Phlebotomy Phlebotomy

In the Emergency DepartmentIn the Emergency Department

OBJECTIVESOBJECTIVES

• Identify and verify patientIdentify and verify patient• Assemble suppliesAssemble supplies• Select siteSelect site• Perform venipuncturePerform venipuncture• Label specimensLabel specimens• DocumentDocument

Patient IdentificationPatient Identification

• At bedside, read ID At bedside, read ID braceletbracelet

• CHI’s TWO pt. CHI’s TWO pt. Identifiers are full Identifiers are full name and DOBname and DOB

• If no band, get one If no band, get one before the draw.before the draw.

• Do not draw unless Do not draw unless proper ID!proper ID!

                                  

Bedside IdentificationBedside Identification

• Identification of the patient is critical!Identification of the patient is critical!• At least TWO patient identifiers MUST BE At least TWO patient identifiers MUST BE

USED.USED.• Compare the stickers from the chart to Compare the stickers from the chart to

the patients armband, and ask their the patients armband, and ask their name and birthday.name and birthday.

• Do not drawDo not draw specimens from any patient specimens from any patient who does not have proper ID.who does not have proper ID.

• If question remains, contact the nurse. If question remains, contact the nurse. Report any discrepancy.Report any discrepancy.

Special CircumstancesSpecial Circumstances

• Unconscious Unconscious patient:patient:

• If ID bracelet not If ID bracelet not available, get one.available, get one.

• Use Doe,Jane or Use Doe,Jane or Trauma,Joe 1,2,3 Trauma,Joe 1,2,3 etc.etc.

• Non English Non English speaking or speaking or deaf:deaf:

• Obtain an Obtain an interpreter from interpreter from the foreign the foreign telephone telephone language line or language line or TV.TV.

Special CircumstancesSpecial Circumstances

• Latex allergy:Latex allergy:• Must draw with Must draw with

Latex free Latex free productsproducts

• These include: These include: blue tourniquet, blue tourniquet, blue latex free blue latex free gloves, and paper gloves, and paper tape.tape.

• Ensure a green Ensure a green allergy band is on allergy band is on stating the word stating the word “latex”.“latex”.

Approaching the patientApproaching the patient

• Identify yourself!Identify yourself!• Explain what you Explain what you

are about to do.are about to do.• Tell the pt that Tell the pt that

they will feel they will feel discomfort, but discomfort, but not that it will not not that it will not hurt.hurt.

• No chewing No chewing gum,food, or gum,food, or thermometer thermometer should be in pts should be in pts mouth at the time mouth at the time of venipuncture.of venipuncture.

• Consider the pts Consider the pts age and culture.age and culture.

Semiconscious statesSemiconscious states

• Special care must be Special care must be taken when drawing taken when drawing unconscious, unconscious, semiconscious, or semiconscious, or sleeping patients.sleeping patients.

• Try first to gently Try first to gently wake the pt. wake the pt.

• Anticipate Anticipate unexpected unexpected movements or jerks movements or jerks of the arm.of the arm.

• Request Request assistance if assistance if needed.needed.

• A gauze pad A gauze pad should be readily should be readily available and available and tourniquet quickly tourniquet quickly released in the released in the event of event of dislodgement.dislodgement.

Information regarding the test being drawn must be given according to policy.

General information only may be provided, detailed info related to the test will be given by the nurse or MD.

Do not try to give a detailed explanation of testing and possible implications of results.

Do not draw blood against the pts wishes!

Notify the nurse or MD who will explain the reasons for the tests.

Document reason for delay.

Assemble EquipmentAssemble Equipment

• GlovesGloves• Vacutainer or butterflyVacutainer or butterfly• Tourniquet, Chlorascrub, betadyne, Tourniquet, Chlorascrub, betadyne,

tape, gauzetape, gauze• Blood Collection tubesBlood Collection tubes• Blood transfer deviceBlood transfer device• LabelsLabels

Vein SelectionVein Selection

• Apply tourniquet 3-4 inches above Apply tourniquet 3-4 inches above intended puncture site. Release after 1 intended puncture site. Release after 1 minute.minute.

• Have patient make a fist, no pumping.Have patient make a fist, no pumping.• Select vein only. If an artery is Select vein only. If an artery is

accidentally punctured, apply firm, accidentally punctured, apply firm, direct pressure for 5 min.direct pressure for 5 min.

• Do not select an arm with a pink arm Do not select an arm with a pink arm band (restricted limb).band (restricted limb).

Vein SelectionVein Selection

• Veins should feel like spongy, elastic Veins should feel like spongy, elastic tubes.tubes.

