PHLEBOTOMY LECTURE NOTES Lets not just take a stab at Phlebotomy Give your best the first time

and every time History of Phlebotomy o 13th Century the European barbers performed therapeutic bloodletting while customers received haircuts. The pole symbolizes the staff the customers grasped during the procedure. o Excessive phlebotomy may have contributed to George Washingtons death, although suffered from a throat infection o Phlebotomy is not considered a cure, however for Polycythemia Vera it is a treatment Phlebotomy Timeline 1970----------1980-------------1990
lab assistants/bottle washers------phlebotomist--------certified phlebotomist----------Move to primary care giver--------PSA performing phlebotomy

Becoming a Phlebotomist Social, Clerical, Technical Skills o Phlebotomy is a link between the patient and the laboratory/Accurate Patient Identification o Apart of the Health Care Team o Work Environment Professionalism o DARR: Discipline, Accountability, Responsibility, Respect o Speak and Act with confidence o Personal appearance: Read the article of the pierced tongue Dress code: clean, neat with hair pulled back o Ethics Moral and legal responsibilities: Care for your patient as you would like to be cared for Codes of Conduct Daily contact with patients May encounter unpleasant, uncooperative, abusive patients: Counter reactions: calm, profession, pleasant Use gentle persuasion, if patient refuses Patient Relations o Bedside manners: Compassion Be organized Introduction Proper Identification Gently awake patient, before puncture Good lighting Patient is in a secured position Proper Phlebotomy Techniques Bandage Patient: papertape or band-aid Patient Rights o Patient privacy Confidentiality Patient refusal: Remind the patient that the procedure will aid in their care Leave the room and return later, once the patient has awaken o Each patient contact can provide an educational opportunity, share what you learn in this training Patient Care Management o Quality Assurance, Quality Improvement, Quality Measures o Take a personal interest in each specimen, consider if the patient was your grandmothers o Quality of the laboratory results depend on the specimen collected from the patientpre-analytical Step in laboratory testing o Give your best the first time and every time Basic Medical Terminology-Refer to definitions

Introduction To Anatomy and Physiology o Circulatory System- refer to diagram o 6 liters=7-9 pints Components: Arteries: triple-walled vessel, very elastic, bright red in color, oxygenated blood Veins: deoxygenated blood, double-walled vessel/thin walls, less elastic Capillaries: bridges between the arteries and veins Blood 45% Cellular 55% Fluids and Plasma Blood cells: WBC, RBC, platelets Refer to text page 8 Blood Components o Whole blood: cells suspended in plasma o Plasma: The fluid portion of anticoagulated blood that is separated from the cells for testing o Serum: The clear fluid portion of clotted blood that has been separated from the cells for testing o 1ml blood=0.5-0.7ml of serum or plasma Case Study/Role Playing Communications: Social skill o Be a Good Listener, this provides a message to the patient that I CARE o Make the patient feel as comfortable as possible during the procedure through explanations o Less Refusals o Instruct the patient that it may cause discomfort Communication with the laboratory Call the laboratory for clarification of laboratory orders Call the laboratory for clarification of specimen collection tubes Contact the laboratory regarding minimum volumes DO NOT DISGARD a sample when in question Communicate to the laboratory any situations that may affect the integrity of the specimen Proper Patient Identificaiton/Specimen Labeling Practices o Identify hospital patient by the hospital identification band o Identify outpatients by asking for the first and last names, as for spelling to verify o Do not perform a phlebotomy on any one that you have not accurately identified o Verify identification of the laboratory orders and pre-printed labels, match the patient identification o Label all specimens at the bedside or at the phlebotomy chairside o Printer Generated Labels: Adhesive labels, more legible, o Be Cautious that all labels have the same name o Ensure your label is CORRECTand the requisition matches Proper placement on the tube-over the preexisting label Below the cap of the tube Unacceptable practices Placement to cover the tube completely Flagging technique Wrapped method o Manual Tube Labeling Full name include Sr. or Jr. Patient number/Hospital number Birth date Date/time drawn and Initials Copy from the Identification Band PRINT LEGIBLY o Blood Bank specimen labeling o Upcoming: bar-coding labels Rejection of Specimen

