PHLEBOTOMY FOR HEALTHCARE PROVIDERS

By
KLINS B. OLIVER, RP-RN,KU-RN,UAE-RN,IVTN CCRN, CRNS, CPS

By the end of this training, we are to:

To learn the foundation of Phlebotomy practice.
-History -Anatomy and Physiology

To know what specific skills and ability we are to have in the course of our practice. Indications and Limitations of Phlebotomy Practice

By the end of this training, we are to:

To learn the 3 Basic Procedural Approaches in Phlebotomy and their Scopes
-Venipuncture -Finger Prick -Arterial Blood Gas Sampling -Smearing Microscopical Scope

To learn and master Safety and Infection Protocols along with the Legal Aspects of the Practice

Overview of Phlebotomy

 Phlebotomists they draw blood for laboratory analysis and monitoring. They also handle a wide range of specimens from blood other body fluids. An allied collaborative health provision.

Skills Required
Ability to insert needles quickly and accurately Maintain sterility of the sample Adheres to safety standards and deals with different emergent situations Good bedside attitude Maintains good and accurate records.

History of Phlebotomy
-An in-depth view of the foundations of practice

5th Century B.C.

HIPPOCRATES
4 HUMORS

Blood, Phlegm, Yellow Bile (Chole) Black Bile (Melan Chole)

Middle Ages
Surgeons and Barbers are sought after for Blood Letting services whenever they feel something not good in their body.

18th to 19th Century

Mayflower, Bloodletting was introduced in US. George Washington was the first patient. Drained 16-20oz of blood. Fainting is a sign of affectivity and efficacy of treatment.

1875 1900s Dark Ages

phlebotomy was declared witchcraft and quackery. Collection and draining of blood was considered as a grave offense payable with life.

DEVICES USED IN THE PAST

Spring Loaded lancet first lancet in the 5the Century Fleam 18th 19th Century Scarificators 18th Century Device Flint Cup shallow bowls to catch and drain the blood during the procedure

ANATOMY AND PHYSIOLOGY

Vein and Artery Anatomy and Physiology

Veins are unlike arteries in that they are
1)superficial, 2) display dark red blood at skin surface and 3) have no pulsation

Vein Anatomy

- Tunica Adventitia
- Tunica Media - Tunica Intima - Valves

Tunica Adventitia -the outer layer of the vessel

Connective tissue Contains the arteries and veins supplying blood to vessel wall

Tunica Media -the middle layer of the vessel

Contains nerve endings and muscle fibers

The vasoconstrictive response occurs at this layer

Tunica Intima the inner layer of the vessel

One layer of endothelial No nerve endings Surface for platelet aggregation w/trauma and recognition of foreign object at this level

Valves present in MOST veins

Prevent backflow and pooling More in lower extremities and longer vessels

Vein dilates at valve attachment

Arteries
Walls contains smooth and hard muscles that withstand blood pressure. Transports clean blood away from the heart.(in exemption to the function of the pulmonary artery.

Vein and Artery Cross-section

Vein and Artery Cross-section

Vein and Artery

ARTERIES Transport blood away from the heart. Have relatively narrow lumens and more muscle elastic tissue. Transports blood at higher pressure. Do not have valves. VEINS Transports blood towards the heart. Have relatively wide lumens and less muscle elastic tissue. Transports blood at lower pressure. Contains valves.

BLOOD AND COMPARTMENTALIZATION

FUNCTIONS OF THE BLOOD Transportation of gases, nutrients and waste products Transport of processed molecules Transport of regulatory molecules Regulation of Ph and osmosis Maintenance of body temperature Protection against foreign substances Clot formation

THE SYSTEMIC CIRCULATION

COMPOSITION AND COMPONMENTS PLASMA

Is a pale yellow fluid that consists of about 91% water, 7% proteins and 2% other substances. Water acts as solvent, medium of suspension
Proteins maintains osmotic pressure Ions maintains acid-base balance

COMPOSITION AND COMPONMENTS PLASMA

Ions maintains acid-base balance Nutrients source of energy and the building blocks of more complex molecules Gases involves in aerobic respiration Waste products breakdown of protein metabolism (UREA/AMMONIA SALTS) erythrocytes (BILIRUBIN) and anaerobic respiration (LACTIC ACID) Regulatory substances catalyze chemical reactions.

COMPOSITION AND COMPONMENTS FORMED ELEMENTS

SITES FOR PHLEBOTOMY

Digital Vessels
-Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORT

Metacarpal Vessels
-Located between joints & metacarpal bones (act as natural splint). Formed by union of digital veins.

