps biohazard container which must be within reach Do not recap needles! Reason: For protection against needle sticks 220 221 Step 23 Label all tubes immediately, if no computer label is available. Information to be included is the patients name, identification number, date, time of collection, and your initials Make sure that the tube that you are labeling does come into contact with the requistion Reason to prevent an error that can result in a unreliable result. You must be 100% accurate when identifying a patient and labeling tubes 222 223 Step 24 Sites must be observed for 5 – 10 seconds before applying bandage Reason: to prevent a hematoma. 224 Step 25 Thank the patient and say goodbye Reason: Customer satisfaction should always be a top consideration. 225 Step 23 Remove and discard all contaminated items into the biohazard container, wiping up any spills with 1:10 bleach solution. Reason: Standard precautions 226 Step 24 Remove gloves Wash your hands Reason: Standard precautions 227 Step 26 Any deviation from the approved procedure ( SOP – Standard Operating Practices) must be documented 228 Butterfly Method (also called Winged Infusion set) 229 The butterfly infusion set Consists of ½ to ¾ inch stainless steel Connected to 5 – 12 inch tubing Winged – shaped plastic extensions used for gripping the needle Used for fragile veins (hands, elderly or children) When small volume of blood is sufficient 23 gauge needle is the most common 230 If a coagulation tube is the first tube be drawn by using a butterfly, a discard tube should be drawn first. This is to fill up the dead space and maintain blood / anticoagulant ratio 9: 1 The discard tube should be a no additive tube or another light blue tube. It does not have to be filled up completely. Label it DISCARD 231 Venipuncture by butterfly 232 Step 1 Make sure the patient information is entered into the computer system or log book of the laboratory 233 Step 1 Register the patient information and tests into the computer system or log book. Reason – A record must be kept of all information and test results. Also a record of the request 234 Step 2 Verify the orders for the patient Reason You want to make sure the necessary amount of blood and the correct tubes for the tests ordered are drawn. 235 Step 3 Greet and ask the patient his/her name. Introduce yourself and explain what you intend to do. This is PHIA Also ask the patient if they ever had problems with prior draws. 236 Step 4 Verifies patient identification The following must match exactly. – First and Last Name – Ask patient to spell their name – Date of Birth – PHIN Number ( This is the 9 digit number on the Manitoba Health Card) or other unique identifier ( example Hospital Number) 237 Ask patient to spell their name, give birth date. Also ask the patient to show their PHIN number ( or other identifier) If the patient is in the hospital , look at their arm band. Make sure that all the information that you need is correct. ( Name, DOB, Hospital number) The information on the arm band must match exactly to what is on the requisition. 238 Reason: The patient must be positively identified in order to prevent a lab error. The patient is to be made as comfortable as possible 239 Step 5 Make sure the patient has been following dietary instructions if required for a specific test. Reason If the patient has not followed these restrictions, the lab tests will be inaccurate. You will need to call the patient back when he has followed the dietary instructions 240 Step 6 Wash your hands and put on gloves 241 Step 7 Position the patient’s arm. For a hand puncture have the patient gently close his/her hand. Have the tubes slightly lower than the puncture site. 242 Step 8 Apply the tourniquet. To be left on for only 1 minute For a hand draw the tourniquet is applied just above the wrist bone. 243 Step 9 Palpate a vein. On a hand draw be careful not to hit a bone. 244 Step 10 Remove tourniquet Reason A tourniquet left on too long can cause hemoconcentration and unnecessary discomfort 245 Step 11 Assemble the butterfly apparatus, with uncoiled tubing and Luer adapter attached to a tube holder or syringe. ( tube holder is recommended) 246 Step 12 Reapply tourniquet Re palpate the vein you selected. Make sure that your body is in the right position. 247 Step 13 Cleanse the site with alcohol 248 Step 14 Anchor the vein 249 Step 15 Insert the needle at a 15° angle with the bevel up, following the direction of the vein. Thread the needle ¼ inch within the vein. Be sure that the needle does not move. The Butterfly set must be secure at throughout the procedure. ( by hand ) 250 Step 16 Release the tourniquet once there is blood in the tubing. 251 Step 17 Fill the tubes according to the correct order of draw. Invert additive tubes to mix. 252 Step 18 Withdraw the needle and apply pressure with a clean gauze to the site. Immediately discard entire butterfly assembly in a sharps container. 