Phlebotomy Lecture by Lorenzo Rodrigo A. Jamer

Venipuncture presentation.

1. Phlebotomy Lecture Lorenzo Rodrigo a. jamer,rmt

2. outline Introduction: Parts of the syringe system + size of needles Definition and purpose of Phlebotomy Phlebotomy kit Steps of phlebotomy procedure + site selection (cephalic – thumb; basilic – pinky) Order of draw and purpose of each tube Fasting period of tests + labelling

3. Other important topics Levels of precautions Handwashing Hemolysis Specimen Rejection Non-blood specimen Patient complications Donning and Doffing

4. Parts of a syringe

5. Size of Needles 16 - Gauge (Blood Donor Collection) 21- Gauge (Routine Venipuncture) 23 - Gauge (Patient with small veins, butterfly)

6. Definition and Purpose of phlebotomy Definition: It is an invasive procedure that invades the body through cutting or puncture, and is performed by a Phlebotomist. Purpose: Obtain blood for patient monitoring, and diagnostic purposes.

7. Phlebotomy kit: Must have Tourniquet Syringes / Evacuated tube system Antiseptics cotton Lancets micropore Sharps disposal Gloves Blood collection tubes Blood culture bottles

8. Steps of phlebotomy procedure 1. Review or prepare the physician order and ensure that it contains all the necessary information. 2. Make sure all of the appropriate supplies are available for the procedure. Prepare the necessary equipment for the procedure. 3. Identify the patient, introduce yourself, and then explain to the patient the procedure. 4. Apply the tourniquet; it should be applied 3-4 inches above the site where the venipuncture. 5. Ask the patient to make a fist.

9. continuation 6. Determine the exact vein location by palpating the antecubital area and clean the said area in a circular motion. 7. Grasp the patient's arm firmly while drawing the patient's skin tautly. Apply the needle, through the skin, bevel up, at a 15-30 degree angle 8. Ask the patient to release his/her fist as soon as the blood is flowing freely. 9. Release the tourniquet. 10. Withdraw the needle from the patient's arm.

10. continuation 11. Place folded cotton over the venipuncture site and apply pressure until the bleeding stops. 12. Discard needles properly. 13. Fill the tubes in the correct order of draw. 14. Accurately label each collected specimen, noting the patient's name and ID number, the time and date of collection, and your initials. 15. Bring the specimen to the laboratory and wash your hands afterwards.

11. Site selection: Antecubital fossa

12. Avoid these areas! Hematomas – Test results may be altered cause blood drawn from a hematoma not as fresh as venous blood. The side of the body that has undergone mastectomy (surgery to remove a breast) – lymph stasis here can affect test results IV sites – when possible, avoid drawing blood from an arm that has an IV in place. If no alternate site is available, be sure to perform specimen collection from a site that is distal to (or below) the IV. The 5 mL of blood should be discarded to prevent interference by the IV medications and fluids.

13. Order of draw

14. BLOOD CULTURE

15. Blood culture Tests: To check if bacteria or fungi are infecting your blood. Additives: Sodium polyanethol sulfonate (SPS) At least two (2) sets of blood cultures should be obtained each set includes : one aerobic one anaerobic bottle Note : use proper, sterile technique to decontaminate the patient's skin before collecting the blood culture. If disinfecting steps are not properly followed, skin bacteria can transfer to the bottle and cause false positive results.

16. COAGULATION TUBE

17. Coagulation tube Tests: Coagulation tests Additives: Sodium citrate Specimen: Plasma Note: Fill the tube completely to maintain the ratio of nine parts blood to one part sodium citrate (e.g., 4.5 mL of blood to 0.5 mL of citrate). Invert three or four times.

18. Serum Separator (SST)

19. Serum separator tube (SST) Additive : Contains separating Gel and Clot Activator Tests: used for various chemistry, serology immunology tests, hepatitis, HIV and endocrinology testing. Specimen: Whole blood / Serum

20. red

21. RED Tests: Chemistry, Serology, blood bank Additives: Clot activators in plastic, none in glass Specimen: Serum Take Note: Plastic tubes should be inverted gently five times. Blood collected in a red-topped plastic or glass tube takes 60 minutes to clot. Serum is separated by centrifugation after clotting.

