Week 4 Phlebotomy Handout PDF

MA - 156 - Phlebotomy WEEK 4 Butterfly Draw and Phlebotomy Complications 01 BUTTERFLY DRAW The winged infusion set (WIS) also called a butterfly, is ideal for collection from small and fragile veins, such as those on the back of the hand. The WIS generally uses a smaller gauge needle connected to a...

MA - 156 - Phlebotomy WEEK 4 Butterfly Draw and Phlebotomy Complications 01 BUTTERFLY DRAW The winged infusion set (WIS) also called a butterfly, is ideal for collection from small and fragile veins, such as those on the back of the hand. The WIS generally uses a smaller gauge needle connected to a tube or a syringe. A butterfly is ideal for a hand draw, because the tubing allows for a lower angle of insertion than a standard needle and tube holder. A syringe allows you to control the suction to pull blood slowly from the veins, which is particularly important for elderly and pediatric patients. But WIS can be used with a vacationer set up as well. The steps in collecting blood from the back of the hand are similar to those for routine venipuncture. The biggest difference is the angle of insertion and the and how the needle is held. Depending on the organization you are at WIS maybe the preferred system for routine venipuntures for the antecubital and the back of the hand. In the antecubital a 21g WIS can be used with evacuated tubes or a syringe. On the back of the hand generally a 23g WIS is used also with an evacuated tube system or a syringe depending on the fragility of the veins. When using a WIS in the antecubital the angle if insertion is the same as with a straight needle, 15-30 degrees. On the back of the hand the angle decreases to 10 to 15 degrees. Holing a WIS is slightly different then holding a straight needle with needle holder. Rather than holding with your fingers above and below the needle hub, you will pinch either the wings or the needle hub. This allows the degree of insertion to be decreased. 02 COMPLICATIONS BEFORE THE DRAW While you will not be able to control many variables of patient condition or preparation, you do have control over many other preanalytical variables. When problems and complications arise, your job is to solve the problems you can, minimize the effects of the ones you cannot, and document any discrepancies. Factors that Prevent Access to the Patient Locating the Patient If the patient is not in his or her room, make every effort to locate the patient by checking with the nursing station. If the patient is in another department and the test is a short turnaround time (stat) or timed request, proceed to that area and draw the blood there. Always let the nurse know if the request needs to be rescheduled. Identifying the Patient As you learned earlier, positive identification (ID) of the patient is the most important procedure in phlebotomy. Several situations can make ID difficult, including the following: emergency requisitions emergency room (ER) collections orders telephoned in to the laboratory requisitions picked up at the site Despite the difficulties these situations may present, the information on the requisition must match exactly the information on the patient’s ID band. Any discrepancies must be resolved before collecting the specimen. When the ID band is missing, contact the nursing station so that one can be attached by the nurse on duty. Even if an ID band is in the room, unless it is on the patient, you must not draw blood. Specific policies regarding the resolution of patient ID problems may vary from institution to institution. Be sure to follow the policy of your institution. The American Association of Blood Banks requires special ID for patients receiving blood transfusions. Most institutions use a commercial ID system, in which the ID band comes with matching labels for the specimens. If you are collecting a blood bank specimen and your institution uses this system, be sure to have the appropriate labels. Barriers to Communicating with the Patient Sleeping or Unconscious Patients If you encounter a sleeping patient, you should make one or two attempts to gently wake the patient, and give them time to become oriented, before you begin the draw. A sleeping patient cannot give informed consent or confirm their identity. Drawing from a patient without their consent may expose you to charges of assault. A patient who awakens during a draw may move suddenly, risking injury to himself or herself, or you. If the patient cannot be awakened, consult the nurse or your supervisor. There are times when you must draw from a patient who is unconscious and cannot be awakened. Unconscious patients are most commonly encountered in the intensive care unit (ICU), emergency department, and nursing home. The medical facility will have a protocol in place that needs to be followed for obtaining consent and ensuring the safety of the draw. As a phlebotomist, you will often not know the reason a patient is unconscious. A patient may be recovering from a procedure, or experiencing the side effects of medications. Treat an unconscious patient just as you would a conscious one, including identifying yourself and describing the procedure. Unconscious patients may be