SITES FOR PHLEBOTOMY

Cephalic (Interns Vein) -Starts at radial aspect of wrist -Access anywhere along entire length (BEWARE of radial artery/nerve) Medial Cephalic (On ramp to Cephalic Vein) -Joins the Cephalic below the elbow bend -Accepts larger gauge catheters, but may be a difficult angle to hit and maintain

SITES FOR PHLEBOTOMY

Basilic - Originates from the ulnar side of the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked because of its location on the back of the arm, but flexing the elbow/bending the arm brings this vein into view

SITES FOR PHLEBOTOMY

Medial Basilic - Empties into the Basilic vein running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters. - BEWARE of Brachial Artery/Nerve

Certain areas are to be avoided when choosing a site:

Extensive scars from burns and surgery - it is difficult to puncture the scar tissue and obtain a specimen. The upper extremity on the side of a previous mastectomy - test results may be affected because of lymphedema.

Certain areas are to be avoided when choosing a site:

Hematoma - may cause erroneous test results. If another site is not available, collect the specimen distal to the hematoma.

Intravenous therapy (IV) / blood transfusions - fluid may dilute the specimen, so collect from the opposite arm if possible. Otherwise, satisfactory samples may be drawn below the IV by following these procedures:

Certain areas are to be avoided when choosing a site:

Cannula/fistula/heparin lock - hospitals have special policies regarding these devices. In general, blood should not be drawn from an arm with a fistula or cannula without consulting the attending physician. Edematous extremities tissue fluid accumulation alters test results.

INDICATIONS FOR PHLEBOTOMY

INDICATIONS
CBC To differentiate bacterial or viral infection LFTs: to determine liver function : to differentiate between diagnosis of cholecystitis & pancreatitis Renal function BUN Creatinine: before giving drugs. Ex. Contrast dye, Gentamycin Cultures To assess Coagulation status Blood typing/RH status

BASIC PROCEDURAL APPROACHES IN PHLEBOTOMY

-Venipuncture -Finger Pricking -Arterial Blood Gas Sampling

Venipuncture

 Other name: Blood-Draw/ Phlebotomy is the process of obtaining intravenous access for the purpose of intravenous therapy or obtaining a sample of venous blood. is one of the most routinely performed invasive procedures and is carried out for two reasons, to obtain blood for diagnostic purposes or to monitor levels of blood components

Potential Complications Bruising or swelling at the site if:

Multiple attempts are made Pressure is not maintained over the site of the following procedure The patient is on anticoagulant or ASA

Hematoma Hemoconcentration Blood Hemolysis

EQUIPMENT
Evacuated Collection Tubes - The tubes are designed to fill with a predetermined volume of blood by vacuum. The rubber stoppers are color coded according to the additive that the tube contains. Various sizes are available. Blood should NEVER be poured from one tube to another since the tubes can have different additives or coatings.

Needles - The gauge number indicates the bore size: the larger the gauge number, the smaller the needle bore. Needles are available for evacuated systems and for use with a syringe, single draw or butterfly system. Holder/Adapter - use with the evacuated collection system. Tourniquet - Wipe off with alcohol and replace frequently

Gloves - can be made of latex, rubber, vinyl, etc.; worn to protect the patient and the phlebotomist. Syringes - may be used in place of the evacuated collection tube for special circumstances.

ORDER FORM / REQUISITION

A requisition form must accompany each sample submitted to the laboratory. This requisition form must contain the proper information in order to process the specimen. The essential elements of the requisition form are:

1. Patient's surname, first name, and middle initial. 2. Patient's ID number. 3. Patient's date of birth and sex. (NOTE NEW GUIDELINES) 4. Requesting physician's complete name. 5. Source of specimen. This information must be given when requesting microbiology, cytology, fluid analysis, or other testing where analysis and reporting is site specific. 6. Date and time of collection. 7. Initials of phlebotomist. 8. Indicating the test(s) requested.

An example of a simple requisition form with the essential elements is shown below:

 Identify the patient. Assess the patient's physical disposition (i.e. diet, exercise, stress, basal state). Check the requisition form for requested tests, patient information, and any special requirements. Select a suitable site for venipuncture. Prepare the equipment, the patient and the puncture site. Perform the venipuncture.

 Collect the sample in the appropriate container. Recognize complications associated with the phlebotomy procedure. Assess the need for sample recollection and/or rejection. Label the collection tubes at the bedside or drawing area. Promptly send the specimens with the requisition to the laboratory.

LABELING THE SAMPLE

A properly labeled sample is essential so that the results of the test match the patient. The key elements in labeling are:
Patient's surname, first and middle. Patient's ID number. NOTE: Both of the above MUST match the same on the requisition form. Date, time and initials of the phlebotomist must be on the label of EACH tube.

