phlebotomy

Neerogya Health Care Pvt Ltd Dr Asela

Phlebotomy

Dr. Asela Kalinga Neerogya Health Care Pvt Ltd


What is phlebotomy

• withdrawal of blood from a vein, artery, or the capillary bed for lab analysis or blood transfusion.


Who is a phlebotomist

• Collects blood and other specimens • Prepares specimens for testing

• Interacts with patients & health care professionals• plays a vital role in any health care system

Other medical professionals, including doctors, nurses, technologists, and medical assistants must also be trained to collect blood specimens.


Phlebotomist


Laboratory work flow cycle


What do you keep

• Professionalism• Confidentiality• Attitude• Appearance • Safety


Professionalism


Confidentiality

• All employees are responsible for maintaining confidentiality of medical information


Attitude

• Tone of voice and facial expression will determine how patients respond to you.

• Always be polite, friendly, calm, and considerate.


• polite


• friendly


• calm


• considerate


Appearance • Your personal appearance will also affect the

impression you make. • Comply with your facility’s dress code and

personal appearance policies.


Safety


Anatomy & Physiology


Anatomy is the branch of science concerned with the study of the structure of the body.

Physiology is the branch of science concerned with the study of the function of the body.


• The cardiovascular system consists of the Heart, and Blood Vessels.

• Its main function is circulate oxygenated blood from the lungs to various organs, and return blood depleted of oxygen to the lungs, where it is re-oxygenated.


Structure of capillary


How to select site for bleeding


• Vein should feel like spongy tube.


Blood Components


• Circulating whole blood is a mixture of: • Plasma (which contains fluid, proteins, and

lipids), and • Formed elements, consisting of red cells,

white cells, and platelets.


Whole Blood


RBC


WBC


Platelets


Blood Clot

• When a blood sample is left standing without anticoagulant, it forms a coagulum or blood clot.

• The clot contains coagulation proteins, platelets, and entrapped red and white blood cells.


Plasma


Serum• Serum contains all the same substances as

plasma, except for the coagulation proteins, which are left behind in the blood clot.


Equipments


• Trays• Blood Collection tubes• Syringes• Needles• Lancets• Tourniquets• Sterilization• Bandaging Material• Gloves• Sharp Disposal Container


• Marking Pen• Washing material• Cool box/ Refrigerator


Trays


• Trays should be sanitized daily using appropriate disinfectant

• Kept Organized and well-stocked.


Blood Collection tubes• glass or plastic tube with a rubber stopper.• It has a vacuum so that blood will flow into the

tube. • anticoagulants and/or other chemical

additives. • Rubber stoppers of blood collection tubes are

color coded. • Each type of stopper indicates a different

additive or a different tube type.


Green tube / Lavender

• EDTA to prevent clotting • hematology studies. • Should be completely filled • Must be inverted after filling


“MCV is not influenced by K3EDTA concentrations up to ten times normal, while K2EDTA, at high concentrations, results in a slight increase in MCV, as measured with three of the instruments2”. In addition, it has also been reported that “the difference in MCV between K2EDTA and K3EDTA was more marked under the condition of lower blood pH4”.


Red tube• No additives• Blood bank tests, toxicology, serology• Must not be inverted after filing


Light blue• sodium citrate.• coagulation (clotting) studies. • must be completely filled • must be inverted immediately after filling


Function of Sodium Citrate

Sodium citrate act as chelating agent to bind the calcium in the blood.

Calcium need * To make a Plt aggregation * To form fibrin.


ESR tube


Gel & Clot activator


What is gel tube ?

• Gel tubes are Serum tubes, with presence of clot activator and separator Acrylic gel for automatic separation of clot and serum during centrifugation.


Gel Advantages• Gel forms Stable barrier between the Separated serum and clot.

– Prevents interference of substances released from blood clot into serum ( eg : release of K+ / LDH from Lysed RBC’s).