• If it has a pulse, it is an artery, do not If it has a pulse, it is an artery, do not use.use.

• Thrombosed veins feel cordlike and Thrombosed veins feel cordlike and rigid. They should not be used.rigid. They should not be used.

• Palpate and trace the path of the vein Palpate and trace the path of the vein several times with the index finger.several times with the index finger.

• Feet may be used by physician order Feet may be used by physician order only.only.

Special TechniquesSpecial Techniques

• Arm massageArm massage• Tapping vein with fingersTapping vein with fingers• Apply warm, damp washcloth Apply warm, damp washcloth • Lower extrem. over bedsideLower extrem. over bedside• Check other armCheck other arm

Vein ExclusionsVein Exclusions

Extensive scarring

Mastectomy

Hematoma

Fistula, vascular graft

Preferred VeinsPreferred Veins

Veins Arteries

1. Cephalic vein2. Basilic vein3. Median cubital vein4. Median cutaneous nerve5. Lateral cutaneous nerve

Veins Arteries

There are three nerves that enter the anterior compartment: 1) musculocutaneous, 2) median and 3) ulnar. The musculocutaneous nerve is the nerve that supplies the 3 muscles of this compartment but the other 2 nerves are merely passing through to perform their functions in the forearm and hand.

Forearm veinsForearm veins

1. Cephalic vein2. Basilic vein3. Median cubital vein

Venous Layer

Aponeurotic Layer

1. Bicipital aponeurosis2. Biceps tendon

Artery-nerve Layer

1. Brachial artery2. Median nerve

Tendons of the HandTendons of the Hand

Can ya find anything?Can ya find anything?

Cleansing the siteCleansing the site

• Site must be Site must be cleansed to prevent cleansed to prevent contamination of contamination of either the patient or either the patient or the specimen.the specimen.

• Use an alcohol pad. Use an alcohol pad. Cleanse in a circular Cleanse in a circular motion, starting from motion, starting from the center to the the center to the periphery.periphery.

• Allow to air dry.Allow to air dry.

• For blood cultures, For blood cultures, cleanse with cleanse with Chlorascrub Chlorascrub spongesticks for 60 spongesticks for 60 seconds on one side seconds on one side and 60 seconds on and 60 seconds on the other. Let dry.the other. Let dry.

• Cleanse the rubber Cleanse the rubber tops of each cx tops of each cx bottles w/ 2 bottles w/ 2 betadyne snappy betadyne snappy stix.stix.

A tourniquet is used to increase venous filling. This makes the veins more prominent.

Tourniquet Application

Wrap the tourniquet around the arm 3-4 in. above site.

Tourniquet ApplicationTourniquet Application

• Release after no more than one Release after no more than one minuteminute

• Localized stasis or hematoma can Localized stasis or hematoma can occur = high valuesoccur = high values

• Can apply over gown or gauze if pt Can apply over gown or gauze if pt has a skin problemhas a skin problem

Inspect EquipmentInspect Equipment

1. Visually inspect the tip of the needle

2. Move syringe plunger up and down in the barrel to test movement

3. Tap additive tubes to dislodge from walls or stopper

4. Apply gloves

Ready?Ready?

Vacutainer drawsVacutainer draws

• Choose appropriate needle sizeChoose appropriate needle size• Thread the needle into vacutainer Thread the needle into vacutainer

holderholder• Make sure pt arm is in downward Make sure pt arm is in downward

positionposition• Grasp arm firmly. Use thumb to Grasp arm firmly. Use thumb to

draw skin taught. Thumb will be 1-draw skin taught. Thumb will be 1-2” below venipuncture site2” below venipuncture site

Vacutainer collectionVacutainer collection

VenipunctureVenipuncture

• With bevel lined With bevel lined upwards, line up upwards, line up the needle with the needle with the vein and the vein and puncture the vein.puncture the vein.

• Push the needle Push the needle into the the vein.into the the vein.

VenipunctureVenipuncture

• Grasp the flange Grasp the flange of the needle of the needle holder and push holder and push tube forward.tube forward.

• Tube will start to Tube will start to fill with blood.fill with blood.

• It will stop when It will stop when the correct blood the correct blood level is reached.level is reached.

• Do not change Do not change position of tube position of tube until withdrawn until withdrawn from needle.from needle.

• Keep constant Keep constant slight forward slight forward pressure.pressure.

• Be careful not to Be careful not to move needle from move needle from veinvein

VenipunctureVenipuncture

• Mix immediately Mix immediately after drawing after drawing each tube by each tube by gently rotating 5-gently rotating 5-10 times.10 times.