able to hear you, even if they cannot respond. Presence of Physicians or Clergy If a physician or clergy member is in the room, return at another time for the procedure unless it is a stat or timed collection. In that case, you should respectfully interrupt and explain the reason for the interruption. If the physician enters while you are preparing to draw, leave the room until he or she is finished with the patient. If the physician enters after you have begun to draw blood, you may request a few minutes to complete the procedure. Presence of Visitors When you enter a room with visitors, greet them as you would the patient. Explain the purpose of your visit to the patient, and ask the visitors if they would mind stepping outside. Most visitors will exit to leave you to work without distraction. If the patient is a child, the presence of visitors or family members during the collection may be helpful. Apprehensive Patients Many patients have some apprehension about being stuck with a needle or having their blood drawn. Most patients can be easily calmed by engaging them in a little distracting conversation on neutral topics, such as the weather, traffic, or local news. If a patient is very nervous or you expect difficulty keeping the patient still or calm during the collection, it is helpful to request a nurse’s assistance. This is especially true if the patient is a child. Language Problems When the patient cannot understand you, he or she cannot give informed consent. In this situation, you may need a translator. Alternatively, if you can effectively communicate with the patient by showing him or her what you will do, you may be able to obtain consent without a translator. Patient Refusal The patient always retains the right to refuse a blood collection. When a patient refuses to have his or her blood drawn, thank the patient and leave the room. Find the nurse or the provider you are working with and explain that the patient has refused the procedure. The nurse or provider may ask you to return with him or her to the room. If the patient again refuses, document this on the request, along with the nurse’s name, and notify the healthcare provider. Remember: never force a patient to have blood drawn. Problems in Site Selection The antecubital fossa is the most common site for routine venipuncture. However, the presence of certain conditions at the chosen site may alter the quality of a specimen or cause harm to the patient. In that case, another site must be chosen. Occluded and Sclerosed Veins Veins that are occluded (blocked) or sclerosed (hardened) feel hard or cordlike and lack resiliency. Occlusion and sclerosis can be caused by inflammation, disease, chemotherapy, prolonged IV therapy or repeated venipunctures. Such veins are susceptible to infection, and because the blood flow is impaired, the sample may produce erroneous test results. Hematomas A hematoma is a reddened, swollen area where blood collects under the skin. It is formed when blood escapes from any break in the vascular circulation into the surrounding tissue. As the blood degrades, the color changes from red to purple/blue to black. Hematomas may be caused by the needle going through the vein, by having the bevel opening only partially in the vein, or by failing to apply enough pressure after withdrawal. Blood from a hematoma is no longer fresh from the vein, and the hematoma can obstruct the vein, slowing blood flow. Each of these factors can alter test results. Edematous Tissue Edema is swelling that is caused when interstitial fluid (which normally circulates between the blood stream and the lymphatic system) is retained in the tissue. Edema can be caused by some diseases, medications, or treatments such as fluid from an IV bag. Mastectomy patients often have edema. Localized edema affects areas like the arm or leg. Collection from edematous tissue alters tests results because of contamination of the sample with tissue fluid. Burns, Scars, and Tattoos Areas with burns or scars have impaired circulation, are susceptible to infection, and may be painful or difficult to penetrate, and should be avoided. Tattoos need not be avoided unless they are inflamed or infected. Mastectomies The removal of lymph tissue on the side of the mastectomy causes lymphostasis, or lack of lymph fluid movement. This can affect test results. The collection also may be painful to the patient, and the risk of infection may be increased. According to Clinical and Laboratory Standards Institute (CLSI), a physician’s written consent is required before drawing on the same side as the mastectomy. Intravenous Sites IV lines are used to administer medications, blood products, or fluids to patients. The IV is inserted into the vein, allowing the medications or fluids to flow directly into the circulatory system. Blood should not be drawn from an arm when there is an IV device in place. Use the other arm instead, or an alternative site. If no other sites are available, blood should be drawn from a site distal to (further away from), not proximal to, the IV. This will minimize the likelihood of IV contents getting into the sample. The following procedure is the best practice for drawing blood