Week 7 Handout PDF

MA - 156 - Phlebotomy WEEK 7 Blood Cultures and Specialty draws and considerations 01 BLOOD CULTURES A blood culture (BC) is ordered to detect the presence of microorganisms in the blood, a potentially life-threatening situation. Such microorganisms include bacteria, fungi, and protozoa. Bacteremia...

MA - 156 - Phlebotomy WEEK 7 Blood Cultures and Specialty draws and considerations 01 BLOOD CULTURES A blood culture (BC) is ordered to detect the presence of microorganisms in the blood, a potentially life-threatening situation. Such microorganisms include bacteria, fungi, and protozoa. Bacteremia refers specifically to the presence of bacteria in the blood. Bacteria occasionally enter the bloodstream, for instance through the gut or from excessively vigorous toothbrushing, which breaks capillaries. These rarely cause illness. Septicemia is a lifethreatening infection caused by rapid multiplication of pathogens in the bloodstream. When microorganisms in the blood trigger a systemic inflammatory response, it is called sepsis. Patients with symptoms of chills and fever, or fever of unknown origin (FUO), may require a BC. BCs are ordered as short turnaround time (stat) or timed specimens. Isolating pathogenic organisms from blood is difficult because the number of organisms may be low (leading to false-negative results) and the potential for sample contamination from normal skin flora is high (leading to false-positive results). To decrease the number of false positives, it is important to collect the BC before the patient is given antimicrobial therapy. Proper antiseptic preparation of the skin before collection is also vital to reduce false-positive results because of skin contaminants. Aseptic collection technique is critical for meaningful results. To increase the likelihood of finding pathogens, drawing the correct volume is critical. Always check the collection bottle and your institution’s guidelines for volume requirements. When the concentration of pathogens present in the blood is low, drawing a larger volume of blood increases the chance of collecting a sufficient number of organisms to grow in culture. Sufficient volume is more important than collection from multiple sites with time draws. Drawing the correct volume is also important for maintaining the correct ratio of blood to culture media. Volumes for pediatric patients differ from those for adults. Other strategies used to increase organism recovery include collection at timed intervals and from multiple sites. Always check your institution’s guidelines. Types of Collection Containers There are three basic types of containers for collecting BCs: 1. A long-necked bottle, which accepts a BD Vacutainer needle and tube holder. 2. A shorter bottle, which accepts a winged infusion device, such as a BD Bactec, using a special adapter. 3. A standard evacuated tube with sodium polyanethole sulfonate (SPS) anticoagulant. In addition to culture media, some BC containers have an antibiotic removal device (ARD). ARDs have a resin that absorbs antibiotics from the patient’s blood so that they do not inhibit the growth of bacteria in the culture tube. Site Preparation With Antiseptics Proper antiseptic preparation of the skin reduces the presence of normal skin flora contaminants in the BC sample, reducing the risk of a false positive. The preferred antiseptics are alcoholic preparations of iodine, povidone-iodine, or chlorohexide gluconate (CHG). The Clinical and Laboratory Standards Institute recommends CHG for adults and infants over 2 months. Prepackaged antiseptic kits are commercially available. Apply antiseptic to the top of BC containers before adding patient blood to reduce contamination because of normal flora. Timing The number of organisms in the bloodstream is often highest just before a spike in the patient’s temperature. By frequently recording the temperature, these spikes can often be predicted and collection scheduled accordingly. The best time to draw a BC is 30 minutes before the patient’s fever spikes. If a second set is ordered, it is best not to delay the collection of the second set (this was the usual practice in the past). Instead, draw from the second site within a few minutes of the first. Multiple Sites Contamination of the sample by skin bacteria is a frequent complication of BC collection. However, distinguishing contaminants from true pathogens can be difficult because some contaminants can grow on indwelling devices, causing infection in the patient. To reduce errors caused by this contamination, a known skin contaminant must be cultured from at least two different sites to be considered a blood pathogen. It is even better to collect two pairs of samples from two different sites. This helps detect