22. Green (heparin)

23. Green (heparin) Tests: prevents clotting, chromosome testing, ammonia, lactate Additives: Sodium Heparin or Lithium Heparin (anticoagulant) Specimen: Plasma

24. Edta

25. edta Tests: Complete blood count (CBC), erythrocyte sedimentation rate (ESR) – the faster your RBC sink indicates that you have an infection in your body, routine immunohematology testing Additives: EDTA (ethylenediaminetetraacetic acid) Specimen: Whole blood Notes: Dipotassium (Ky) EDTA is spray-dried onto the sides of the tube. This is the form preferred Commonly used for hematology testing of the following tests: CBC, Reticulocyte Count, Erythrocyte, Sedimentation.

26. gray

27. gray Tests: Lactic acid measurement, glucose tolerance test, fasting blood sugar (FBS), blood alcohol levels Additives: Antiglycolytic agent (iodoacetate or sodium fluoride) that preserves glucose, perhaps the anticoagulant potassium oxalate or heparin Specimen: Plasma Notes: Iodoacetates preserves glucose for 24 hours, sodium fluoride preserves glucose for 3 days

28. Labelling of specimen Label tubes immediately after finishing the specimen collection. (In an inpatient setting, tubes should be labeled before leaving the patient’s room.) Specimen labels should contain the following information: - Patient’s full name - Patient’s ID number (if applicable) - Time and date of collection - Phlebotomist’s initials

29. What are tests that require fasting? Fasting blood glucose – measures the amount of glucose (sugar) in your blood to test for diabetes or prediabetes. Typical fasting time: 6 to 8 hours. Lipid Profile – checks the level of cholesterol and other blood fats, like triglycerides. High levels put you at risk for developing heart disease or having a stroke. Typical fasting time: 10-12 hours. Gamma-glutamyl transferase – shows the level of the GGT enzyme in your system. A high reading may indicate liver disease, bile duct problems, or alcohol abuse. Your doctor may ask you to avoid alcohol in order to avoid affecting GGT levels. Typical fasting time: 8 hours.

30. Other important topics

31. Levels of precautions STANDARD PRECAUTIONS - set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin and mucous membrane. Consider every person (patient or staff) as potentially infectious and susceptible to infection. Practice proper hand hygiene. Wear gloves and other appropriate PPE before touching broken skin, mucous membranes, blood or other body fluids or soiled instruments and contaminated waste materials or before performing invasive procedures. Dispose of sharps properly in puncture-proof containers. Practice proper respiratory hygiene and cough etiquette.

32. LEVELS OF PRECAUTIONS TRANSMISSION-BASED PRECAUTIONS - also known as Expanded Precautions (EPs used when the patient is known or suspected of being infected with contagious disease). CONTACT PRECAUTIONS - Infectious agents (bacteria, viruses, or parasites) are transmitted directly or indirectly from one infected or colonized person to a susceptible host. - Wear clean, non-sterile examination gloves when entering the room. - Change gloves after contact with infective material (e.g., fecal materials or wound drainage). - Remove gloves before leaving patient room. - Wash hands

33. LEVELS OF PRECAUTIONS AIRBORNE PRECAUTIONS - Precautions are designed to reduce the nosocomial transmission that can remain in the air for several hours and be widely dispersed. - Wash hands and wear specially fit respirators prior to entering rooms with patients that are suspected of being infected with airborne illnesses. DROPLET PRECAUTIONS - Precautions reduce the risks for nosocomial transmission of pathogens that can cause disease. - Perform hand hygiene and wear a mask upon entering the patient’s room.

34. HANDWASHING

35. HEMOLYSIS - destruction of red blood cells - normally turns plasma and serum bright red or pink. CAUSES: a. needle is up against a vein wall or the plunger is pulled back too hard b. the tube was shaken vigorously c. using a needle that is smaller than 25-gauge

36. Proper technique to prevent hemolysis - Avoid tourniquet application longer than 1 minute - After cleansing with alcohol, allow the site to air-dry - Do not collect a blood specimen in a site that has hematoma - Avoid pulling the syringe plunger back too quickly - When mixing blood in tubes containing additives, gently invert them. Do not shake them vigorously

37. Specimen rejection Improper labeling or identification Hemolysis Expired tubes Using the improper tube for the test that is being ordered Clotting in anticoagulated specimens

38. Specimen rejection Contaminated specimens Insufficient volume of specimen for testing. This is noted as QNS, as “quality not sufficient” Inadequately filled tube (lower than recommended specimen to additive ratio) Incorrect specimen collection time for timed specimens Improper handling (examples: bilirubin specimens that were not protected from the light or specimens delivered to the laboratory at the incorrect temperature) Delayed delivery to the laboratory

39. Non-blood specimen URINE SPECIMEN - Check for clarity, specific gravity, color, pH among other parameters - C&S (culture and sensitivity) testing is used for UTI symptoms and must be a mid-stream clean catch specimen - A major drawback of a 24-hour urine collection is patient cooperation – often patients get tired of participating, and the entire test is then null and void. - Pregnancy testing is used to identify the presence of HCG (human chorionic gonadotropin which is a tissue found in embryos which will be part of the placenta) usually present in body after 10 days post conception. First morning specimen is preferred.