• DO NOT SHAKE!DO NOT SHAKE!

• Insert next tube Insert next tube into holder. into holder.

• Observe CHI order Observe CHI order of draw.of draw.

• Do NOT draw Do NOT draw above a running above a running IV.IV.

Order of DrawOrder of Draw

1. Blood cultures

2. Red-tox screen

3. Blue-coags

4. Yellow-chemistry

5. Green-cardiac

6. Lavender-CBC 7. Grey

TroubleshootingTroubleshooting

• Change position of the needleChange position of the needle• Try another tubeTry another tube• Loosen the tourniquetLoosen the tourniquet• Do not probe.Do not probe.

NO FISHING!

VenipunctureVenipuncture

• CHI policy – Do CHI policy – Do not attempt a not attempt a venipuncture venipuncture more than twice.more than twice.

• Notify the nurse.Notify the nurse.• Notify the lab to Notify the lab to

come over and come over and draw.draw.

• Other Other alternatives:alternatives:

• Safety Lok Safety Lok Butterfly drawButterfly draw

• FingerstickFingerstick• Lower extrem. Lower extrem.

access. (Order access. (Order only)only)

Needle WithdrawalNeedle Withdrawal

• Release tourniquetRelease tourniquet• Ensure pt hand is openEnsure pt hand is open• Place gauze padPlace gauze pad• Remove the needleRemove the needle• Engage safety deviceEngage safety device• Hold pressure 2-3 min. Observe for Hold pressure 2-3 min. Observe for

excess bleeding. Pt. not to bend excess bleeding. Pt. not to bend arm.arm.

Hemolysis in Blood Hemolysis in Blood CollectionCollection

Don’t do it.Don’t do it.

What is HemolysisWhat is Hemolysis

• Rupture or breakage of the red blood cell’s Rupture or breakage of the red blood cell’s (RBC’s) membrane, causing the release of (RBC’s) membrane, causing the release of the hemoglobin and other internal the hemoglobin and other internal components into the surrounding fluid.components into the surrounding fluid.

• Visually detected by showing a pink to red Visually detected by showing a pink to red tinge in serum or plasma. tinge in serum or plasma.

• Common occurrence seen in serum samples Common occurrence seen in serum samples and may compromise the laboratory’s test and may compromise the laboratory’s test parameters. parameters.

Hemolysis Cause and Hemolysis Cause and EffectEffect

• Hemolysis is caused by many Hemolysis is caused by many variables including variables including – Traumatic VenipunctureTraumatic Venipuncture– Improper Handling and Processing of Improper Handling and Processing of

blood tubesblood tubes– Adverse conditions when transporting Adverse conditions when transporting

blood specimensblood specimens

Specimen Collection Specimen Collection TechniqueTechnique

• Vein Size and TraumaVein Size and Trauma– Puncturing small or fragile veins and probing Puncturing small or fragile veins and probing

or “fishing” for the vein can lead to or “fishing” for the vein can lead to hemolysishemolysis

– If a vein is traumatized during puncture, the If a vein is traumatized during puncture, the tube collected may be hemolyzedtube collected may be hemolyzed

– Avoid puncturing sites that have a Avoid puncturing sites that have a hematoma. Hematomas are caused by blood hematoma. Hematomas are caused by blood leaking under the surface of the skin around leaking under the surface of the skin around the vein. If this “old blood” gets into your the vein. If this “old blood” gets into your sample it will cause hemolysissample it will cause hemolysis

Specimen Collection Specimen Collection TechniqueTechnique

• Needle SizeNeedle Size– Using large bore needles can cause hemolysis Using large bore needles can cause hemolysis

by allowing a large amount of blood to by allowing a large amount of blood to suddenly enter the tube with great forcesuddenly enter the tube with great force

– Using needles that are too small causes Using needles that are too small causes hemolysis by forcing blood to travel through a hemolysis by forcing blood to travel through a small opening under great force due to the small opening under great force due to the vacuum suction from the blood tubes.vacuum suction from the blood tubes.

Alcohol PreparationAlcohol Preparation

– Allow alcohol to dry completely prior Allow alcohol to dry completely prior to venipuncture. The needle can to venipuncture. The needle can transfer wet alcohol from the skin into transfer wet alcohol from the skin into the blood sample and cause hemolysisthe blood sample and cause hemolysis

Specimen Collection Specimen Collection TechniqueTechnique

• Under filled TubesUnder filled Tubes– Fill all tube to full capacity to ensure Fill all tube to full capacity to ensure

proper blood-to-additive ratio. Certain proper blood-to-additive ratio. Certain tubes contain additives and in high tubes contain additives and in high concentration due to insufficient blood concentration due to insufficient blood sample these additives will cause sample these additives will cause hemolysis.hemolysis.

