PHLEBOTOMY BASICSPHLEBOTOMY BASICS

Janet J. Nelson RN,CMAJanet J. Nelson RN,CMA

OBJECTIVES

After completing this unit the student will be able to:o Define the termso List the components of bloodo Describe how to prepare a patient for a

venipuncture.o Describe how to collect a specimen via

venipuncture.o Describe how to process blood specimens for

testing

TERMINOLOGY• Anticoagulant:substance that prevents clotting

(EDTA and Heparin)• Hematocrit: the % of RBC in blood• Hemoglobin: iron containing protein of blood that

carries oxygen• Hemolysis: breakdown of blood cells• Lumen: the diameter of…. e.g. needle or vein• Phlebotomy: blood collection using venipuncture• Venipuncture: process of withdrawing blood from a

vein

Phlebotomy Whys??

• Webster’s – the act of bloodletting as a therapeutic measure

• To aid in diagnosis of illness

• Monitor effectiveness of treatment

• Screening for absence of illness

What is Blood?

• Thick red fluid flowing through circulatory system consisting of liquid components and cellular components

• Plasma: Liquid part of blood• Serum: Liquid part of blood after

clotting (minus fibrin)• Cells: erythrocytes, leukocytes

and platelets• Volume: approx.10 pints in

average adult

                                         

  

Blood’s Function

• Carries O2 and nutrients to tissue=Artery

• Carries CO2 and waste from tissue=Vein

• Capillary= tiny blood vessels connecting arterioles and venules

• RBC’s composed of Hemoglobin=O2/CO2 carrier

• WBC’s fight infection

• Platelets – Hemostasis/coagulation

To Spin or Not to Spin?To Spin or Not to Spin?

TUBES

TUBE ORDER

• Choice of tube depends on lack of additive or additive.

Blood CultureBlood CultureRed or MarbledRed or MarbledBlueBlueGoldGoldGreenGreenLavendarLavendarGrayGray

Test Requisition

• Computerized• Paper• Must include:

– Patient Name, – Physician Name– Date– Patient ID/age/birthdate – Test request,– Your initials

Patient Identification

• The most critical step in phlebotomy

• Inpatients – Must have correct wristband prior to collection

• Ask patient to state their full name and birth date.

• Match wristband information with test req.

Technology & patient identificationTechnology & patient identification

NEEDLES• Needles vary in length

and diameter

• Diameter is measure in gauge

• The smaller the gauge the LARGER the needle.

• The manufactures use colors to differentiate the gauges.

Basic Phlebotomy Supplies

• Requisition• Gloves• Tourniquet• Needle• Barrel or Syringe• Tubes• Alcohol• Cotton or Gauze• Bandage or Tape

Standard Precautions • Always wear gloves

• Keep needle sterile

• Use proper protective equipment – PPE’s

• Remove tourniquet

prior to removing needle

Never recap needles

Wear glovesWear gloves

Wash hands after Wash hands after every patientevery patient

Dispose of Dispose of equipment properlyequipment properly

The integrity of the specimen

• THE RIGHT PATIENT• THE RIGHT CONTAINER• THE RIGHT TIME• USE CORRECT TECHNIQUE/SITE• LABEL CORRECTLY AND COMPELETLY• AVOID HEMOLYSIS

To begin the phlebotomy procedure:

Exp

lain

“Th

is w

ill n

ot...

Ask

, “Are

you

Mr P

er...

Ask

the

patie

nt to

spel

...

Apply

the

tour

nique

t

0% 0%

88%

12%

1. Explain “This will not hurt”

2. Ask, “Are you Mr Perez?”

3. Ask the patient to spell his last name

4. Apply the tourniquet

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

What do you want to puncture during a venipuncture?

A p

ulsat

ing

arte

ry

A s

mal

l cap

illar

y

A s

tringy

tendon

A s

pongy v

ein

A h

ard v

ein

0%6%

0%

94%

0%

1. A pulsating artery

2. A small capillary

3. A stringy tendon

4. A spongy vein

5. A hard vein

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

A needle’s colored cap indicates:

Gau

ge

Len

gth

Typ

e

Rec

omm

ende

d use

59%

0%

35%

6%

1. Gauge

2. Length

3. Type

4. Recommended use

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Which size needle is best used for a venipuncture?

18 19 22 25 27

24%

6% 6%

12%

53%

1. 18

2. 19

3. 22

4. 25

5. 27

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

What is serum?

Whi

te b

lood c

ells

Red

blo

od bel

ls

Pla

tele

ts

Liq

uid p

art o

f blo

od b...

Liq

uid p

art o

f blo

od af

...

0% 0%

82%

18%

0%

1. White blood cells

2. Red blood bells

3. Platelets

4. Liquid part of blood before clotting

5. Liquid part of blood after clotting

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Technique

1.1.Identify patientIdentify patient2.2.Reassure patient and position armReassure patient and position arm3.3.Assemble equipmentAssemble equipment4.4.Verify order and paperworkVerify order and paperwork5.5.Select vein siteSelect vein site6.6.Apply tourniquet (NO MORE THAN 1 min)Apply tourniquet (NO MORE THAN 1 min)7.7.Vigorously alcohol site/dry with gauzeVigorously alcohol site/dry with gauze8.8.Perform venipuncturePerform venipuncture

Puncture at 15 degree anglePuncture at 15 degree angle

Veins feel soft and bouncy. Blood is dark redVeins feel soft and bouncy. Blood is dark red Veins are more superficial than arteriesVeins are more superficial than arteries Arteries have a pulse and blood is bright or Arteries have a pulse and blood is bright or

scarlet redscarlet red Damage to an artery can endanger distal Damage to an artery can endanger distal tissuetissue

Technique continuedTechnique continued

9. Release the tourniquet9. Release the tourniquet10. Remove needle10. Remove needle11. Gently agitate tube 11. Gently agitate tube 12. Correctly label the tubes12. Correctly label the tubes13. Bandage arm13. Bandage arm14. Dispose of vacutainer/tube & trash14. Dispose of vacutainer/tube & trash15. Deliver sample to lab or prepare 15. Deliver sample to lab or prepare

specimen for lab pickup.specimen for lab pickup.