contamination of samples by skin bacteria. The ordering physician will write the order describing the exact sites and timing of the multiple sets. Sample Collection As noted earlier, samples are collected either directly into a bottle containing culture media or indirectly into a sterile anticoagulated tube for later transfer to culture media in the laboratory. The ratio of blood to culture media is crucial to the culture, so be sure to collect the sample size indicated on the bottle. Also, some bacteria, called an aerobic bacteria, cannot tolerate oxygen, while others, called aerobic bacteria, use it. Some samples you collect will exclude oxygen and will be used to grow anaerobic bacteria. Other samples you collect will include oxygen and will be used to grow aerobic bacteria. For direct collection into culture media, two samples, one aerobic and one anaerobic, are collected from each site. When using a syringe, collect the anaerobic sample first and the aerobic sample second, since the second sample will be more likely to have been exposed to air. The transfer must be performed with the appropriate transfer safety device. When using a butterfly, the opposite order is used: collect the aerobic sample first, since there is air inside the butterfly tube, and then collect the anaerobic sample. Be sure to label the samples to reflect their order of collection. Because pathogen recovery is dependent on sufficient blood volume, when the sample you have collected is short, add the blood to the aerobic bottle since most significant pathogens are aerobes. For anticoagulated tube collections, only one tube is collected per site. At the laboratory, the specimen is cultured onto the appropriate media. Prepare the site - Proper site preparation is critical to obtain a valid blood culture (BC) specimen. After identifying the site, scrub it vigorously with alcohol to clean 2.5 inches beyond the intended puncture site in each direction. Scrub vigorously for 60 seconds with 2% iodine or a povidone–iodine swab stick. Using a new swab stick, clean the site, moving outward in a concentric circle. An alternative is to use a one-step Medi-flex ChloraPrep applicator instead of the two steps outlined here. Allow the site to dry for 1 minute. This ensures enough time for the antiseptic to kill surface bacteria. Avoid touching the site once it has been cleaned. If you must touch it, reclean the site afterward. Prepare your collection equipment - After removing the cap of the collection container, clean the top of container with iodine or alcohol, depending on your institution’s protocol (rubber tops are usually cleaned with alcohol). Place a clean alcohol pad on top of each bottle until it is inoculated. Immediately before inoculation, wipe the top with the pad to prevent iodine contamination of the sample. Be sure not to touch the bottle tops directly, and allow to dry. Collect the sample - Reapply the tourniquet, and perform the venipuncture. Collect two samples. Fill containers to the minimum/maximum fill line. Accurate recovery of pathogens depends on having an adequate blood volume. Label one “anaerobic” and the other “aerobic,” and indicate the site of the puncture. (Remember that for a syringe collection the first sample is anaerobic and the second is aerobic. For a butterfly collection, the first sample is aerobic and the second is anaerobic.) Mix containers thoroughly by inversion. Attend to the patient - After collection, remove the iodine from the patient’s arm with alcohol. Do not touch the puncture site because this could cause stinging for the patient at that site. Check the puncture site to be sure bleeding has stopped. Apply a bandage, using a fresh adhesive bandage or placing adhesive tape over the gauze square. Raise the bed rail if you lowered it. Dispose of all contaminated materials in a biohazard container. Deliver the BC to the laboratory ASAP or STAT. Do not refrigerate. 02 SPECIALTY COLLECTIONS Fasting and Timed Specimens Fasting Specimens Many factors influence the composition of blood, including the food the patient has recently consumed. To minimize the interference of diet on test results, many tests require a fasting specimen, taken when the patient has not had anything to eat or drink (except water) for 8 hours. Caffeine and nicotine are also prohibited during the fasting period, as these are metabolic stimulants. Some test results are more affected than others when a patient has not been scrupulously fasting for at least 8 hours, especially glucose, triglycerides, lipids, and cholesterol. If a fasting specimen is requested, the phlebotomist must ask the patient if he or she has had anything to eat or drink other than water, or has had any caffeine or nicotine, within the past 8 hours. It is better to