Specimen Collection Specimen Collection TechniqueTechnique

• Loose ConnectionsLoose Connections– Ensure that all components are Ensure that all components are

tightened. Loose connection introduce tightened. Loose connection introduce air into the system and cause frothing air into the system and cause frothing in the specimen which will cause in the specimen which will cause hemolysis.hemolysis.

Specimen Collection Specimen Collection TechniqueTechnique

• Extended tourniquet timeExtended tourniquet time

– A prolonged tourniquet time may lead to A prolonged tourniquet time may lead to blood pooling at the venipuncture site, a blood pooling at the venipuncture site, a condition called hemoconcentration. condition called hemoconcentration. Hemoconcentration can cause hemolysisHemoconcentration can cause hemolysis

– Ideally, the tourniquet should be in place Ideally, the tourniquet should be in place no longer than one minute to prevent no longer than one minute to prevent hemoconcentrationhemoconcentration

Specimen Collection Specimen Collection TechniqueTechnique

• Peripheral Catheter CollectionsPeripheral Catheter Collections– Studies show that specimens drawn Studies show that specimens drawn

through an IV catheter are 3 times more through an IV catheter are 3 times more likely to hemolyze than blood drawn likely to hemolyze than blood drawn through a straight venipuncture.through a straight venipuncture.

Specimen Handling Specimen Handling TechniquesTechniques

• Do NotDo Not draw above and IV. draw above and IV.• Mix the tubes through gentle tube Mix the tubes through gentle tube

inversion. inversion. DO NOTDO NOT shake the tubes shake the tubes after collection.after collection.

                                    

        

Why is Hemolysis so Why is Hemolysis so Important?Important?

• Hemolysis can significantly elevate some Hemolysis can significantly elevate some results while significantly decreasing others.results while significantly decreasing others.

Seriously Seriously AffectedAffected

Noticeably Noticeably AffectedAffected

Slightly Slightly AffectedAffected

Potassium (K)Potassium (K)

LDHLDH

ASTAST

Troponin, HGB, Troponin, HGB, PlateletPlatelet

Iron (Fe)Iron (Fe)

ALTALT

T4T4

PhosphorusPhosphorus

Total ProteinTotal Protein

Mg CaMg Ca

Post-carePost-care

• Release Release tourniquettourniquet

• Open pt’s handOpen pt’s hand• Place gauze padPlace gauze pad• Remove needleRemove needle• Bandage the armBandage the arm• Dispose in sharps Dispose in sharps

containercontainer

Labeling SpecimensLabeling Specimens

At the BedsideAt the Bedside

Specimen LabelingSpecimen Labeling

• The patient and patients blood sample The patient and patients blood sample MUST BE POSITIVELY IDENTIFIED AT THE MUST BE POSITIVELY IDENTIFIED AT THE BEDSIDE.BEDSIDE.

• Use TWO patient identifiers – name and Use TWO patient identifiers – name and birth date.birth date.

• Position label over stickered area long-Position label over stickered area long-ways.ways.

• Chill if required (gray) lactic acid or Chill if required (gray) lactic acid or (green) ammonia.(green) ammonia.

DocumentationDocumentation

• Location Location • Number of Number of

attemptsattempts• Name and titleName and title• Time to labTime to lab• Any patient Any patient

commentscomments

• Example:Example:• Blood drawn left Blood drawn left

AC 1AC 1stst attempt. Pt attempt. Pt stated “You are stated “You are awesome!” Blood awesome!” Blood to lab at this time.to lab at this time.

B. Safe, EDT.B. Safe, EDT.

Blood Culture CollectionBlood Culture Collection

• AdultAdult- 2 sets at - 2 sets at different sitesdifferent sites

• One green and one One green and one lavenderlavender

• Green only if not Green only if not enough bloodenough blood

• 8-10 cc per bottle8-10 cc per bottle• PediPedi-one set-one set• Yellow 1-4 ccYellow 1-4 cc

Type and ScreenType and Screen

• BB# band must contain 6 things: BB# band must contain 6 things: • BB#, Pt name, Pt birthday, Date…BB#, Pt name, Pt birthday, Date…• Phlebotomists initials and time.Phlebotomists initials and time.• ID band and Orange Band must match.ID band and Orange Band must match.• Label tube with BB# small stickerLabel tube with BB# small sticker• Send rest of labels to labSend rest of labels to lab

QUESTIONS?QUESTIONS?