o Hemolysis: poor technique, not allowing the alcohol to dry, shaking the tube, you must invert 4-5 for proper mixing o Rare: autoimmune hemolytic anemia, transfusion reaction o Extreme hot or cold o Clots: insufficient inverting of the sample o Mislabeling/Incorrect Identification of specimens o Improper tube collection o Overfilling/Underfilling-improper filling of the tube Specimen Handling and Transporting Specimen A must be sample is collected, processed, stored, assayed and transported correctly or results may be invalid. Certain samples: placed on ice, kept at body temperature, and some certrifuged/ frozen immediately o Proper identification before submitting to the lab-recheck o Special Handling o ASAP and STAT o Pneumatic policy-carriers return to the floor immediately o Arrival in the lab Laboratory Requisition o All laboratory test must be requested or ordered by a licensed physician o Lab Order Entry o Special Instruction for specimen collection and test-specific blood tubes o Include Special Comments: difficult draw, drawn from IV site, edematous site Specimen Processing o Received in the lab o Matching requisitions with specimens o Centrifugation o Alliquoting o Distribution to the work areas Additive: A substance that is added to blood tubes for preservation of blood AIDS: Acquired Immunodeficiency Syndrome a disease in which the bodys immune system breaks down. A person with AIDS can develop a variety of life-threatening illnesses and health complications. Anticoagulants: A substance that suppresses, delays or nullifies coagulation (clot formation) of the blood. Anticubital fossa: The region at the bend of the elbow Aphasia: A defect or loss of the power of expression by speech, writing, or signs or comprehension of spoken or written language, due to disease or injury to the brain centers. Artery: Blood vessel in the circulatory system, which distributes blood from heart to the tissues. The arteries are heavy oxygenated and release the oxygen for tissue metabolism. ASAP: As Soon As Possible. A method of prioritizing your workload. Bevel: The slanted point of the needle that punctures the vein as it is inserted Biohazard: Potentially hazardous material. International symbol. Bore: The opening of the needle at the tip of the needle for expelling or retracting fluid Buffy Coat: A cellular portion of plasma that contains white blood cells and platelets Butterfly: A blood collection system for minute or pediatric blood collection Capillary: Minute blood vessels that connect the smallest arteries to the smallest veins CBC: Complete Blood Count Clot: A fibrin mass of cellular elements Clot retraction: A silica material that speeds clot formation Convulsions: An involuntary contraction of the muscles Diurnal: Occurring during the daytime, opposed to nocturnal

Edema: Abnormal accumulation of fluid in cells, tissues or body cavities resulting in swelling Electrolytes: Blood elements which conduct electricity, for example: Sodium, Potassium, Chloride, and Carbon Dioxide Ethics: A code of standards of conduct and moral judgment Fasting: To abstain from food for a given period Gauge of a needle: The diameter of a needle Glucose: Sweet carbohydrate which occurs in nature and is assimilated with animals Hemoglobin: Iron-containing respiratory pigment of red blood cells that function by carry oxygen to the tissues. Hematocrit: Percentage of red cells in a standard volume Hematoma: A swelling of the skin, tissue or organ because of a broken blood vessel Hemolysis/Hemolyzed: Lysis of red blood cells with the release of hemoglobin Interstitial fluid: 15% of total body weight which occupies the spaces between the organs Lancet: A sharp-pointed instrument used to make an puncture or incision Lytes: An abbreviation for Electrolytes Leukocyte: White blood cell Microcollection: Collection of minute samples of blood for analysis Minimum volume: the smallest amount of blood that can be collected for a test Nausea: nau sea (seasickness) A stomach distress with an urge to vomit Nosocomial infection: An infection acquired during a stay in a healthcare facility Palpate: To medically examine by touch Phlebotomy: The taking of blood for transfusion, or diagnosis in the treatment of disease Plasma: The fluid part of blood that suspends the cellular portion Platelets: Round, disk-shape blood components that is important in blood coagulation (clotting) Postprandial: After a meal Random: Without a designated time Requisition: A form documenting the doctors orders for laboratory tests RBC: Red Blood Cells Serum: The fluid expelled after the coagulation STAT: Immediately Syncope: To faint Thrombocytes: Blood platelets Tourniquet: A device to aid in locating veins Vacutainer: A blood tube collection system Vein: Blood vessels that carry blood from the capillaries to the heart Venipuncture: The technique of blood collection by puncturing a vein WBC: White Blood Cell Whole blood: Cells well-suspended in plasma PHLEBOTOMY LECTURE Practical Phlebotomy Safety Universal Precautions o A standard that considers all patients as potentially infectious o A standard when handling all body fluids or unfixed tissues o Gloves are required when performing a venipuncture or skin puncture 1. Wash hands when changing gloves and between patients 2. Wear gloves when there may be a chances of handling body fluids 3. Wear a protective cover or lab coat 4. Wear mask/eye protection 5. Needles and sharps must be disposed in a puncture-resistant sharps container Biohazard Contaminated with body fluids Sharps Container Infection Control o Hand washing: Most important means of controlling the spread of infection. o Lather with disinfectant soap from the wrist to the fingertips