253 Step 19 Label all tubes immediately. 254 Step 20 Examine the patient’s arm for bleeding and apply a band aid. Must be examine for 5 – 10 seconds before applying bandage 255 Step 21 Thank the patient and say goodbye 256 Step 22 Remove and discard all contaminated material into a biohazard container. Wipe up any spills with 1:10 Javex solution. 257 Step 23 Wash your hands 258 Step 24 Any deviation from the approved procedure ( SOP – Standard Operating Practices) must be documented 259 Skin Punctures Also called capillary collections, finger sticks, or dermal punctures 260 Capillary Composition Capillary specimens is a mixture of venous, arterial blood and interstitial fluid. Because arterial blood enters the capillaries under great pressure than venous blood, capillary blood contains a higher portion of atrial blood than venous blood. 261 Capillary collection is uses Capillary collection is use when only a few drops of blood is needed for testing 262 Two common sites of Capillary Collection Finger Heel 263 Lancets There are 2 types of lancets 1)Devices that puncture the skin 2)Devices that make an inscion in the skin Both are called lancets 264 Microtainer Tubes used for skin punctures. They vary in size from 200 ul to 750 ul. They have the same color codes as blood collection tubes.( depending on the additive) They use scoops or capillary tubes to direct the drops of blood into the tube. 265 When to choose a skin puncture The patient has fragile or superficial veins The patient is an infant as his/her blood volume is low The patient is a child with no adequate veins found for venipuncture A patient will not cooperate with you and requests a finger poke A child may request a finger poke 266 When to choose a skin puncture The test ordered may require only a few drops of blood ( PKU, glucometer reading) Burn patients with no visible venipuncture sites Patient with thrombotic problems Patient is obese and no veins can be found 267 A skin puncture should not be done when: The patient's extremities are cold Dehydration Lab tests require more blood than can be obtained with a finger poke Poor circulation Edema Shock Patient refuses a finger poke 268 Capillaries Capillaries are tiny vessels. This is where the exchange of gases and nutrients occur. Capillaries contain a mixture of arterial ,venous blood and interstitial fluid. Therefore, capillary collection is not the same a venous collection. The refences ranges for capillary collection might be different than the 269 Complications of a skin puncture The blood may be contaminated with interstitial fluid. You may have to squeeze the site repeatedly causing excessive dilution of the blood with interstitial fluid as well as damage to the RBCs 270 Remember If you have to warm the site, make sure that the temperature is no more than 42oC. Do not use providine iodine on skin punctures. ( affects uric acid, phosphate, and potassium) Do not use a scooping action against the skin. ( It might activate platelets) Turn off UV light if collecting for bilirubin Double sticking is never acceptable If you have to collect the card and other blood work, separate puncture site should be used. 271 Finger tip Most common Usually middle finger ( or ring finger) of the non dominate hand Puncture should be made in the fleshy portion of the finger, to the side of centre and perpendicular to the grooves 272 273 Recommended incision depth depends on age and recommended puncture site. Lancet depth Recommended Recommended incision depth puncture site up to Premature neonates heel 0.85 mm (up to 3 kg) Infants under 6 heel 2.0 mm months of age Child aged 6 months finger 1.5 mm to 8 years Child older than 8 finger 2.4 mm years and adults 274 Finger Stick 275 Finger stick procedure Step 1 Wash your hands 276 Step 2 Make sure you read the requisition carefully and have all your supplies ready and convenient. Make sure you know how much blood to collect for all the tests ordered 277 Step 3 Greet and identify the patient 278 Verifies patient identification The following must match exactly. – First and Last Name – Ask parent to spell name – Date of Birth – PHIN Number ( This is the 9 digit number on the Manitoba Health Card) or other unique identifier ( example Hospital Number) 279 Step 4 Explain the procedure to the patient. If the patient is a child be calm and reassuring as the child may be frightened IF necessary have the child sit on a parents lap. 280 Step 5 Select a puncture site Usually it is the middle finger of the non dominate hand Massage or warm the puncture site if necessary 281 Step 5 The site should be warm, normal color, ad free from scars, burns, rashes. It should not be cyanotic It should be edematous 282 Step 6 Put on new gloves that fit snugly and are intact 283 Step 7 Cleanse the area with 70% alcohol to remove any possible contaminants 284 Step 8 Remove the cover of the lancet or other device being used. 285 Step 9 Grasp the patients finger and place your thumb at the base of the finger nail. Wrap your fingers around the side of the finger 286 Step 10 Place the lancet at the side of the finger. Make sure it is flat against the skin, ensuring good skin contact Engage lancet device 287 Step 11 Dispose of lancet into sharps container 288 Step 12 Apply gentle pressure to the patient's finger until the first drop of blood is formed Wipe away the first blood drop This to avoid unnecessary tissue fluid dilution. 