ask the question in that form, rather than to ask, “Have you been fasting for 8 hours?”, because some patients may not consider an evening snack or morning juice to be a violation of their fast. If the patient has violated the fast, you can still draw the sample, but make a note on the requisition. You may also contact your supervisor to see whether the physician should be notified before the draw. Often, the physician will reschedule the laboratory work, particularly if a lipid profile is ordered. Timed Specimens Timed specimens are collected at specific times to determine changes in the substances of interest over time. Timed specimens are collected to monitor normal diurnal variation of various substances throughout the day. metabolism of a dietary component, such as carbohydrates. cardiac enzymes, used to rule out or diagnose myocardial infarction (heart attack). These are tested at admission and then twice more at 8-hour intervals. medication levels, such as coumadin or heparin. changes in a patient’s condition because of treatment (e.g., hemoglobin or arterial blood gas). The request for the collection of a timed specimen should state exactly when the sample should be taken. If the specimen is collected before or after the requested time, the results will not be accurate. This can result in improper treatment for the patient. It is critical that the actual collection time is accurately recorded on the tube and the requisition. Diurnal Variation Diurnal variation refers to the normal daily fluctuations in body chemistry related to hormonal cycles, sleep–wake cycles, and other regular patterns of change. Many substances in the blood, especially hormones, show diurnal variation, or regular changes throughout the day. Cortisol, for instance, is usually twice as high in the morning as in the late afternoon. The time for the draw is usually scheduled for the diurnal peak or trough. Cortisol is usually drawn between 0700 and 1000 (7 a.m. and 10 a.m.), or within 1 hour of waking up. The afternoon draw is scheduled for between 1500 and 1700 (3 p.m. and 5 p.m.). Therapeutic Drug Monitoring Patients differ greatly in the rate at which they metabolize or excrete medications. In addition, the “margin of safety,” or the difference between the level at which a drug is therapeutic and the level at which it becomes toxic, may be narrow. To maintain constant therapeutic plasma drug levels and ensure that the drug does not reach toxic levels, a patient may require timed specimens to measure the levels of the medication. This is known as therapeutic drug monitoring (TDM). Results of TDM are used by the pharmacy to adjust drug dosing. The rate of metabolism is often given in terms of the drug’s half-life, the time for half of the drug to be metabolized. Drugs with long half-lives, including digoxin, often require only one timed specimen. Drugs with short half-lives, such as the aminoglycoside antibiotics (including gentamicin, tobramycin, and vancomycin) require the most careful monitoring. Monitoring for these rapidly metabolized antibiotics is done with a pair of specimens, known as a peak and a trough. Collection is usually timed to coincide with either the trough or the peak serum level. The trough level is the lowest serum level and occurs immediately before administration of the next dose of medication. The requisition will specify the actual collection time, which is usually 30 minutes before the dose. The peak level, or highest serum level, occurs sometime after the dose is given; exactly when depends on the characteristics of the drug, the patient’s own metabolism, and the method of administration. The peak level is typically drawn from 30 minutes to a few hours after administering the drug; the tube should be labeled with the draw time in all cases. Careful attention to the correct timing of draw, and accurate labeling, are vital to the patient’s health. TDM results are needed promptly, because the pharmacy is usually waiting for the results of the peak and trough to determine both the timing and the dose of drug. By properly timing the administration of medications, the doctor can have the maximum beneficial effect with the fewest side effects. Most TDM samples need to be collected in a red top tube because the gel in a serum separator tube interferes with the analysis of the drugs. Diabetes Testing Patients with diabetes have dysfunctional glucose metabolism, causing persistent high blood glucose (hyperglycemia). The level of glucose that enters cells is controlled by the hormone insulin. When insulin is not present, or when cells cannot respond to the insulin that is present, diabetes may occur. There are four major types of diabetes: type 1, caused by autoimmune destruction of insulin-producing cells in