Phlebotomy: Collecting & Processing Blood PDF

Phlebotomy: Collecting & Processing Blood Outline ❑ Demonstrate and describe the skills needed to interact with patients when collecting specimens ❑ Identifying the appropriate tube needed for a specific test ❑ Compare common anticoagulants and additives used to preserve blood specimens and the...

Phlebotomy: Collecting & Processing Blood Outline ❑ Demonstrate and describe the skills needed to interact with patients when collecting specimens ❑ Identifying the appropriate tube needed for a specific test ❑ Compare common anticoagulants and additives used to preserve blood specimens and the general use of each type of anticoagulant ❑ Utilizing appropriate equipment, demonstrate knowledge and order of procedures in specimen collection ❑ Locate an appropriate vein to perform venipuncture Public Relations and Client Interaction Blood collection personnel Patient Professionalism; Appearance. Attitude. Communication skills. Bedside manner. Appearance; Lab coat, shoes, and personnel hygiene Attitude; the way that you think and feel about something or job. Integrity or honesty; CLSI standards, quality of test results. Compassion Motivation Diplomacy Ethical behavior Communication Skills; Good communication; patient develops a favorable impression of the phlebotomist & facility. First 30 seconds make a judgement Pleasant facial expression, neat appearance, and professional manner. Introduce yourself and state your mission Identify patient(ask for full name and date and compare to information on requisition) Remain calm, compassionate and professional Thank patient Inpatient–MUST use 3-wayID Ask patient their full name and date of birth Compare to information on requisition form. Compare requisition to armband No armband NO draw Bedside manner; Phlebotomist may encounter family when collecting specimens during phlebotomy procedure Patient consent Phlebotomy Drawing of blood for transfusion, apheresis, diagnostic testing, or experimental procedures just platelets Two general sources of blood for clinical laboratory tests: a. Venous blood b. Peripheral or capillary blood(skin puncture). Note; Arterial blood for special test like blood gas analysis. Blood specimens may be collected by health care personnel; Clinical laboratory scientist Medical technologist Clinical laboratory technician Medical laboratory technician Specially trained individuals, Blood Composition and Functions Blood; a thick and homogeneous fluid(pH= 7.4), has both liquid and cellular components. Plasma; clear, pale, yellow; 90 % water&10% solutes (proteins, nutrients and other substances) Erythrocytes Leukocytes Platelets Functions, Distributing substances, regulating blood levels of particular substances, or protecting the body Types of Blood Specimens Whole Blood Blood that is collected and the same as what is in circulation; non-clot; not separated; must use anticoagulant Serum Blood that is collected and allowed to clot; separates into cells and serum; does not contain Fibrinogen thrombin (factor I) red-no anticouglant fibrin Plasma Blood that has been prevented from clotting by use of an anticoagulant; when centrifuged, separates into cells, buffy coat and plasma; contains fibrinogen Department of Clinical Laboratory Medicine Clinical Chemistry Hematology Coagulation Urinalysis Microbiology Serology Immunohematology Anticoagulants Substances that prevent blood from clotting via two methods Chelating (binding calcium) –precipitation of calcium so it is not available. Inhibiting formation of thrombin; not converting fibrinogen to fibrin. Whole blood; will separate into red cells on bottom, WBCs and platelets, then plasma. 44 Anticoagulants Most common anticoagulants EDTA – chelates calcium; primarily used for hematology; K2EDTA (spray- dried), Na2EDTA (freeze dried), K3EDTA (liquid) Must mix immediately after collection to prevent platelets clumping NCCLS recommends K2EDTA Lavender or pink tops 45 Anticoagulants Citrates – chelate or bind calcium Used for coagulation studies Most common sodium citrate Critical blood ratio (9:1); must be filled to capacity Light blue stoppered tops Anticoagulants Heparin – inhibits thrombin; accelerates antithrombin III which neutralizes thrombin and further conversion of prothrombin to thrombin. Ammonium, lithium and sodium heparin. Must mix immediately after collection Green stoppers or royal blue w/ green label 47 Anticoagulants Oxalates – precipitate calcium to prevent coagulation Types – ammonium, lithium, potassium and sodium oxalate; potassium most used Mix immediately Gray stoppers 48 Other Additives Gel separator (Polymer barrier) – inert; forms barrier b/w cells and serum (after centrifugation) to prevent cells from metabolizing substances (glucose) Gold tops or red/gray mottled (serum separator tubes (SST) Also available with heparin (light green) and EDTA (special lavender) Other Additives Anti-glycolytic agents – inhibits glycolysis; sodium fluoride (3 days) or lithium iodoacetate (24 hrs); gray stoppers Clot activators (silica or glass particles)– initiates or enhances coagulation; cause blood to clot w/in 15-30 minutes. Order of Draw Special sequence of tube collection that reduces risk of specimen contamination by microorganisms and additive carryover. Additive Carryover Occurs when blood in an additive tube touches needle during venipuncture or transfer from a syringe Additive in blood on or within needle can be transferred to next tube drawn or filled Tests affected by additive carryover; EDTA – calcium, K, Na, PT, PTT, & serum iron Heparin – activating clotting time, PTT, PT Potassium oxalate – PTT, PT, K and RBC morphology. Microbial contamination – special cleaning techniques Clinical Chemistry Perform chemical analyses on serum and plasma. Many diseases of the major organs systems can be diagnosed such as heart attacks, hepatitis, renal failure, diabetes, etc. Blood is drawn in red or green stoppered tube Clinical Chemistry Blood to which an anticoagulant has been added will not clot. Blood cells will settle to the bottom of the tube leaving plasma at the top of the tube containing fibrinogen and clotting factors Clinical Chemistry Blood to which no anticoagulant has been added will clot. Blood cells get caught in the clot leaving serum behind. Clinical Chemistry. Blood lipids (fat), Iron and total iron binding capacity to diagnose anemia. Electrolytes - sodium, potassium, CO2 and chloride Uric acid, Creatinine and Blood Urea Nitrogen (BUN) Liver function tests -AST, ALT, alkaline phosphatase, LDH, and bilirubin. Cardiac enzymes -CK, ALT, LDH along with electrolytes Amylase and lipase Glucose to diagnose and monitor diabetes. (May use gray stoppered tube) Hormones such as thyroxine (T4), parathyroid hormone, insulin, testosterone, renin activity, luteinizing hormone, prolactin, and cortisol Hematology The study of the formed elements of the blood to identify diseases associated with blood and blood forming tissues. Hematology tests aid the physician in diagnosing infections, leukemia, anemia and other blood abnormalities. Hematology CBC is actually a multi-part assay which includes the following (purple Stoppered tube): hematocrit (HCT) hemoglobin (HGB) red blood cell (RBC) count white blood cell (WBC) count platelet count Mean cell hemoglobin (MCH) Coagulation Often housed in the hematology area Coagulation deals with the study of defects in the blood clotting mechanism and monitoring of medication given to patients as "blood thinners" or anticoagulant therapy. Coagulation Blood for the following tests is always collected in blue stoppered tubes. Prothrombin time (PT) Partial thromboplastin time (PTT) Fibrinogen Microbiology Results of the Culture and Susceptibility test (C&S): tell the physician the type of organisms present as well as the particular antibiotic that would be most effective for treatment. Microbiology The culture of microorganisms from blood is required for the laboratory diagnosis blood borne pathogen. Serology To detect the body's response to the presence of bacterial, viral, fungal, parasitic and other conditions which stimulate detectable antigen-antibody reactions in a test system to aid in the diagnosis of the patient. Serology The following tests may be performed in the Serology department (red stoppered tube) Cold agglutinins (CAG) - specimen must be kept warm. Haptoglobin (HP) Rubella C-Reactive Protein (CRP) Immunohematology Also known as the blood bank performs tests to provide blood and blood products to patients for transfusion purposes. The blood bank technologist relies on the phlebotomist to perform identification of the patient without error, since patients will die if given the wrong blood type. Immunohematology Tests include the following: ABO/D (Rh) typing Antibody screen AKA indirect antiglobulin test (IAT). Type and Screen (T&S) Crossmatch Direct Antiglobulin Test (DAT or DC) Rh Immune Globulin (RHIG) or Rhogam workup Antibody titer Antigen typing Antibody Identification Anatomy & Physiology Anterior(ventral)–front Posterior(dorsal)–back External(superficial)–on or near the surface Internal (deep) within or near the center Medial –towards the midline Lateral –toward the side Proximal–nearest the center of the body,point of attachment Distal –farthest from the center Dr. The Three Major Types of Blood Vessels: Arteries, Veins, and Capillaries Why draw blood from veins rather than arteries? Veins are easier to access due to their superficial location compared to the arteries which are located deeper under the skin. Veins are low pressure compared to the higher pressure of arteries so less chance of bleeding, causing a hematoma. Veins have thinner walls than arteries, so piercing them with a needle requires less force and doesn't hurt as much. Vein Selection: Priority List 1) Median cubital vein; Located in the center of the antecubital area – close to the skin. Large vein - easy to anchor - remains stationary during venipuncture. Least risk of injury. 2) Cephalic vein; Located on the outer side of the antecubital area. Easier to anchor and less painful to puncture than the basilic vein. https://emedicine.medscape.com/article/1998221-overview 3) Basilic vein; Located on the inner side (medial) of the antecubital area. Use only when the other veins are unacceptable for a venipuncture procedure. 1) Dorsal hand veins; Acceptable secondary site if veins in the antecubital area of both arms are not viable https://www.pinterest.com/pin/433753007855270267/ Recommended maximum allowable blood draw volumes https://d2xk4h2me8pjt2.cloudfront.net/webjc/attachment s/185/4d8a365-recommended-max-blood-draw- volumes.pdf Procedure for drawing blood ❑ Assemble equipment ❑ Identify and prepare the patient ❑ Select the site ❑ Perform hand hygiene and put on gloves ❑ Take blood ❑ Draw samples in the correct order ❑ Clean contaminated surfaces and complete patient procedure ❑ prepare samples for transportation Venipuncture Blood Collection Equipment Phlebotomy cart Gloves , Bandages – adhesive; gauze folded over and taped Antiseptics – used to prevent sepsis;; used to clean skin area for venipuncture(70% isopropyl alcohol (most common); povidone- iodine (blood cultures/blood gas); 0.5% chlorhexidne gluconate (allergy to iodine) Gauze or cotton balls –to hold pressure on site after collection procedure Sharps disposal containers –needles, lancets and other sharp objects must be discarded in “sharps” containers Pen/Watch – label at bedside; non-smear ink Tourniquet – enlarges veins and makes them easier to find and pierce Different types: latex band, straps, non-latex (watch for patients with latex allergies)  Characteristics Needles – sterile; disposable; single use, a) Evacuated tube system(Multi-sample) b) Hypodermic (syringe) c) Butterfly systems Hub Note; most needles have safety devices; never recap a needle Sizes – indicated by gauge; relates to the diameter of the lumen or “bore” of the needle; Selected according to size and condition of patient’s veins 25 gauge – butterfly needles 18 gauge – blood donation needle size Length – needles come in various lengths; generally 1 to 1 ½ inches; butterfly needles are ½ inch to ¾ inches; depends on personal preference and depth of vein Blood-sampling systems WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy.,2010 Evacuated tube system Evacuated Tubes;  Blood collected directly into tube  Glass or plastic; filled with vacuum(allows for automatic filling; draw precise volume)  Color coded stoppers –indicate type of additive/anticoagulant Plastic holder(adapter); One end of the double pointed needle enters the vein, the other end pierces the top of the tube, and the vacuum aspirates the blood. Syringe system  Used for patients with difficult veins; get “flash”  Use a hypodermic needle attached to a plastic syringe; transfer blood to evacuated tubes  Various sizes – 2 to 10mL  Parts – barrel (graduated) and plunger  When collecting, must slowly pull back on the plunger to fill barrel w/ blood  Use a transfer device to transfer into a tube Winged Infusion Set / Butterfly  Collecting blood from small or difficult veins (hands; elderly pts; children)  Allows flexibility and precision  ½ inch needle permanently connected to 5 to 12 inch tubing with an attachment to allow a syringe or evacuated tube to be applied to the end  Small diameter needles (23 or 25 gauge) Requisition received by lab  Phleb. reviews test reqs.  