289 Step 13 Apply gentle pressure the finger again from the base of the finger to the tip and fill the collection tubes 290 Step 14 Collect hematology samples first to minimize the possibility of platelets clumping in the collection tubes 291 Step 15 If the blood flow starts to decrease, wipe the puncture site with alcohol. Alcohol can inhibit clotting. Dry with a gauze and begin again. 292 Step 16 Mix the collection tubes Label all specimens 293 Step 17 After collection place a clean dry gauze to the site. Have the patient ( or parent) apply pressure. Use a band aid for children > 2 years 294 Step 18 Dispose of all contaminated equipment in a biohazard container 295 Step 19 Remove gloves Wash your hands 296 Step 20 Any deviation from the approved procedure ( SOP – Standard Operating Practices) must be documented 297 Heel Stick 298 Heel stick Recommended for children less than 1 year old Be careful not to puncture a bone. Puncture to the bone may cause osteomyelitis or osteochondritis 299 What is the max. amount of blood taken ? It depends on the weight of the patient 2cc/ kg Example: a patient weighs 1 kg. Therefore, max amount of blood ( nor plasma or serum) is 2 ml 300 Lancets and Tubes For infants the penetration depth should be less than 2.0 mm on heel sticks to avoid penetrating the bone. Quikheel Lancet is recommended 301 Lancets Quikheel Lancet is recommended 302 Metabolic Screening Cards 303 Metabolic Screening Newborn screening for phenylketonuria (PKU) since 1964. Congenital hypothyroidism (CH) since 1977 to all infants born in Manitoba. 304 Metabolic Screening Today, newborn screening has expanded to screen for over 40 metabolic and endocrine disorders. Individually, these disorders are rare, but as a group, will be detected in 10-12 newborns each year of children born in Manitoba. 305 Examples of some test that are screened Phenylketonuria (PKU) Citrullinemia (CIT) Tyrosinemia (TYR) Maple syrup urine disease (MSU 306 Congenital hypothyroidism (CH) Congenital adrenal hyperplasia (CAH) Cystic fibrosis (CF) Galactosemia (GALT) 307 Metabolic Screening The Cadham Provincial Laboratory (CPL) in Winnipeg conducts all newborn screening for these disorders 308 Heel sticks can be for metabolic screening or for blood tests 309 Heel Stick Procedure 310 Performing a heel stick Step 1 Wash your hands 311 Step 2 Properly ID the patient and the tests ordered 312 Step 3 Put on gloves 313 Step 4 Assemble your supplies. Lancet for heel pokes cannot penetrate over 2.0 mm. Have everything ready and within reach 314 315 Step 5 Warm or gently massage the heel. ( make sure if using a warm cloth that it will not burn the heel) 316 Step 6 Select an appropriate site 317 Step 7 Grasp the infants heel firmly. Put your forefinger over the arch of the baby’s foot and your thumb below the puncture site. Your remaining fingers should rest on top of the foot. The foot should be resting between your index finger and your third finger. 318 Step 8 Clean the area thoroughly with alcohol. Dry the site with the sterile gauze 319 Step 9 Puncture the skin using the appropriate procedure. The puncture should be perpendicular to the heel print lines. 320 Step 10 Wipe away the first drop of blood to prevent dilution with tissue fluids. 321 Step 11 Fill the card With one drop of blood touch the filter paper. Fill each circle. Ensure that the circle is fill on both sides. ( one drop of blood per circle) Fill the circle completely Do not let the filter paper touch the skin 322 Fill hematology tubes first to prevent clumping of the platelets. 323 324 Step 12 If the blood flow starts to decrease, wipe the puncture site with alcohol. Alcohol can inhibit clotting. Dry with a gauze. 325 Step 13 When finished elevate the infants foot and apply clean gauze with gentle pressure. For newborns you may be asked to put paper tape on the foot 326 Step 14 Mix the collection tubes Label all specimens 327 Step 15 Dispose of all contaminated equipment in a biohazard container 328 Step 16 Remove gloves Wash hands 329 Step 17 Any deviation from the approved procedure ( SOP – Standard Operating Practices) must be documented 330 Infant phlebotomy station 331 Reasons for recollection of the Metabolic Card NSQ.The circles are not filled properly. Can cause false positive or negative. Layering-.Applying successive blood drops. Can cause false positive or negative. Clotting. Slow application may allow the blood to clot. Can cause false positive or negative. Abrading. Damage to filter paper. Can cause false positive or negative. 