o Shut the facet with paper towel to avoid soiling clean hands o Wash after removing gloves Prevention of the Spread of Infection: Nosocomial Infection o Chain of infection: Source of infection (patient, visitor, staff) o Mean of transporting the organism: phlebotomy tray o Susceptible Host: another patient, staff, family members o To break the spread of infection: Isolation o No eating, drinking, applying cosmetics, handling contacts Material Safety Data Sheet: MSDS Provides employees the information necessary in case of a spill or splatter. To provide the employee with safe working environment. Phlebotomy Equipment: Monday and Tuesday pm Specimen Collection Procedures Minimize the Trauma of Phlebotomy: Strive to give our best the first time, every time Being stuck too many times Enduring the discomfort while the person drawing the blood digs or fishes around for a vein Experiencing excruciating pain Experiencing extensive bruising Collection Complications o Uncooperative Patient: Compassion, kind words, attentive listening will assist in diffusing the anger o Professionalism: I CARE o Thou shalt treat all patients as if they are family. Fainting o Patient is in a safe, secure position. Bed rails up. The prone position in a hospital setting is the safest. Pass out/ Convulsion/Patient is not harmed o Cool compresses on the back of the neck Edema Abnormal accumulation in the interstitial areas o Edematous areas should be avoided because of the contamination/dilution with tissue fluid o Look for alternative site/get assistance if necessary o Note on the requisition if drawn from a edematous site because of no alternative sites Mastectomy o Should not draw from the arm adjacent to the surgery, risk for infection o Double mastectomy consult your ward/nursing manager for their assistance Hematoma Needle has gone through the vein or has not penetrated the upper wall of the vein o Blood collects around the vein and underneath the skin o Remove the tourniquet and withdraw the needle o Apply direct pressure for 2-3 minutes to the puncture site o Inform the patient that there may be bruising continue to place pressure on the site o There may be some discomfort Scarring/Burned Area o Do Not Puncture this area o Induce the risk for infection because the protective skin barrier has been damaged o Choose alternative site Rash/Hives o Do Not Puncture this area o Sting with the application of alcohol o Risk of infection IV Drug User o Do not allow the patient to perform the puncture themselves o Very difficult veins/request assistance Obesity o Veins are usually deep

o Hand may be used as a first choice Reasons for Short Draws o Vein collapses Vein closes the bevel of the needle Palpate the vein above the puncture o Do not Probe, only reposition the needle Reasons for No Flow o Vacuum in the tube has disseminated o Carry extra tubes Specimen Rejection o Specimen is clotted Inadequate mixing Overfilling/inaccurate dilution of anticoagulant Syringe method/delay in the transferring blood from the syringe into the tubes o Hemolysis Poor technique Shaking the tube/ Inversion is the method for mixing the blood with the anticoagulant Mislabeling and Improper identification Special Collection Procedures o Intravenous, arterial, and central venous lines Ask for nursing assistance for flushing the line Potential for contamination/dilution of specimen Draw 7-10 ml before obtaining the volume needed for laboratory testing o Aging Patient Geriatric patient challenges the skills of a phlebotomist. Take extra time in explanation with the geriatric patient this provides comfort and communicates Compassion Be aware of their apprehensions Preparation of the puncture site/susceptible to infection Find the perfect site/lighting is important in the selection of the site Stretch the skin/anchors the vein/loss of connective tissue Apply heat if necessary for dilation of the vein Massage from the wrist to the anticubital Small gauge needle/25 gauge with syringe Bruise easily/apply pressure/papertape and bandaids can cause irritation More susceptible to infection because loss of immune response Blood vessels are less elastic, sclerotic and may yield poor blood flow Transporting Specimens o Doubling bagging o Recheck identification o Sample + requisition=Proper handling o Communicate to the lab o Place in the Red Pneumatic Carriers o Prioritize your workload Laboratory Requisition o LOE: Lab Order Entry o Provides information for minimum volumes, special handling, test-specific blood tubes Laboratory Specimen Processing o Laboratory Tour1. ISOLATION PRECAUTIONS: o Blood and Body Fluid Precautions will be applied to all patients, not just those with diagnosed blood-borne disease such as hepatitis or AIDS. o Additional types of isolation may be required for selected patients, such as respiratory isolation for those with tuberculosis. These precautions would be in addition to the basic requirements for Blood and Body Fluid Precautions. For persons exposed to tuberculosis patients - appropriate