the pancreas; type 2, caused by resistance of the body’s cells to the effects of insulin; gestational diabetes, affecting pregnant women; diabetes caused by other causes. According to the Centers for Disease Control and Prevention, more than 30 million adults in the United States have diabetes, and every year 1.5 million new cases are diagnosed. In addition, more than one-third of adults have prediabetes, or high blood sugar that often leads to diabetes. Diabetes affects many organ systems, causing blindness, kidney disease, and heart disease. Impairment of the circulatory system damages tissues and can lead to the need for amputation of distal extremities. Diagnosis of diabetes or prediabetes relies on the results from four tests: glycated hemoglobin (A1C), fasting glucose, random glucose, and oral glucose tolerance test (OGTT). Depending on the results, the patient will be classified as normal, prediabetic, or diabetic. Hemoglobin A1C Test - The results of this test reflect the average blood glucose over 2 to 3 months. The test does not require fasting and can be drawn as a random sample. It is used with a fasting sample in screening undiagnosed patients. Fasting Glucose Test - This is a fasting sample, drawn in the morning, before the patient eats breakfast. Abnormal results are verified by redraw and repeat analysis. Random Glucose Test - This sample can be drawn at any time, without regard for meals. Oral Glucose Tolerance Test - The OGTT tests for both diabetes and other disorders of carbohydrate metabolism. The test measures the change in blood glucose after drinking a very sweet solution. Hyperglycemia, or abnormally elevated blood sugar, is most commonly caused by diabetes; hypoglycemia, or abnormally lowered blood sugar, may be caused by one of several endocrine disorders or other metabolic disruptions. The OGTT has fallen out of general use for the diagnosis of diabetes, and has been replaced by either the hemoglobin A1C or a fasting glucose sample. Glucose tolerance testing is still widely used in pregnant women, to diagnose gestational diabetes. Gestational diabetes is a form of insulin-resistant diabetes that develops in almost 20% of women late in pregnancy. The initial screen is a 1-hour OGTT, performed without fasting. The patient drinks an intensely sweetened liquid, and a sample is taken 1 hour later. Additional samples may be taken at later intervals. Elevated glucose in the sample indicates potential gestational diabetes. That finding usually prompts the physician to order a second OGTT, this one taken after overnight fasting. Patients will be instructed by their physicians regarding pretest preparation, which includes eating high-carbohydrate meals for several days and then fasting for 12 hours immediately before the test. Testing begins between 0700 and 0900, with the collection of a fasting blood specimen and sometimes a urine specimen. These specimens should be tested before the OGTT proceeds. In the event that the glucose level is severely elevated, the physician may decide not to proceed with the test. The patient then drinks a standardized amount of glucose solution within 5 minutes. Timing for the rest of the procedure begins after the drink is finished. The phlebotomist makes a collection schedule. The first collection is 1 hour after glucose ingestion. The second collection is 2 hours after glucose ingestion, and so on, for the number of hours the physician has indicated. Note that some procedures may call for collection of the first sample at 30 minutes after ingestion of the glucose solution, followed by another collection 30 minutes later at the 1-hour mark, and then hourly samples after that. Follow the protocol of your facility. The phlebotomist gives the patient the collection schedule and instructs the patient to return to the collection station at the appropriate times. Patients should also be instructed to continue to fast and drink plenty of water so that they remain adequately hydrated throughout the test. Some patients do not tolerate the test well. Any vomiting should be reported to the physician ordering the test. If the patient vomits shortly after the test begins, the procedure will have to be started again. All collections should be made on time and using the same collection method (i.e., venipuncture or dermal puncture) and anticoagulant for each sample. A urine specimen may be collected at the same time. Samples should be labeled with the time from test commencement (1 hour, 2 hours, and so forth). Other Tolerance Tests The lactose tolerance test (LTT) determines whether the lactose-digesting enzyme lactase is present in the gut. A 3-hour OGTT is performed first to produce a baseline glucose uptake graph. The following day a lactose tolerance test is