332 Reasons for recollection of the Metabolic Card Drying. Dying should be at room temperature on a clean, dry surface for minimum of 3 hr. High humidity, direct sunlight, or closing the flap too soon should be avoided. Can cause false negative. Contamination. Smearing, or touching the filter paper, or milking of the heel , should be avoided. Can cause false positive or negative. 333 The Syringe System 334 The Syringe System Used for small children Fragile, small, or otherwise difficult veins Preferred for veins that will collapse under a vacuum Consists of a hypodermic needle attached to a sterile, disposable plastic syringe. 335 Syringe needles A sterile needle designed for single use Comes in a variety of gauges ( measure of the diameter of a needle) The larger the gauge the smaller the needle. E.g. a 21 gauge needle is larger than a 23 gauge needle. Lengths vary. Most common is 1 inch to 1 ½ inch. 336 Syringe needles 337 Syringe and needle with guard 338 Syringes 339 Disadvantages of using a syringe An additional step of transferring the blood to an evacuated tube Cannot collect trace metals May damage blood cells Cells can also be damaged if there is difficulty in drawing the blood Needle stick injuries are more common using a syringe 340 DO NOT DO THIS 341 Syringe Transfer Device If drawing blood with a syringe is necessary, needleless blood transfer devices must be implemented. 342 Syringe Transfer Device 343 Venipuncture by Syringe 344 Step 1 Enter the patient information into the computer system or log book. 345 Step 2 Verify the orders for the patient Reason: to make sure the right amount of blood and the correct tubes are collected 346 Step 3 Greet and identify the patient. Introduce yourself and explain what you intend to do. Reason: You must be 100% positive about the ID of the patient to prevent an error. 347 Step 4 Verifies patient identification The following must match exactly. – First and Last Name – Ask patient to spell their name – Date of Birth – PHIN Number ( This is the 9 digit number on the Manitoba Health Card) or other unique identifier ( example Hospital Number) 348 Step 5 Make sure the patient has been following dietary restrictions if applicable to the test ordered 349 Step 6 Wash hands and apply gloves Reason: Standard Precautions 350 Step 7 Position the patient for the venipuncture. Make sure the arm is straight and slightly downward. 351 Step 8 Apply the tourniquet 352 Step 9 Palpate a vein 353 Step 10 Assemble all supplies and equipment, making sure to arrange the tubes in the correct order of draw in a test tube rack Reason: After the draw, you need to take as many precautions as possible during the transfer of blood to the tubes from the syringe. 354 Step 11 Position the equipment, assembling the needle and syringe and popping the barrel of the syringe to force air out of the barrel. Make sure the barrel can move easily Reason: The barrel of the syringe must be popped to make sure that there is not defects in the barrel. 355 Step 12 Re apply the tourniquet Re palpate the vein 356 Step 13 Cleanse the site with alcohol Let the site dry 357 Step 14 Anchor the vein 358 Step 15 Insert the needle at a 15° level , threading the needle ¼ inch inside the vein. Make sure that the needle is not moving. If the blood is being obtained, blood will appear in the hub of the syringe 359 Step 16 Release the tourniquet once there is evidence that there is blood in the hub of the needle. 360 Step 17 Fill the syringe by slowly and firmly pulling on the plunger with the non drawing hand. Reason: Slowly pulling back keeps the blood from being hemolyzed and reduces the chance that the vein might collapse from too much pull 361 Step 18 Withdraw the needle and immediately apply pressure for 3-5 minutes with a clean gauze. 362 Step 19 Apply needle safety guard. Place needle in sharp container 363 364 Step 20 Attach transfer device to syringe 365 366 Step 21 Place a vacuum tube in the transfer device in order of draw Push the tube onto the internal needle until the stopper is pierced 367 368 Step 22 Blood from the syringe is drawn into the tube. Do Not push the plunger 369 Syringe Transfer Device 370 Step 23 Label all tubes immediately 371 Step 24 Dispose of syringe assembly immediately in one piece in a sharps container. Reason: to reduce the chance of a needle stick injury. 372 373 Step 25 Examine the patient’s arm 5 – 10 seconds before apply bandage. 374 Step 26 Thank the patient and say goodbye Reason: phlebotomists are all very nice people!!!! 375 Step 27 Remove and discard all contaminated items into a biohazard container, wiping up any spills with 1:10 bleach solution. Reason: Standard precautions 376 Step 28 Wash your hands Reason: Standard Precautions 377 Step 29 Any deviation from the approved procedure ( SOP – Standard Operating Practices) must be documented 378

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