LABEL THE TUBESLABEL THE TUBES

Patient namePatient name Patient ID (DOB, Age, Bar code)Patient ID (DOB, Age, Bar code) Dr nameDr name Date & timeDate & time TestTest Your initialsYour initials

Special Considerations

• Do not collect above an IV

Avoid Hemolysis

                                                                               

GENTLY agitate tube to mixGENTLY agitate tube to mixAllow blood to enter tube slowlyAllow blood to enter tube slowly

To avoid hemolysis you:

Do n

ot agita

te tu

be

Gen

tly a

gitate

tube

Vig

orousl

y ag

itate

tube

Use

ste

rile

tech

niqu

e...

0% 0%0%

100%1. Do not agitate tube

2. Gently agitate tube

3. Vigorously agitate tube

4. Use sterile technique to acquire specimen

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The best angle of the needle during a venipuncture is:

8-9

deg

rees

15

degre

es

25

degre

es

45

degre

es

90

degre

ess

0%

94%

0%6%

0%

1. 8-9 degrees

2. 15 degrees

3. 25 degrees

4. 45 degrees

5. 90 degreess

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What is NOT included on the tube label?

Dr.

name

Your i

nitial

s T

est

Pat

ient

nam

e an

d ID

Pt b

lood

type

Dat

e & ti

mes

0% 0% 0%

100%

0%0%

1. Dr. name

2. Your initials

3. Test

4. Patient name and ID

5. Pt blood type

6. Date & times

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If the patient has an IV, your BEST choice is to:

Use

oth

er a

rm

Stic

k ab

ove

the

IV

Stic

k bel

ow the

IV

Use

the

foot

Dra

w d

irect

ly fr

om t.

.

65%

6%0%0%

29%

1. Use other arm

2. Stick above the IV

3. Stick below the IV

4. Use the foot

5. Draw directly from the IVs

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Which is NOT important for the quality of the blood sample?

Use

right

pat

ient

Dra

w fr

om c

orrect

site

Use

the

smal

lest

nee

...

Lab

el tu

bes

corr

ectly

6% 0%

94%

0%

1. Use right patient

2. Draw from correct site

3. Use the smallest needle that is possible

4. Label tubes correctly

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What is the next step after filling the tubes?

Rem

ove th

e nee

dle

Rem

ove th

e to

urni

quet

Gen

tly a

gitate

the

tubes

Pre

ss d

own on th

e n...

18%

6%6%

71%

1. Remove the needle

2. Remove the tourniquet

3. Gently agitate the tubes

4. Press down on the needle with gauze pads while removing the needle

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Geriatric Considerations

• Treat elderly as if they were your parents

• Use smaller needles / tubes• Use syringe or butterfly instead

of Vacutainer• Assess hearing acuity• Avoid tape – use “Koban”• Minimize hematomas – apply

pressure longer

Butterfly

Syringe / Butterfly

• Alternative to Vacutainer• Elderly, young, collapsing veins• Using the hand or foot• Acquire adequate amount of blood as you will be

filling tubes after the blood draw• Instill blood into tube at angle to prevent

hemolysis

Heel Collections

Finger PunctureFinger Puncture

Puncture across Puncture across the fingertipthe fingertip Wipe away the Wipe away the first drop first drop Collect in Collect in microtubes or microtubes or capillary tubescapillary tubes

Blood Cultures

• Aseptic Technique

• Cleanse site with 2% Chlorhexidine gluconate or Iodine

• Allow site to dry – do not touch site

• Fill bottles with appropriate volume of blood

Butterflies are used for blood draws:

For t

he el

derly

For t

he yo

ung

For t

he han

d

For t

he wris

t

For a

rteria

l blo

od

20% 20% 20%20%20%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

21 22 23 24 25 26 27 28 29 30

1. For the elderly

2. For the young

3. For the hand

4. For the wrist

5. For arterial blood

Puncture the babies:

Cen

ter o

f hee

l

Lat

eral

sid

e of

hee

l

Toes

Lat

eral

sid

e of

foot

25% 25%25%25%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

21 22 23 24 25 26 27 28 29 30

1. Center of heel

2. Lateral side of heel

3. Toes

4. Lateral side of foot

When drawing a geriatric patient:

Use

a la

rge

lum

en n

...

Apply

pre

ssure

for a

...

Use

sm

all l

umen

nee

... a

& b

a &

c

b &

c

17% 17% 17%17%17%17%

1. Use a large lumen needle

2. Apply pressure for a longer period of time

3. Use small lumen needles or butterfly

4. a & b5. a & c6. b & c1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

21 22 23 24 25 26 27 28 29 30