40. continuation Types of Urine Collection: a. Regular voided specimen (random urine specimen) b. Timed specimens - collected at specific times - samples collected over a period of 24 hours in a single container to provide one large specimen. The patient discards the first morning urine., then collects all urine samples for the next 24 hours, ending with the first urine the following morning.

41. continuation c. Midstream - clean catch specimen d. Catharized specimens - collected through use of a catheter that is inserted through the urethra into the bladder. e. Suprapubic specimens, or suprapubic aspiration collections - can only be performed by a physician. These samples are collected through use of a needle inserted through the abdominal wall directly into the bladder.

42. Non-blood specimen STOOL SPECIMENS - collected to test for bacterial or viral intestinal infections. - used to screen for occult blood, indicative of colorectal cancer - samples must be collected in a clean, dry container with a tightly fitted lid.

43. Non-blood specimen SEMEN SPECIMENS - used in fertility testing, to determine the effectiveness of a vasectomy, or for forensic analysis as part of a rape kit. - Patients are advised to abstain from sexual activity or ejaculation for 3 days prior to the specimen collection. - the sample is ejaculated into a sterile specimen cup. - time of the collection is noted, sample is kept warm, close to body temperature, and transported to the laboratory within 30 minutes of collection.

44. Non-blood specimen CEREBROSPINAL FLUID SPECIMENS - referred to as CSF - fluid that circulates in the brain and spinal cord - used to diagnose infections of the central nervous system, such as meningitis - CSF is obtained by lumbar puncture, also called a spinal tap.

45. Non-blood specimen AMNIOTIC FLUID SPECIMENS - found surrounding the fetus in the amniotic sac in pregnant women. - specimens are collected through a special procedure known as an amniocentesis only be performed by a physician. - A needle is inserted through the mother’s abdominal wall and directly into the amniotic sac, from which fluid is removed and transferred into a sterile container.

46. Patient complications a . Syncope - sudden fainting can occur during specimen collection - Do not turn your back on the patient and stay with the patient at least 15 minutes after the blood collection to assure the patient’s safety. - If syncope occurs during collection, end the draw immediately following proper procedure and call for assistance.

47. continuation b. Hematoma - occurs when blood is leaking into the surrounding tissues. - can be caused by advancing the needle too far or at the wrong angle - by failing to apply appropriate pressure after needle withdrawal - by bending the arm at the antecubital area after needle withdrawal. - Not following proper procedure and removing the needle before removing the tourniquet can also cause a hematoma.

48. continuation c. Petechiae - small, red, smooth, hemorrhagic spots appearing on a patient’s skin - indicates that minute amounts of blood have leaked in the skin epithelium. - Petechiae can be caused by applying the tourniquet too tightly

49. continuation d. Excessive bleeding - Coagulation times may vary if the patient is on a blood thinner - Be sure to apply appropriate pressure for a longer period for patients taking anticoagulants. - elderly lead to longer healing times, requiring pressure to be applied for longer periods for these patients after needle withdrawal as well.

50. continuation e. Hemoconcentration decrease in the plasma volume with an increased concentration of cells and molecules may be caused by prolonged tourniquet f. Collapsed vein - Too strong of a vacuum on a small vein may cause the vein to collapse. - To prevent this from occurring, use smaller tubes if possible, or when using the syringe system, pull the plunger gently and slowly.

51. continuation g. Hemolysis - RBC’s are lysed - hemoglobin is released and serum, which is normally straw colored, becomes tinged with pink or red. - drawing blood too quickly into a syringe - excessively or vigorously inverting tubes after collection - using too small a needle with respect to vein size.

52. continuation h. Lack of blood flow - Blood will not flow if a defective evacuated tube without proper vacuum is used. - A complete lack of blood flow indicated that the vein was missed - Intermittent or slow blood flow indicates improper needle position.