– Gel Serves as excellent tube medium for transportation and storage of Specimen.• Allows use of primary tubes on analyzers.• Allows storage of specimens in primary tubes.• Eliminates time of serum transfer and aliquoting, Hence Improves

turnaround time.• Reduces the risk of contamination and exposure of sample to atmosphere

during multiple transfers.• Reduces waste and contamination• Reduces labeling error, invited by repeated aliquoting.• Eliminates cost of secondary aliquot assembly - Aliquot tubes, transfer

pipette tip , Multiple labels.


• Fluoride tube

• Inhibitor for glycolysis + anticoagulant• Sodium Fluride +potassium oxalate. • glucose levels.


See expiry date on tube


Syringes


Components of syringe


Types of syringe

• Luer lock syringe


• Slip tip syringe


• Eccentric tip syringe


• Catheter tip syringe


Needles


Components of needle


Colour code


Butterfly Needle


• Winged infusion set• Difficult venupuncutre including pediatric

draws• with a syringe or a holder and vacuum

collection tube system. • 21, 23, or 25 gauge• number-one cause of needlesprik injuries, so

proper use of their safety devices is critical.


Lancets


• Lancets are used for difficult venupuncutre, including pediatric draws.


Tourniquets


• Vein easier to SEE, FEEL, and PUNCTURE


Sterilization


Bandaging Material


Gloves

• Gloves must be worn for all procedures requiring vascular access.

• Non-powdered latex gloves are most commonly used;


Collecting of blood sample


Greeting

• Always greet patient in a professional, friendly manner.

• A good initial impression will earn the patients trust, and make it easier and more pleasant to draw a good specimen.

• Knock on the patient’s door before entering. • Identify yourself by name and department. • Explain the reason for your presence.


• The more relaxed and trusting your patient, the greater chance of a successful atraumatic venupuncutre.

• Good verbal, listening, and nonverbal skills are very important for patient reassurance


Identification of patient• Make sure the name, medical record number,

and date of birth on your order/requisition match those on the patient’s armband.

• Verify the patient’s identity by politely asking them to state their full name.

• Properly identifying patients and specimens is probably the single most critical part of your job.

• The consequences of misidentifying a specimen can be life threatening.


• Never rely on the patient name on the door or above the bed. Patients are frequently moved from room to room.


Standard Precautions

01. Hand wash


Proper method


Applying glovesPatients are often reassured that proper safety measures are being followed when gloves are put on in their presence.


Positioning the Patient


• Comfortable position• Turn the arm so that the wrist and palm face

upward, and the antecubital area is accessible• When supporting the patient’s arm, do not

hyperextend the elbow. This may make vein palpation difficult.


Applying the tourniquet• Tie the tourniquet just above the elbow.


• The tourniquet should be tight enough to stop venous blood flow in the superficial arm veins


• The tourniquet should be applied a maximum of 1 – 2 minutes, approximately 2 to 3 inches above the antecubital fossa


• After applying the tourniquet, you may ask the patient to make a fist to further distend the arm veins


• Patients often think they are helping by pumping their fists

• This is an acceptable practice when donating blood, but not in sample collection as this can lead to haemoconcentration


Preferred sites• The median cubital vein • Cephalic vein, or the Basilic vein.


• Veins on the back of the hand.• Use a much smaller needle for these hand

veins.


• Using the nondominant hand routinely for palpation may be helpful when additional palpation is required immediately before performing the puncture.

• Often, a patient has veins that are more prominent in the dominant arm.


Never draw from these areas

• Scarred, abraded, or inflamed skin


• Arms containing IV catheters


• Oedematous arms


• Occluded Veins• Shunts


Cleansing the site

• Isopropyl alcohol swab • Outward expanding spiral starting with the

actual venupuncutre site.• Allow the alcohol to dry:- 1-disinfect the site 2-prevent a burning sensation


Hold vein in place


• Insert needle


• Gently push the tube onto the needle holder so that the catheter inside the needle holder penetrates the tube.

• Blood flow should be visible at this point.