from the arm where there is an IV: Request that the nurse turn off the IV. Wait 2 to 3 minutes. Find a vein by applying the tourniquet distal to the IV site. The best choice is a vein other than the vein being used for the IV. Once you perform the venipuncture, discard the first 5 mL or the first tube. Collect the remaining tubes for the appropriate tests. When the venipuncture is complete, request that the nurse restart the IV. Document on the requisition that the blood was drawn from the arm being infused and the contents of the IV. CLSI standards state that it is acceptable to draw blood from an arm with an IV as long as the aforementioned steps are followed. However, analytes being tested must not be those being infused. For example, if the IV fluid contains glucose or electrolytes, you cannot collect blood for a basic metabolic panel, which tests for glucose, sodium, and chloride. Follow your facility’s established policy. Other Situations Any condition resulting in disruption of skin integrity means that the site should be avoided. Open or weeping lesions, skin rashes, recent tattoos, or incompletely healed stitches are examples of sites that should be avoided because of the increased risk of infection. Difficulty Finding a Vein When you cannot find a vein, several techniques can help: Check the Other Arm - Examine the other arm for a suitable site. Ask the patient about sites of previous successful phlebotomy. Enhance Vein Prominence Massage gently upward from the wrist to the elbow. Dangle the arm in a downward position to increase blood in the arm. Apply heat. Moist heat should be avoided if possible. Rotate the wrist to increase the prominence of the cephalic vein. Use a Sphygmomanometer - A sphygmomanometer (blood pressure cuff) can be used instead of a tourniquet for hard-to-find veins. The blood pressure cuff should be placed 3 to 4 inches above the venipuncture site, and inflated to a pressure of 40 mm Hg. If necessary, both arms should be checked to find a good vein. The phlebotomist needs special training to use the blood pressure cuff. Use an Alternative Site - When a suitable vein cannot be found in the antecubital fossa, you will have to collect the blood from somewhere else—the hand, foot, or leg. The leg and foot are more susceptible to infections and clots, and they are not recommended sites for patients with diabetes or those on anticoagulant therapy (heparin or warfarin). Collection from the leg and foot requires the physician’s written permission. The veins of the back of the hand are small and fragile. For this reason, you should use a winged infusion set, with a smaller gauge needle and tube or a syringe. It is not permissible to use veins on the palmer side of the wrist or lateral wrist above the thumb. Problems Associated With Cleaning the Site When drawing a blood alcohol test, 70% isopropyl alcohol, methanol, ethyl alcohol, or tincture of iodine cannot be used to cleanse the site because of alcohol content. The alcohol in those antiseptics will contaminate the blood causing false positive test results. In these cases, povidone–iodine or benzalkonium chloride (Bzlk) is used instead. These antiseptics are not recommended for children under 2 years. For patients allergic to iodine, chlorhexidine gluconate is available. Povidone–iodine is not recommended for dermal punctures, because it may elevate test results for bilirubin, uric acid, phosphorus, and potassium (BURPP). When you use an alternative antiseptic, document it on the requisition. Problems Associated With Tourniquet Application Hemoconcentration A tourniquet should not remain in place for more than 1 minute at a time. This is to prevent hemoconcentration, or alteration in the ratio of elements in the blood. When a tourniquet remains in place too long, the plasma portion of the blood filters into the tissue, causing an increase in the proportion of cells remaining in the vein. Primarily, this affects determinations of the large molecules, such as plasma proteins, enzymes, and lipids. It also increases RBC counts and iron and calcium levels. Prolonged tourniquet application can also alter potassium and lactic acid levels by a different mechanism. These problems can be avoided by releasing the tourniquet as soon as blood flow begins in the first tube. Hemoconcentration can also be caused by pumping of the fist, excessive and forceful massaging of the arm, sclerosed or occluded veins, long-term IV therapy, or dehydration. Formation of Petechiae Petechiae are small, nonraised red spots that appear on the skin when the tourniquet is applied to a patient with a capillary wall or platelet disorder. The appearance of petechiae indicates that the site may bleed excessively after the procedure and requires longer application of pressure on the puncture site. Tourniquet Applied too Tightly If there is no arterial pulse or the patient complains of pinching or numbing of the arm, the tourniquet is too tight. Loosen it slightly before proceeding. Latex Allergy Latex allergy is becoming increasingly common, and all patients must be asked whether they have a latex allergy. Nonlatex tourniquets and gloves are available and in wide use in hospitals, clinics, and nursing homes. Latex bandages should also be avoided for these patients. 03 COMPLICATIONS DURING DRAW Complications During Collection Changes in Patient Status In all of the following cases, be sure your patient is in a safe position before leaving the room. Syncope - Syncope (pronounced “SIN-co-pee”) is the medical term for fainting. Before syncope, the patient’s skin often feels cold, damp, and clammy; beads of sweat may form on the forehead or upper lip; the patient may state that they are not feeling well, or will stop talking; their eyes may start to roll back, or their head could tilt either forward or backward. If syncope occurs during the procedure, remove the tourniquet and needle immediately and apply pressure to the site. Fainting is more common with outpatients; inpatients lying in bed are less likely to faint. Outpatient draw areas should be equipped with pillows and blankets to properly respond to this emergency. Simple questions to assess how the patient is feeling are helpful. It is also helpful to ask your patient before the draw if the patient has a history of fainting during a blood draw. Place a patient with a history of fainting in a recumbent or a reclined position before venipuncture. Patients with no history of fainting must still be monitored closely during the blood collection procedure for signs of syncope. Appropriate first aid must be applied when the patient experiences syncope. If the patient is conscious but woozy, have the patient lower his or her head between the knees, and apply a cold compress to the neck or forehead. Call a nurse to check the patient’s blood pressure, or perform this yourself if you have been trained to do so. If the patient is unconscious, call the nurse immediately. The patient should be safely moved to a recumbent (lying down) position until he or she regains consciousness. CLSI does not recommend the use of ammonia inhalants as some patients may be asthmatic and it could trigger respiratory distress. All incidents of syncope must be documented. Seizures - If a patient has a seizure during venipuncture, remove the tourniquet and needle immediately and apply pressure to the site. If possible, move the patient to a recumbent position on the floor. Do not put anything in the patient’s mouth; this is of no use during a seizure and can cause injury. Follow your institution procedures for patients having a seizure. Nausea and Vomiting (Emesis) - When emesis (EM-eh-sis) occurs, reassure the patient and make him or her comfortable. Give the patient an emesis basin, and instruct him or her to breathe slowly and deeply. A wet washcloth for the head is often helpful. Pain - To prevent the startle reflex, warn the patient before the needlestick that there may be a little poke, pinch, or sting. Be aware of any pain experienced by the patient during the venipuncture by listening for any vocal distress. If this occurs, stop immediately by removing the tourniquet and needle and putting pressure on the site. Pain during the venipuncture is caused by excessive probing/digging and blind, lateral movement of the needle to establish blood flow. Inappropriate needle adjustment can damage nerves, veins, and arteries. Hematoma - If a hematoma develops during the procedure, remove the tourniquet and needle immediately and apply pressure to the site. A cool cloth or cold pack can slow swelling from blood and ease pain. The following are the most common causes of hematoma: Excessive probing to obtain blood. Failure to insert the needle far enough into the vein. Passage of the needle through both sides of the vein. Failure to remove the tourniquet before removing the needle. Inadequate pressure on the site after removal of the needle. Bending the elbow while applying pressure. Lack of Blood Flow Lack of blood flow can be caused by a defective tube, an improperly positioned needle, or missing the vein. Intermittent or slow blood flow indicates improper needle position or a collapsed vein. Defective Evacuated Tube - Occasionally, blood will not flow into a tube because the vacuum in the tube has been depleted. This may occur from a manufacturing defect, use of an expired tube, or a very fine crack (which may occur if the tube is dropped). If the tube is pushed past the tube advancement mark on the holder before insertion in the vein, the vacuum will be depleted. Vacuum will also be lost if the needle bevel comes out of the skin during needle adjustment or switching tubes during venipuncture. Always take extra tubes to the bedside or the outpatient area to be prepared for defects or errors. If you find a defective tube, be sure to note the expiration date and lot number. Document this information, and then dispose of the defective tube in the appropriate sharps container immediately. Do not leave a defective tube lying around the draw area for someone else to use! Improperly Positioned Needle - If the tube is not the problem, the needle may not be properly positioned in the vein, and you may need to adjust it. When the needle is not in the correct position with respect to the vein, blood flow may stop or may be intermittent. Any one of the following may have occurred: The bevel is stuck to the vein