performed. The procedure is identical to the OGTT except that lactose is consumed and a tourniquet may not be used when taking the sample. Be sure to follow the protocol for your facility. Because lactose is broken down into glucose and galactose, the timed samples should produce an identical glucose uptake graph. Lower glucose levels indicate a problem with lactose metabolism. Lactose intolerance can also be determined using the hydrogen breath test, which does not require a blood sample. In this test, the patient drinks a lactose solution and then exhales into a collection bag. Hydrogen in the breath is a sign of undigested lactose in the gut. A stool acidity test may be ordered for patients and children who are unable to undergo the other tests. Lactic acid and other acids from undigested lactose can be detected in a stool, or fecal, sample. Blood Donor Collection Blood donation is a vital link in the healthcare system, and the phlebotomist plays a central role in the collection of donated blood. Blood banks collect and store donated blood for use in both emergency and scheduled transfusions. Guidelines for uniform collection procedures and safeguards have been established by the American Association of Blood Banks (AABB) and the U.S. Food and Drug Administration (FDA). Potential donors must be screened to ensure that the donation is not harmful to the donor or the recipient. Donors must be at least 17 years old (16 years in some states), weigh a minimum of 110 pounds, and not have donated blood in the past 8 weeks. Donor screening is usually done by the phlebotomist. All information provided during the screening is confidential. The screening process is performed every time a person donates blood. Screening involves the following: Registration. The donor must provide his or her name, date of birth, address, other identifying information, and written consent. All information must be kept on file for at least 10 years. Interview and medical history. This is done in private by a trained interviewer. All responses are kept confidential. Potential donors may be rejected for a variety of reasons, including exposure to human immunodeficiency virus (HIV) or viral hepatitis, current drug use, or cardiovascular conditions. Physical examination. The donor’s weight, temperature, blood pressure, pulse, and hemoglobin level are determined. Hemoglobin is usually measured with a drop of whole blood from a dermal puncture. A hematocrit may be substituted for the hemoglobin determination. Collection Procedure Blood is collected by the unit, whose volume is 400 to 500 mL, or approximately 0.5 L. It is collected directly into a sterile plastic bag, which hangs below the collection site and fills by gravity. The weight of the filled bag triggers a clamp that stops the collection. A 16- to 18gauge needle is used for collection. This large needle speeds the collection and prevents hemolysis. A large vein in the antecubital area is used for donor collection. The site is cleaned first with soap and water and then with iodine. After the puncture, the needle is secured to the arm with tape to prevent motion during the collection. The donor is instructed to pump his or her fist to increase flow. (Hemoconcentration may result from this action, but this is not a concern with blood collected for transfusion.) The phlebotomist stays with the donor during the collection and observes for any signs of distress, anxiety, or pale skin. After needle removal, the phlebotomist instructs the patient to apply firm pressure to the site and bandages the site when the bleeding has stopped. Autologous Donation An autologous donation is blood donated by a patient for his or her own use later. Patients planning surgery can elect to make autologous donations before the procedure. This requires a written order from the patient’s doctor. Autologous donation may reduce the likelihood of complications and may be especially useful for patients with rare blood types. Because multiple units might be needed during surgery, patients may donate several times every 3 to 7 days. The patient’s hemoglobin/hematocrit must be measured before the autologous donation. The hemoglobin must be at least 11 g/dL and the hematocrit must be at least 33%. The patient may be able to donate blood up to 72 hours before the surgical procedure. Therapeutic Phlebotomy Therapeutic phlebotomy is the removal of blood from a patient’s system as part of the treatment for a disorder. The principal disorders treated by therapeutic phlebotomy are polycythemia, a disease characterized by excessive production of red blood cells (RBCs), and hereditary hemochromatosis, an excess of iron in the blood. In both cases, periodic removal of a unit of blood may be part of the treatment program. Because