Order is complete, priority, location, time and date of collection  Status – STAT, ASAP, timed, routine  Patient Contact  Check reqs and make sure needed equipment is available on tray  or cart Patient Contact  Enter pts room – knock, open door slightly and say something before going into room; make your presence known  Look for signs – on door or wall behind pt; infection control precautions, no draws from a specific room, allergies to latex, DNR, NPOs  Identify yourself – who you are and why you are there; communicate if you are a student and ask if you can collect specimen (pt rights) Special situations  Pt asleep – gently wake and ask to turn on lights; nudge bed  Pt unconscious – speak to pt as if awake  Physician or clergy present – don’t disturb, wait until through unless  instructed to proceed  Visitors – ask them to step outside  Pt not available – check with pt’s nurse Patient Identification  Ask pt to state name; do not ask “Are you Mrs. Smith?”  Check pts ID band; no band, no collection; match name, DOB and unique MR#  Discrepancies? – contact nurse  Never use ID band attached to bed or other equipment  ID procedures may vary for ER pts, infants, outpatients  Prepare Patient for Procedure  Bedside manner – gain pt’s trust and confidence; put pt at ease Professional manner and appearance; confidence  Remember the patient’s feelings  Explain the procedure  If pt asks about what tests are being done, no the hospital  policies; instruct pt to consult w/ nurse or Dr.  Pt objections – instruct pt that their physician ordered and it is important to cooperate; if still refuses, inform nurse Specimen Collection Selection of an appropriate site  Visually inspect both arms, In the arm. Feel vein to make sure it is acceptable (size, depth, direction).  Never choose a vein above an IV site. Apply tourniquet  Apply 3-4 inches above site, Do not leave the tourniquet on for more than 1 minute. Prolonged tourniquet application can elevate certain blood chemistry analytes, including albumin, aspartate aminotransferase (AST), calcium, cholesterol, iron, lipids, total bilirubin, and total protein  To make the veins more prominent, ask the patient to make a fist. With the index finger, palpate (feel)  Release tourniquet  Clean site with antiseptic; clean in circular motion starting in center and work outward; allow area to dry before proceeding  Do not dry with unsterile gauze; do not fan; do not touch with finger  Verify equipment (system, needle); place within easy reach  Reapply tourniquet  Position equipment  Hold in dominant hand, thumb on top and fingers underneath holder; position tube in holder, do not push past holder guideline, may lose vacuum  Remove needle cover and inspect needle tip  Anchor the vein; place thumb of other hand 1-2 inches below selected site and pull skin taut; wrap fingers around arm to hold pt’s arm Specimen Collection  Insert needle into vein  With needle bevel up, and needle in same direction as vein, inform pt that there is going to be a poke/stick; insert needle at 15 – 30 degree angle  With one smooth motion, penetrate first the skin and then the vein; when in vein, will feel a slight “give” or “pop”; stop advancing  Holding blood apparatus steady, push tube onto needle hub and fill tubes (use thumb to push the tube while index fingers grasp flange of the tube holder)  Fill as many tubes as needed, do not exceed 1 minute  Be sure to mix tubes when changing  Specimen Collection  Remove last tube and Release tourniquet  Withdraw the needle (fold gauze over site and withdraw in a smooth motion) apply pressure, activate safety device  Apply pressure for 3-5 mins or until bleeding stops  Do not bend arm, keep it extended or raised  Dispose of sharps  Label the tubes  Pt name, MR#, DOB, date & time of collection, phlebotomist’s initials  Preprinted labels  Label at bedside  Special handling instructions  Crushed ice – ammonia; warm – cold agglutinin; light - bilirubin WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy.,2010 WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy.,2010