wall. Slightly rotate the needle. The needle has passed through both sides of the vein (“blowing” the vein). Slowly pull back on the needle. The needle is not advanced far enough into the vein. Slowly advance the needle. The vein was missed completely. Pull the needle out slightly, palpate to relocate the vein, and redirect the needle. The tube is too large for the vein, causing the excessive vacuum to pull the vein onto the bevel and block blood flow. Remove the tube, wait a few seconds, and then switch to a smaller-volume tube. The bevel is stuck to the vein wall. Slightly rotate the needle The needle is not advanced far enough into the vein. Slowly advance the needle The needle has passed through both sides of the vein (“blowing” the vein). Slowly pull back on the needle. The vein was missed completely. Remove the tourniquet, pull the needle out slightly, palpate to relocate the vein, and redirect the needle. Collapsed Vein A collapsed vein is caused by too much vacuum on a small vein. When using the evacuated tube system, a collapsed vein becomes evident when the tube is pushed onto the inner needle. During a syringe collection, it may occur when the plunger is pulled too quickly. Using smaller tubes or pulling the syringe plunger more gently can help prevent collapsed veins. Once a vein collapses, remove the tourniquet, pull out the needle, and select a different vein, or switch to using a butterfly on a hand vein. Veins That Roll Excessively Where a vein is not held in place by connective tissue, it may roll, or move from side to side under the skin. Rolling veins occur in all patients but are most commonly encountered in older patients. The best strategy for veins that roll excessively is to anchor the vein to minimize rolling. Anchor the vein with your free hand by placing your thumb below where the vein is palpated. Trace the direction of the vein as it moves up the arm, then place your index finger at that place. Once you determine the most optimal spot to enter the vein, pull the skin taut using the index finger and thumb. Insert the needle quickly to prevent further motion. Inadvertent Puncture of the Artery Puncture of an artery produces bright red blood and may cause spurting or pulsing of blood into the tube. A patient with a low blood oxygen level has arterial blood that is darker in color, similar to venous blood. This may make it difficult to determine if an artery has been punctured. If you think an artery has been punctured, immediately withdraw the needle and apply pressure for 5 to 10 minutes or until the bleeding has stopped. After sample collection and needle withdrawal, you should apply pressure for 10 minutes, and check the site before applying a bandage. The sample may not have to be redrawn, but because some values are different for arterial versus venous blood, label the specimen as an arterial sample. Notify the nurse if the artery was inadvertently punctured. Failure to Collect on the First Try The policy at most institutions is that a second try is acceptable. A new needle and tube must be used. For second tries, go distal to the previous site or use the other arm. After a second unsuccessful try, another phlebotomist should be found to draw blood from the patient. 04 OTHER COMPLICATIONS Prolonged Bleeding Normally, the site should stop bleeding within 5 minutes. However, aspirin or anticoagulant therapy can prolong bleeding times after the venipuncture procedure. In all cases, you must continue to apply pressure until the bleeding has stopped. Inform the nurse if the patient has a prolonged bleeding time. Failure to apply adequate pressure, particularly with patients on excessive doses of warfarin (Coumadin) or with a coagulation disorder, can cause compartment syndrome (discussed later in this chapter). In these patients, it is important to apply pressure to the site beyond 5 minutes and ask the patient about any symptoms or significant pain. Factors That Affect Sample Integrity Hemolysis Hemolysis is the destruction of blood cells, resulting in the release of hemoglobin and cellular contents into the plasma. Hemolysis can be caused by a range of factors: Blood frothing caused by a needle improperly attached to a syringe Drawing blood too quickly into a syringe Excessively shaking or rotating the blood Failing to allow the blood to run down the side of the tube when using a syringe to fill the tube Forcing blood from a syringe into a vacuum tube Using too small a needle with respect to vein size Using a needle smaller than 23 gauge (usually, any smaller needle causes hemolysis) Using a small needle with a large vacuum tube Using a small needle to transfer blood from syringe to tube Mishandling and improper transport of specimen Readjustment of the needle in the vein The serum or plasma is pinkish or red in a hemolyzed sample because of rupture of RBCs. Hemolysis interferes with many test results, as shown in below. The laboratory may request a redraw if the sample cannot give accurate results for the requested test. Chemistry and Hematology Tests Affected by Hemolysis Seriously Affected Aspartate aminotransferase Potassium Lactate dehydrogenase Moderately Affected Alanine aminotransferase Complete