such a large volume (500 mL) must be removed, therapeutic phlebotomy is performed in the donor center, although a special area may be set aside for this purpose. This blood cannot be used for transfusion in most instances. Special Equipment Used in the Intensive Care Unit and Emergency Room Patients in the ICU or ER are likely to have some type of vascular access device (VAD) or indwelling line in place that may affect your collection. A VAD is a tube that is inserted into either a vein or an artery and is used to administer fluids or medications, monitor blood pressure, or draw blood. Blood collection from a VAD is done only by trained personnel on the physician’s order. The phlebotomist may be asked to assist with the collection or handle the sample after collection. Understanding the types of devices and the requirements they impose will improve your ability to work in these areas. Types of Vascular Access Devices The name of the VAD is based on the location of the tubing in the vascular system. A central venous catheter (CVC), also called a central venous line, is the most common type of VAD. Central refers to the large veins emptying into the heart, into which the CVC is inserted. CVCs are most commonly inserted into the subclavian vein and then pushed into the superior vena cava, proximal to the right atrium. Access is gained through the several inches of tubing that sit outside the entry site. Types of CVCs include Broviac, Groshong, Hickman, and triple lumen. An implanted port is a chamber located under the skin and connected to an indwelling line. This reduces the risk of infection. To access this device, a noncoring needle is inserted through the skin into the chamber, through a self-sealing septum. A peripherally inserted central catheter (PICC) is threaded into a central vein after insertion into a peripheral (noncentral) vein, usually the basilic or cephalic, accessed from the antecubital area. PICCs are most commonly used in angioplasty procedures, in which the lumen of an obstructed central vein is rewidened. They are not used for drawing blood, however, because the tubing collapses easily when aspirated. An arterial line is placed in an artery for continuous monitoring of blood pressure or frequent collection of samples for blood gas testing. The radial artery is the most common site; the brachial, axillary, and femoral arteries are alternative sites. A heparin lock or saline lock is a tube temporarily placed in a peripheral vein to administer medicine or draw blood. A winged infusion or IV catheter set connected to the tubing provides the venous access; the other end has a port with a rubber septum through which a needle can pass. These devices are most commonly inserted in the lower arm just above the wrist and may be left in place up to 48 hours. To prevent a clot from blocking the line, it is flushed with either saline or heparin just before and after the procedure. Saline is becoming the more frequent choice over heparin. An arteriovenous (AV) shunt is an artificial connection between an artery and a vein. AV shunts in the lower arm are used for dialysis patients to provide access for blood removal, purification, and return. Venipuncture should not be performed on an arm with an AV shunt. Nor should the arm be used for taking blood pressure or for any other procedure that would impair circulation. An external AV shunt consists of a cannula with a rubber septum through which a needle may be inserted for drawing blood. An internal AV shunt consists of a fistula, or permanent internal connection between the artery and the vein, using the patient’s tissue, a piece of bovine tissue, or a synthetic tube. An arm containing a fistula is used for phlebotomy procedures only with the physician’s permission. Drawing From a Vascular Access Device As stated earlier, only specially trained personnel can draw blood from a VAD and usually only with the physician’s order. Important considerations in the procedure include the following: Never use a syringe larger than 20 mL, because pulling on the plunger can create enough vacuum to collapse the line. VADs are often periodically flushed with heparin to keep the line open. For this reason, the first sample of blood collected through the line should not be used. The amount discarded depends on the dead-space volume in the line, the sample type, and the type of VAD. For noncoagulation specimens, discard twice the dead-space volume. For coagulation specimens, discard six times the dead-space volume, or 5 mL. The order of draw should be blood cultures, anticoagulated tubes, and then clotted tubes. Working With Intravenous Lines When a patient has an IV line in place in one arm, blood should be drawn from the other arm whenever possible. If this is impossible, or