Blood won’t flowIf you do not see blood flow, the tip of the

needle:

1. May not yet be within the vein.2. May have already passed through the vein.3. May have missed the vein entirely.4. May be pushed up against the inside wall of

the vein.


Incomplete collection or no blood is obtained

• Change the position of the needle. Move it forward (it may not be in the lumen)


• or move it backward (it may have penetrated too far).

• Adjust the angle (the bevel may be against the vein wall).


• Loosen the tourniquet. It may be obstructing blood flow.

• Try another tube. There may be no vacuum in the one being used.

• Re-anchor the vein. Veins sometimes roll away from the point of the needle and puncture site.


Other Problems • A hematoma forms under the skin adjacent to

the puncture site - release the tourniquet immediately and withdraw the needle. Apply firm pressure.


• The blood is bright red (arterial) rather than venous. Apply firm pressure for more than 5 minutes


Removing the Needle• Gently release the tourniquet before the last

tube of blood is filled• Remove the last tube from the needle• Withdraw the needle in a single quick

movement


• Quickly place clean gauze over the site, and apply pressure.

• You may ask the patient to continue applying pressure until bleeding stops.


• Apply pressure to the puncture site and instruct the patient to keep the arm in a straight position. Have the patient hold pressure for at least 3 minutes.


• Take this time to invert any tubes that need to have anticoagulant mixed with the blood.

• Label specimens.


Re-inspect the puncture site to make sure bleeding has stopped, and apply a bandage.


Needle disposal

• Remove the needle from the holder if appropriate, and properly discard it in an approved sharps disposal container.

• Discard all waste and gloves in the appropriate biohazardous waste container.

• Wash hands.


Specimen Labeling

• Label specimens at the bedside according to your institution’s standard procedures, or apply pre-printed labels.

• Proper labelling is the single most critical task you are asked to perform


Proper labelling generally includes• Patient’s first and last name• Hospital identification number• Date & time• Phlebotomist initials• Your institution may provide bar coded

computer generated labels that contain this information.


Labeling Errors• Labeling errors are the most common cause of

incorrect laboratory results.• If detected, the incorrectly labeled specimen

will be rejected.• If undetected, it will produce incorrect results

which might adversely affect your patient’s care


Finger stick-Specimen collection


• A safety Lancet, which controls the depth of incision

• Finger-sticks should not be performed on children under one year of age.

• If possible, use the fourth (ring) finger or the middle finger.

• Many patients prefer that you use fingers on their nondominant hand.

• Choose a puncture site near the right or left edge of the finger tip.

• Clean the site as you would for routine venupuncutre.


• Select a safety lancet appropriate for the size of the patient’s finger.

• You may warm the finger prior to puncture to increase blood flow.

• Make the puncture perpendicular, rather than parallel, to the finger print.

• Wipe away the first drop of blood using gauze to remove tissue fluid contamination.


• Collect blood into an appropriate tube.• Label specimens appropriately.• Make sure bleeding has stopped. Apply an

adhesive bandage if necessary.• Discard sharps appropriately.


Heel stick• Veins of small children and infants are too

small for venupuncutre;• Butterfly needles may be used to collect

venous blood in older children.


Heel stick neonatal blood collection

• These devices are designed to control the depth of incision, since going too deep into an infant’s heel could injure the heel bone, and cause osteomyelitis (bone infection).


• Firmly grasp the infants foot.• Do not use a tourniquet.• The heel may be warmed with a cloth to help

increase blood flow.• Wipe the collection site with an alcohol prep

pad, and allow the alcohol to dry.• Wipe the site with sterile cotton or gauze, to

be sure all the alcohol has been removed.


• Puncture the left or right side (outskirt) of the heel, not the bottom of the foot.

• Wipe away the first drop of blood since it may contain excess tissue fluid or alcohol which could alter test results.


• Collect the blood into the appropriate tube.• Do not: Squeeze the infant’s foot too tightly

and wipe with alcohol during the collection


• After collection is completed, apply pressure to the puncture site with a sterile gauze pad until bleeding has stopped.