blood count (CBC) Serum iron Thyroxine Slightly Affected Acid phosphatase Albumin Calcium Magnesium Phosphorus Total protein Blood Drawn From a Hematoma The blood in a hematoma is older than fresh venous blood, and use of such a sample can alter the results of some tests. The most frequent cause of hematoma is improper insertion or removal of the needle, causing blood to leak or be forced into the surrounding tissue. Patient Position The position of the patient during collection can affect some test results because body fluids shift between the seated and supine positions. The standard position for drawing blood from an outpatient is with the patient seated. In very rare instances a physician may request that an outpatient lie down before specimen collection. Tests Affected by Patient Position Albumin Bilirubin Calcium Cell counts Cholesterol Hemoglobin or hematocrit High-density lipoprotein Iron Lipids Reflux of Anticoagulant Reflux is the flow of blood from the collection tube back into the needle and then into the patient’s vein. This is rare, but it can occur when the tube contents come in contact with the stopper during the draw. Anticoagulant, as well as blood, may be drawn back into the patient’s vein. This is a problem, because some patients have adverse reactions to anticoagulants (e.g., ethylenediaminetetraacetic acid, or EDTA), and loss of additive from the tube can alter test results. It may also result in the contamination of the next tube with additive from the previous tube. To prevent reflux, keep the patient’s arm angled downward so that the tube is always below the site, allowing it to fill from the bottom up. Also after removing the tourniquet, disengage the tube from the needle before removing the needle from the patient’s arm. Long-Term Complications Associated With Venipuncture Iatrogenic Anemia Iatrogenic anemia is anemia caused by excessive removal of blood at the request of a physician. Removal of as little as 3 or 4 mL of blood per day may result in the development of iron deficiency anemia in some patients. For this reason, it is important to minimize the amount of blood drawn and the frequency of collection. Your institution should have a procedure in place for documenting the total volume of blood drawn from a patient. If a single test is required, it may be appropriate to acquire blood with a dermal puncture instead of venipuncture. Compartment Syndrome For patients receiving excessive doses of anticoagulants, such as warfarin, or who have a coagulation disorder, such as hemophilia, routine venipuncture may cause bleeding into the tissue surrounding the puncture site. A small amount of blood leads to a hematoma. Larger amounts may cause compartment syndrome, a condition in which pressure within the tissue prevents blood from flowing freely in the blood vessels. This causes swelling and pain, and it carries the risk of permanent damage to nerves and other tissues. Severe pain, burning, and numbness may be followed by paralysis distal to the puncture site. The patient should seek immediate medical attention if compartment syndrome is suspected. Nerve Damage Nerves in the antecubital area can be damaged if they are contacted with the needle during collection. The patient will experience a shooting pain or “electric shock” sensation down the arm, numbness, or tingling in the fingers. If the patient experiences this type of sensation, immediately remove the needle. The procedure should be performed at another site, preferably in the other arm. This incident should be documented according to your institution’s protocol. To prevent nerve damage, avoid excessive or blind probing during venipuncture. Avoid using the basilic vein whenever possible. Infection Infection can be prevented by adhering to venipuncture protocol. Proper aseptic technique before and during collection must be followed. It is best practice not to touch the site once it has been cleansed. If it becomes necessary to repalpate the site, the gloved finger must be cleansed with alcohol to not contaminate the site. Outpatients should be instructed to leave the bandage in place for at least 15 minutes. Specimen Rejection / Specimen Recollection Specimens may be rejected by the laboratory for a variety of reasons. Almost all of these can be avoided by proper care before, during, and after the procedure. Sometimes, problems with the sample cannot be identified until after testing. In this case, another sample will have to be collected. Some of the reasons for rejection and recollection are listed below. Reasons for Specimen Rejection/Recollection Clotted blood in an anticoagulated specimen Collection in the wrong tube Contaminated specimens and containers Defective tube Hemolysis Improper special handling Incompletely or inadequately filled tube No requisition form Unlabeled or mislabeled specimens Expired tubes used in the collection QNS—quantity not sufficient Incorrect time of collection Delay in testing Improper special handling Incomplete drying of antiseptic Unlabeled or mislabeled tube Use of the wrong antiseptic SOURCE: Warekois, Robin, S. et al. Phlebotomy. Available from: Pageburstls, (5th Edition). Elsevier Health Sciences (US), 2020.