if there are lines in both arms, the following points should be kept in mind: Have the nurse turn off the IV drip before the draw for the appropriate amount of time for the IV to clear of medications. This may take from 2 to 15 minutes. Apply a tourniquet distal to the IV insertion site. Select a vein distal to the IV insertion site and different from the vein with the IV line. Discard the first 5 mL of blood, because it will be contaminated with the IV fluid. Note on the requisition that the specimen was drawn from an arm with an IV line, identify the IV solution, and note how long the drip was turned off. Once the draw is completed, notify the nurse so that the IV drip can be turned on. 03 SPECIAL CONSIDERATIONS Geriatric Patients With the aging of the population, many of your patients are likely to be geriatric patients. As with infants, collection from geriatric patients presents both physical and psychologic challenges. Working with geriatric patients can also bring considerable rewards for phlebotomists who take the time to get to know their patients as people. You are likely to encounter geriatric patients in all types of facilities, from outpatient clinics to acute treatment hospital wards to long-term care (LTC) facilities, such as nursing homes, assisted living facilities, and rehabilitation settings. Geriatric patients are also the most likely clients in adult daycare settings and home care. Patients in LTC facilities are often coping with the special challenges that have led to the need for institutionalization. These challenges may include chronic illness, loss of mobility, or cognitive impairment or dementia. For some patients, institutionalization may engender feelings of anger, confusion, combativeness, or hopelessness. As a medical professional, your job includes adjusting to the challenges such patients may pose, with professionalism and compassion. Geriatric patients may feel less in control of their medical situations than other patients do, and some may feel apprehensive about having you perform a collection. As you would with any patient, treat your geriatric patients with consideration for their special concerns and needs. A little extra tender loving care (TLC) goes a long way in this population. You can help ease their anxiety by being friendly, empathetic, and cheerful. Taking the time to listen to your patients and to talk with them can make the experience not only easier for both of you but also more rewarding. Physical Changes As people age, their bodies undergo a number of changes that may have an impact on the safety and effectiveness of normal collection procedures. Skin changes are among the most important. The amount of collagen in the skin is reduced, so the skin becomes less elastic, and the layers of skin become thinner. Bruising is more likely, and it takes longer to replace cells, so longer healing times are needed. Blood vessels too, become less elastic and more fragile because of a reduction in collagen. The veins are easier to see since the skin is thinner, but harder to anchor because of loss of collagen and elasticity. Vessels may narrow because of atherosclerosis. Loss of supporting connective tissue leads to “loose skin,” and loss of muscle tissue may allow veins to move from their usual locations, so the skin needs to be held very taut when anchoring the vein during venipuncture. Veins also are often closer to the skin; therefore the penetration angle of the needle needs to be reduced. Arteries are often closer to the surface in geriatric patients. Do not mistake an artery near the surface for a vein. Before sticking it, check your target “vein” to make sure it is not pulsing. Common Disorders Many conditions in geriatric patients may lead to the need for assistance in the draw, whether from other staff or from a family member. Hearing loss is common among geriatric patients. Begin your encounter with a patient by speaking slowly and deliberately to be sure the patient understands. (However, do not continue using this style once the patient clearly indicates that he or she understands your normal speaking voice.) Visual impairment is common, and may impair the patient’s ability to comply quickly or easily with your requests. Such a patient may need guidance in finding the drawing chair, or returning to the hospital bed before a draw, for instance. A number of conditions, including Parkinson disease and stroke, can lead to unclear speech. Remember that difficulty speaking does not imply difficulty understanding. Arthritis affects a large percentage of geriatric patients. Arthritis may prevent your patient from fully straightening his or her arm or fingers. Do not force a patient’s arm flat; ask if the patient can do this or whether the action is