Automated systems may include labels with bar codes

Examples of labeled collection tubes are shown below:

PROCEDURE FOR SITE SELECTION

Palpate and trace the path of veins with the index finger. Arteries pulsate, are most elastic, and have a thick wall. Thrombosed veins lack resilience, feel cord-like, and roll easily. If superficial veins are not readily apparent, you can force blood into the vein by massaging the arm from wrist to elbow, tap the site with index and second finger, apply a warm, damp washcloth to the site for 5 minutes, or lower the extremity over the bedside to allow the veins to fill.

PERFORMANCE OF A VENIPUNCTURE
Approach the patient in a friendly, calm manner. Provide for their comfort as much as possible, and gain the patient's cooperation. Identify the patient correctly. Properly fill out appropriate requisition forms, indicating the test(s) ordered. Verify the patient's condition. Fasting, dietary restrictions, medications, timing, and medical treatment are all of concern and should be noted on the lab requisition.

Check for any allergies to antiseptics, adhesives, or latex by observing for armbands and/or by asking the patient. Position the patient. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm. Apply the tourniquet 3-4 inches above the selected puncture site. Do not place too tightly or leave on more than 2 minutes.

The patient should make a fist without pumping the hand. Select the venipuncture site. Prepare the patient's arm using an alcohol prep. Cleanse in a circular fashion, beginning at the site and working outward. Allow to air dry. Grasp the patient's arm firmly using your thumb to draw the skin taut and anchor the vein. The needle should form a 10 to 15 degree angle with the surface of the arm. Swiftly insert the needle through the skin and into the lumen of the vein. Avoid trauma and excessive probing.

When the last tube to be drawn is filling, remove the tourniquet. Remove the needle from the patient's arm using a swift backward motion. Press down on the gauze once the needle is out of the arm, applying adequate pressure to avoid formation of a hematoma. Dispose of contaminated materials/supplies in designated containers. Mix and label all appropriate tubes at the patient bedside. Deliver specimens promptly to the laboratory

FINGERSTICK

WHY PERFORM FINGER PRICKS?

Fingersticks (or fingerpricks) are small superficial wounds that provide venous blood for some blood tests. Various methods are used to open the wound, which produces no more than a few drops of blood. The procedure can be painful, but is typically quicker and less distressing than venipuncture. After a droplet has formed, venous blood is sucked up in a capillary tube, usually relying on surface tension, but sometimes by indirect suction.

INDICATIONS
Tests commonly conducted on capillary blood are: glucose levels - diabetics often have a portable blood meter to check on their blood sugar. mononucleosis - fingerstick testing can be used to test for mononucleosis hemoglobin levels - fingerstick testing of hemoglobin is a quick screening procedure to check if a blood or plasma donor has a high enough blood count to be allowed to donate blood or blood components.

INDICATIONS
Tests commonly conducted on capillary blood are: genetic testing - heelprick testing of a newborn's DNA allows for early diagnosis and mitigation of common hereditary disorders. Full CBC (complete blood count) Fingersticks are sometimes done on children and the elderly, when only a small amount of blood (less than 500 g) is needed for a test. Neonates(newborn babies) are given heelpricks instead, as this is less likely to cause permanent damage (and because[vague] babies have very small fingers).

EQUIPMENT
Lancets for pricking either manually or automatically. Lancing Device automatic pricking. Gauze/Cotton balls Gloves Capillary tubes or micro containers

PERFORMANCE OF A FINGERSTICK:
Follow the procedure as outlined above for greeting and identifying the patient. As always, properly fill out appropriate requisition forms, indicating the test(s) ordered. Verify the patient's condition. Fasting, dietary restrictions, medications, timing, and medical treatment are all of concern and should be noted on the lab requisition.

PERFORMANCE OF A FINGERSTICK:

Position the patient. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm. The best locations for fingersticks are the 3rd (middle) and 4th (ring) fingers of the nondominant hand. Do not use the tip of the finger or the center of the finger. Avoid the side of the finger where there is less soft tissue, where vessels and nerves are located, and where the bone is closer to the surface. The 2nd (index) finger tends to have thicker, callused skin. The fifth finger tends to have less soft tissue overlying the bone. Avoid puncturing a finger that is cold or cyanotic, swollen, scarred, or covered with a rash.

PERFORMANCE OF A FINGERSTICK:
Using a sterile lancet, make a skin puncture just off the center of the finger pad. The puncture should be made perpendicular to the ridges of the fingerprint so that the drop of blood does not run down the ridges. Wipe away the first drop of blood, which tends to contain excess tissue fluid.