• Do not apply an adhesive bandage to an infant’s foot since it may injure its delicate skin.


Special situations


• Patients refusing blood work • Fainting• Unsatisfactory Specimens• Haemolysis• Clots• Insufficient volume• Labeling Errors


Patients refusing blood work

• If someone hesitates to let you collect a blood specimen, explain to them that their blood test results are important to their care.

• Patients have a right to refuse blood tests • If the patient still refuses, report and

document patient refusal


Fainting

• Rarely, patients will faint during venupuncutre.

• It is therefore important that patients are properly seated or lying in such a way during venupuncutre so that if they do faint, they won’t hurt themselves.

• self-limited


Signs and symptoms of fainting

• Weakness• Lightheadedness• Nausea• Sweating• Rapid breathing (hyperventilation)• Dimming of vision• Difficulty hearing or ringing in the ears


what to do

• Gently remove the tourniquet and needle from the patients arm, apply gauze and pressure to the skin puncture site.

• Call for help. • If the patient is seated, place his head

between his knees. • A cold compress on the back of the neck may

help to revive the patient more quickly.


If the patient is seated


Get him or her to lie down. (If they are in a situation or place where they really can't lie down then sitting down is the next choice.)Help restore blood flow to the brain by raising the person's legs above the level of the head (about 30cm).

Once the victim is lying down, elevate his feet about 12 inches above the ground.


If someone faints:– Check the ABCs (airway, breathing, circulation), and, if

necessary, begin CPR and call emergency medical services. Continue CPR until help arrives or the person responds and begins to breathe.

– If the person is breathing but unconscious, then put them in the recovery position.

– Loosen constrictive clothing. The person should revive quickly. If the person doesn't regain consciousness within one minute, or if there are any serious injuries as a result of falling from the faint, call for emergency medical assistance. Also call immediately if there are symptoms of stroke (e.g. slurred speech or difficulty moving a limb) after fainting.

– Stay with the person while they are recovering. They may feel tired or weak for several hours afterwards.


Recovery position


Unsatisfactory Specimens

• They can cause misleading laboratory results • Must be rejected by the laboratory. • The patient must then undergo another

venupuncutre to get a better specimen. • It costs time & money to redraw the specimen. • The credibility of the laboratory is reduced if too

many unsatisfactory specimens are drawn.


Haemolysis• Haemolysis means the breakup of fragile red

blood cells within the specimen, and the release of their hemoglobin and other substances, into the plasma.

• A haemolyzed specimen can be recognized after it is centrifuged by the red color of the plasma.


Causes of Haemolysis• Using a too small needle for a relatively bigger

vein• Pulling a syringe plunger too rapidly• Expelling blood vigorously into a tube • Shaking a tube of blood too hard.


• Haemolysis can cause falsely increased potassium, magnesium, iron, and ammonia levels, and other aberrant lab results.


Clots• Blood clots when the coagulation factors

within the plasma are activated.• Blood starts to clot almost immediately after it

is drawn unless it is exposed to an anticoagulant.

• Clots within the blood specimen, even if not visible to the naked eye, will yield inaccurate results.


Causes of Clots• Inadequate mixing of blood and anticoagulant• Delay in expelling blood within a syringe into a

collection tube• Inadequate sample


Insufficient volume

• short draws will result in an incorrect ratio of blood to anticoagulant, and yield incorrect test results.

• Short draws can be caused by:• A vein collapsing during phlebotomy.• The needle coming out of the vein before the

collection tube is full.• Loss of collection tube vacuum before the

tube is full.


Labeling Errors

• Labeling errors are the most common cause of incorrect laboratory results.

• If detected, the incorrectly labeled specimen will be rejected.

• If undetected, it will produce incorrect results which might adversely affect your patient’s care.


Causes• Failure to follow proper patient identification

procedure.• Failure to label the specimen completely and

immediately after collection.

phlebotomy

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