uncomfortable. When the arm cannot be straightened, a butterfly may be useful in the antecubital area. Many patients may be on anticoagulant therapy for previous heart attacks or strokes. Be aware of this possibility, especially because of the delay in clotting time it is likely to cause. These patients have an increased risk of hematoma. Poor nutrition or chronic degenerative disease may lead to emaciation. Nutritional status can affect skin health, hemostasis, and ability to tolerate blood loss. Geriatric patients may also have increased susceptibility to infection caused by disease or loss of immune function with age. Tremor is common in advanced old age and may make it difficult for the patient to hold his or her arm steady during the blood collection process. Mental Impairment Forgetfulness, confusion, and dementia are more common among geriatric patients. These patients may have difficulty communicating and complying with requests and may also be combative. Assistance from a nurse or nursing assistant may be necessary, depending on the patient’s mood and condition. Use the wristband, not the patient’s response, to confirm patient ID. Some patients may be in restraints to prevent them from hurting themselves or others. Be aware of your facility’s policy for use of restraints. Always check with a nurse before loosening restraints. Special Considerations for Blood Collection - Geriatric Identifying the Patient Be especially careful with patient ID. Rely on the ID bracelet if there is any doubt that the patient understands you. Limiting Blood Loss and Bruising Be aware of the frequency of blood draws because the risk for anemia is higher in geriatric patients. If possible, use a winged infusion butterfly with a 23-gauge needle and either a syringe or a small volume tube. Alternatively, use dermal puncture to reduce blood loss and bruising; however, poor circulation may make this inadvisable. Be especially gentle when applying pressure to the finger to avoid bruising. Applying the Tourniquet If you are performing venipuncture, you can apply the tourniquet over clothing to limit bruising. Do not apply the tourniquet as tightly as you would normally, because veins in geriatric patients collapse more easily, and release the tourniquet immediately after inserting the needle. Locating the Vein To improve access and comfort, place the arm on a pillow and have the patient grip a washcloth while the arm is supported on either side by rolled towels. Do not “slap” the arm to find a vein; rather, gently massage the area for several minutes to warm it and improve blood flow. The antecubital fossa may not be the best site. If it is not, look for veins in other locations. Once the appropriate vein is located, cleanse the site with gentle friction in concentric circles, using less force than you would for younger patients. You may need to use several pads to ensure the area is sufficiently cleaned. Performing the Puncture Anchor the vein firmly, as veins have a tendency to roll more easily in geriatric patients. Use a smaller needle or a butterfly and smaller volume tubes for more fragile veins. Do not probe to find the vein. After completing the venipuncture, apply pressure longer to ensure that bleeding has stopped. Patients Requiring Blood Draws for Extended Periods Patients with certain conditions require regular blood testing over an extended, possibly indefinite, period. Conditions can include ; anticoagulation therapy, HIV infection, Hep C infection, Leukemia, Sickle cell disease, and other chronic infections. Frequent blood drawing in these patients often causes the most commonly used sites to become damaged from overuse. The veins may become hardened and difficult to penetrate with the needle, and the skin may develop scar tissue. In some diseases, the trauma to the skin from frequent needle puncture may cause it to become delicate and easily torn. Oncology patients present an added challenge since chemotherapy protocols are given by IV. These treatments cause additional trauma to the veins and skin, making venipuncture more difficult. IV drug use can cause similar damage to veins, it is important to approach any patient with damaged veins with sensitivity and care. For these patients, try to minimize damage to the veins by frequently rotating the sites from which you draw and using the smallest needle consistent with the tests required. Consider hand veins and other sites, but remember that these may require written permission from the physician. If the antecubital vein has already been damaged from overuse, switch to these sites rather than attempting another draw from the damaged area. SOURCE: Warekois, Robin, S. et al. Phlebotomy. Available from: Pageburstls, (5th Edition). Elsevier Health Sciences (US), 2020.