PERFORMANCE OF A FINGERSTICK:
Collect drops of blood into the collection device by gently massaging the finger. Avoid excessive pressure that may squeeze tissue fluid into the drop of blood.

PERFORMANCE OF A FINGERSTICK:
Cap, rotate and invert the collection device to mix the blood collected. Have the patient hold a small gauze pad over the puncture site for a couple of minutes to stop the bleeding. Dispose of contaminated materials/supplies in designated containers. Label all appropriate tubes at the patient bedside. Deliver specimens promptly to the laboratory.

Specimen handling
Ensure that blood gas samples are free of air bubbles. Place the tube horizontally so that the blood is drawn by capillary action and does not collect air bubbles that can alter results. Apply caps to ends of tube. Capillary blood gas samples should be analyzed within 10 minutes or should be kept horizontally on ice for up to 1 hour, and the tube must be rolled prior to analysis.

ARTERIAL BLOOD GAS SAMPLING

Why do ABGs
Precise measurement of acid base balance of the blood Check lungs ability to oxygenate blood and to remove CO2 Assess respiratory function O2 and CO2 levels determined primarily by the lungs

Puncture Procedure
Check for Orders a. Check for indications and contraindications Indications can be wide and varied No absolute contraindications, mostly just extra precautions and hazards Dialysis shunt choose another site Mastectomy use opposite side Pt on anticoagulant therapy MAY have to hold pressure on puncture site longer than normal includes aspirin therapy

Puncture Procedure
Introduce yourself and explain what is ordered a. Patient cooperation needed to help simplify and minimize pain b. if patient refuses, notify physician Make positive patient I.D. a. Ask patient their name b. Check patient I.D. wristband Put on gloves

Puncture Procedure
Assemble needle to syringe a. Keep needle sterile b. Eject excess heparin and air bubbles, if using syringe with liquid heparin c. Pull back syringe plunger to at least 1cc to give room for blood to fill syringe when puncture is made d. NEVER recap needle

Puncture Procedure
Select Site A. Palpate the right and left radials arterial pulse and visualize the course of the artery. B. Pick strongest pulse 1. Radial artery is always the first choice and should be used because of it provides collateral circulation i. if radial pulse weak on right, move to left ii. if pulse on left weak, then try brachial 2. Brachial used as alternative site 3. Femoral is the last choice in normal situations almost every related complication has been with femoral site usually first choice puncture site in code

Other Puncture Sites:

Puncture Procedure: Allens Test

When using radials, perform Allen's Test for collateral circulation A. In a conscious and cooperative patient: 1. compress ulnar and radial arteries at wrist to obliterate pulse 2. have patient clench and release pulse until hand blanches 3. with radial still compressed, release pressure on ulnar artery 4. watch for pinkness to return should pink up within 10 15 second

Puncture Procedure: Allens Test

B. In an unconscious: 1. compress ulnar and radials 2. elevate hand above head, squeeze hard 3. release ulnar and lower hand below heart Palpate left and right radial arteries noting maximal pulse. The one with the stronger pulse will be your site of entry.

Performing Allens Test

The idea here is to figure out if there is adequate collateral circulation from the ulnar artery to perfuse the hand.

Puncture Procedure
Drape the bed and stabilize the wrist in the position that gives maximal pulse (hyper-extended, using a rolled up towel if necessary) Prepare the site Cleanse the chosen area with a alcohol and/or iodine Secure needle to syringe and remove cap from needle

Puncture Procedure

Puncture Procedure
Pierce the skin at puncture site keep needle angle constant Bevel of needle up, or into the arterial flow (Bevel faces the heart)

Angle of Entry

Puncture Procedure
Slowly advance in one plane When the artery is punctured, blood will enter the syringe flash

Puncture Procedure
Slowly allow blood to fill syringe if no blood appears, remove, change needles, and start again

Puncture Procedure
Upon removal of the needle, hold pressure on the puncture site for at least 5 minutes. Pressure may need to be held longer (> 5 mins) if the patient is on anticoagulant therapy

Puncture Procedure
Check for: Bleeding movement of fingers and tingling sensation pulse distal to puncture
if pulse not palpable, notify physician STAT

Post Puncture Procedure

Remove any air bubbles from sample and cap syringe Dispose of needle in sharps container Roll syringe to mix heparin with sample Immerse in ice On lab slip indicate: a. FIO2 b. patient temperature c. ventilator parameters Deliver to lab

Complications of Arterial Punctures:

Complications of Arterial Punctures:

Technical Causes of Abnormal Results:

Delay in running sample O2 consumption will continue as will CO2 production pH does what CO2 tells it to do Iced, sample will last an hour without a change in the results un-iced, ABG's can be significantly changed after 10 min Venous sample drawn Usually this in shocky patient that you expect low pressures and dark blood Should doubt when PO2 is significantly lower than expected
draw venous blood to check comparison or redraw sample

Technical Causes of Abnormal Results:

Capillary samples From infants warmed heel CAUTION pay attention to puncture site and sample type ONLY diagnostic values are pH and PaCO2 PaO2 value is NOT diagnostic Heparin Sodium Heparin 1% solution should be use ammonium heparin will alter pH dry lithium heparin is OK
All unnecessary heparin should be ejected from syringe, excess can effect results

Technical Causes of Abnormal Results:

Patient pain a. Can cause hyperventilation or breath holding b. An anesthetic may be injected prior to stick for pain, although this hurts probably as much
Usually 2% lidocaine

CAUTION some people allergic to caines Machine errors a. Improper calibration b. Air bubbles in electrodes c. Torn membranes

SMEARING AND ORDER OF THE DRAW

Indication 1. A blood film or peripheral blood smear is a thin layer of blood smeared on a microscope slide and then stained in such a way to allow the various blood cells to be examined microscopically. Blood films are usually examined to investigate hematological problems (disorders of the blood) and, occasionally, to look for parasites within the blood such as malaria and filaria.

Indication
Blood films are made by placing a drop of blood on one end of a slide, and using a spreader slide to disperse the blood over the slide's length. The aim is to get a region where the cells are spaced far enough apart to be counted and differentiated. The slide is left to air dry, after which the blood is fixed to the slide by immersing it briefly in methanol. The fixative is essential for good staining and presentation of cellular detail. After fixation, the slide is stained to distinguish the cells from each other.

Blood Smearing
1. A single smear can be made per slide (smear running the length of the slide) or two (or even three) smears can share a slide, with the smears running the width of the slide. Putting two smears per slide saves on weight (glass is heavy) for field trips, and storage space. It is easiest to use microscope slides with a frosted end, so that identifying information can be written there with pencil. Warning: Compare different pencils to find one that does not yield labels that rub off or wash off in the methanol dip.

2.

3.

Place a drop of blood approximately 4 mm in diameter on the slide (near the end if one smear is to be made, or at the proper location if two smears are to share a slide).
Spread the drop by using another slide (called here the spreader), placing the spreader at a 45 angle and BACKING into the drop of blood. The spreader catches the drop and it spreads by capillary action along its edge. To make a short smear, hold the spreader at a steeper angle, and to make a longer smear, hold it closer to the drop. Now, push the spreader across the slide; this PULLS the blood across to make the smear. Do not push the blood by having it ahead of the smearing slide! It should take about one second to smear the drop. A smooth action is required, with the edge of the spreader held against the slide. This will yield a nice, even smear.

4.

SAFETY AND INFECTION CONTROL

LEGAL JURISPRUDENCE

SAFETY AND INFECTION CONTROL

Because of contacts with sick patients and their specimens, it is important to follow safety and infection control procedures.

SAFETY AND INFECTION CONTROL

PROTECT YOURSELF Practice universal precautions: Wear gloves and a lab coat or gown when handling blood/body fluids. Change gloves after each patient or when contaminated. Wash hands frequently. Dispose of items in appropriate containers.

SAFETY AND INFECTION CONTROL

Dispose of needles immediately upon removal from the patient's vein. Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or splashing of contents. Clean up any blood spills with a disinfectant such as freshly made 10% bleach.

SAFETY AND INFECTION CONTROL

If you stick yourself with a contaminated needle:
1. 2. 3. 4. 5. Remove your gloves and dispose of them properly. Squeeze puncture site to promote bleeding. Wash the area well with soap and water. Record the patient's name and ID number. Follow institution's guidelines regarding treatment and follow-up. 6. NOTE: The use of prophylactic zidovudine following blood exposure to HIV has shown effectiveness (about 79%) in preventing seroconversion

PROTECT THE PATIENT

Place blood collection equipment away from patients, especially children and psychiatric patients. Practice hygiene for the patient's protection. When wearing gloves, change them between each patient and wash your hands frequently. Always wear a clean lab coat or gown.

LEGAL IMPLICATIONS ON PRACTICE

Maintain principles of Phlebotomy Practice Avoid untoward circumstances that may hover any untoward implications on both health provider and the patient. Maintain adequate health provider patient interaction. Maintain confidentiality. Defer from any deleterious acts that can compromise patient, health provider and institution. Follow guidelines set and practiced by the institution and state/country where you are working.

THANK YOU