masks, when worn by health care workers or others who must share airspace with a patient who has infectious tuberculosis, may provide additional protection against transmission. A disposable particulate respirator is worn for patients on respiratory isolation. This respirator filters particulates to 1-5 microns and fits snugly around the nose and mouth. All employees who must wear a particulate respirator is required to undergo a medical evaluation and be fit tested prior to entering a respiratory isolation room. o Isolation signs will be posted and supplies provided outside isolation rooms as necessary. changes in isolation procedures. o If contamination of intact skin with blood or body fluid occurs, wash with soap and water. This would not be considered a significant exposure. For needle stick, mucous membrane or wound exposure, wash the infective material first, then supervisor, or manager to report the incident for follow-up. The departmental supervisor should be notified and an incident report completed. 2. SPECIFIC GUIDELINES: o Hand Washing: Frequent hand washing is an important safety precaution, which should be practiced after direct contact with patients and laboratory specimens. Immediately after accidental skin contact with blood, body fluids or tissues, hands or other skin areas should be thoroughly washed with soap and water. If contact occurs through breaks in gloves, the gloves should be immediately removed and hands thoroughly washed. Hands should be washed before eating, drinking, and smoking, applying makeup, changing contact lenses and before and after using the lavatory facilities. Hands should be washed at the completion of work and before leaving the hospital. Hands should be washed before all other activities that entails hand contact with mucous membranes, eyes and breaks in the skin. o Gloves: All phlebotomists must wear gloves while procuring specimens. Gloves must be changed between each patient. Hand washing is not necessary if the gloves remain intact during procedure and through removal. If gloves become grossly contaminated hand should be washed after removal. All laboratory personnel who come in contact with blood and body fluids must wear gloves. Gloves should be removed when visibly contaminated. Frequent hand washing is an important safety practice and should be done after contact with blood and body fluids. Hands should be washed after gloves are removed. o Laboratory coats and gowns: All personnel are to wear either a long-sleeved coat that is buttoned closed or a blue long-sleeved gown that is tied at the back. These garments are to be worn at times when the possibility of blood or body fluids may be splashed on the worker. Coats and gowns must be changed immediately if grossly contaminated with blood or body fluids. If the risk of splashing could occur in the work area the blue gown should be worn which is fluid resistant. If one's personal clothing becomes contaminated the article of

clothing should be removed. Laboratory coat and gowns are not to be worn outside the laboratory. All personnel protective equipment must be removed prior to leaving the work area. o Masks and Goggles or Face Shields: Masks and goggles/face shields are to be worn by those workers while opening tubes of blood or body fluids. When opening tubes of such specimens there is a risk of splatter or aerosolization. Eyeglasses do not provide adequate splash protection. Goggles or face shields should be worn over eyeglasses. Employees required to wear particulate respirators for blood drawing must be fit tested before these masks can be worn. (model 3M 8710) o Specimen Handling: Pouring of a specimen from a cup to a tube or other container is a process that can create an aerosol. To eliminate this potential danger, transport to the lab o Waste and Environmental Sanitation: Solid Waste: All waste that comes in contact with blood or body fluids must be collected in biohazard bags and tied. This waste will be collected by Housekeeping and taken for incineration. Prior autoclaving is not necessary. In the event of an accident or spill, contain and obtain biological spill kit. Sharps: Caution must be used when handling needles, scalpels and other sharp objects. Needles should not be bent, broken or recapped. Needles must be placed in biohazard needle bucket immediately after use; never stick fingers into sharps container. o Disinfection/Decontamination: Spill. Absorb the spilled material with gauze pads or paper towels and discard in red biohazard trash bags. Disinfect the spill site with bleach, freshly made daily, diluted 1:10 (1 part bleach to 9 parts water to give about 5000 mg/L of chlorine). wear gloves during the entire process. . PHLEBOTOMY REMINDERS 1. Employ Universal Precautions: Blood and body fluids from all patients should be considered potentially infectious and adequate barrier techniques should be used to prevent contact with skin or mucous membranes of personnel. Be careful at all times! 2. Obtain Positive Patient Identification - prior to blood drawing procedure. 3. Wear Gloves - during phlebotomy; change when contaminated and between each patient. 4. Wear Buttoned Coats, gowns or aprons during phlebotomy, change when contaminated and do not wear this garment in other areas (i.e., cafeteria, lectures, home, etc.). 5. Wash Hands - when visibly contaminated and after blood draws are completed. 6. Handle Sharps With Caution. Do not recap, bend or break needles - each patient room has sharps container. Use caution in placing sharps in containers. 7. Accurately Label All Specimens At The Bedside - with full name, hospital number, date and technician initials. 8. If An Incident Occurs - (e.g., needle stick), Contact the supervisor and follow-up with Infection Control and Student/Employee Health immediately.

Because prophylactic treatment may be indicated. Copyright 1997 by the Health Science Center of Syracuse. All rights reserved. Please send comments or suggestions to: Jack Gray MT(ASCP), Clinical Pathology, Site Manager.

Last updated: