Phlebotomy Course - Avalon Medical Educators€¦ · 10:50 – 12:30 Phlebotomy a. Electrolyte...

Avalon Medical Educator’s 1.

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Orlando, Florida 32828

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Phlebotomy Course Thank you for your interest in Avalon Medical Educator’s Phlebotomy Course. It is our goal to make this course a stress free and even fun experience for you. The program is made up of two components: an 8 hour home study section and a 8 hour classroom section, for a total of 16 contact hours at the completion of the program. This program is recommended for medical professionals seeking more confidence in or strong foundations in phlebotomy techniques. The program complies with the requirements defined by the Florida Board of Nursing. Again, thank you for choosing Avalon Medical Educator’s for your educational needs. Before you leave, take a look at the additional training programs we offer. We offer many different training locations and are always willing to bring the training to you. *Refer a friend to the course and receive 10% off your next class with Avalon Medical Educator’s.


Phlebotomy

Day 1 Agenda

9:00 – 9:15 Welcome and Introductions 9:15 – 10:00 Introduction to Phlebotomy

a. Safety b. Resources c. Professional and Legal Standards d. Video

10:40 – 10:50 Break 10:50 – 12:30 Phlebotomy

a. Electrolyte Review b. Fluid Review c. Vascular System Review d. Lab test Review e. Possible complications f. Hands on Vein Selection

12:15 – 1:15 Lunch 1:15 – 3:30 Practical Skill Station 3:30 – 3:40 Break 3:40 – 5:00 Written Exam

a. Exam Review b. Course Evaluation


PURPOSE:

The purpose of this class is to provide the healthcare professional with a brief understanding of all aspects of Phlebotomy including: Reasons for Phlebotomy, safe and professional practice, review of anatomy and physiology as related to phlebotomy, and to teach students how to identify and handle complications of Venipuncture.

OBJECTIVES:

At the conclusion of this course, the learner will be able to:

1. Detail the anatomy and physiology of the skin, venous and arterial systems.

2. Introduce students to the theory and practice of phlebotomy.

3. Teach students how to interact professionally with patients.

4. Teach students about occupational health hazards and appropriate precautions,

including the Needlestick Safety and Prevention Act.

5. Demonstrate equipment and supplies used for Venipuncture.

6. Demonstrate phlebotomy procedures.

7. Explain specimen identification, labeling and processing.

8. Use of proper safety precautions with relation to handling blood and body fluids.

9. Describe the complications associated with Venipuncture and how to treat them.


Legal and Ethical Considerations

The Laws governing medicine and medical ethics complement and overlap each other in many cases. In the past, decisions were made by doctors and other health care professionals; however, consumers and patients have become more aware, more critical and much more willing to sue anyone the lawyer deems is at fault, including the phlebotomist. Therefore, the phlebotomist must act in a professional and respectful manner at all times. He or she must follow the professional code of ethics set by the facility they are employed by and be willing to take responsibility for actions taken. • Statutory laws are written laws enacted by state legislatures and the US congress, up to courts to interpret application of law. • Administrative law is the implementation of statutes and ordinances by the executive branch of government through its departments and agencies. * Judicial law resolves disputes in accordance with laws.

o State and federal trial courts o Appeals courts (intermediate courts) • Supreme court

Common Legal issues when performing phlebotomy include:

• Failure to identify patient. • Failure to identify site. • Failure to label specimen at the bedside. • Failure to state the correct date, time or initials of person performing phlebotomy. • Failure to wash hands. • Failure to use proper aseptic technique. • Failure to apply pressure to site and dressing. • Failure to protect patients from injury. • Injuries to veins, poor selection. • Nerve compromise following blood draw.

l Failure to report any incident makes you just as guilty as the person who actually caused the issue. Most facilities have non-punitive reporting policy in place for patient safety.

Phlebotomists are ethically and legally required to keep patient information confidential.


Please match the following terms with their definitions:

__________Abuse

__________Assault

__________Battery

__________Code of Ethics

__________Consent

__________Ethics

__________Informed Consent

__________Implied Consent

__________Liability

__________Neglect

__________Slander

Definitions:

A. The granting of permission by the patient for another person to perform an act/procedure. B. Injurious, pathological, or malignant treatment of a person or living thing. C. The unlawful touching of another without consent. D. A system of moral principals or standards governing conduct. E. A voluntary agreement made by a well-advised and mentally competent patient. F. Health care provider’s responsibilities, even if not at fault, for any harm or injury to the patient. G. The threat of unlawful touching of another. H. Verbal untruths. I. Nonverbal consent suggested by actions of a patient. J. Failure to adhere to one of the following: duty to act, breech of duty, causation, and damages.


Infection Control

Safety First Bloodborne pathogens are the infectious microorganisms (viruses, bacteria, parasites) living in the blood stream. The Occupational Health and Safety Administration (OSHA) estimates that 5.6 million workers in health care and other facilities are at risk for exposure to bloodborne pathogens. As a health care worker you are at risk of exposure through a needlestick or other sharps injury and blood or fluid spatter/splash to the eyes, mouth, mucous membranes, nose, and open cuts or abrasions. Body fluids include:

• Blood • Saliva • Semen • Vaginal secretions • Cerebrospinal fluid • Peritoneal fluid • Pericardial fluid • Pleural fluid • Amniotic fluid

Although there are several bloodborne pathogens you could be exposed to in the workplace, the most significant are:

• Human Immunodeficiency Virus (H.I.V.) • Hepatitis B (HBV) • Hepatitis C (HCV)

H.I.V. attacks the body’s immune system and may cause Acquired Immune Deficiency Syndrome (AIDS). Currently, there is no vaccine or cure for AIDS. H.I.V. is rarely transmitted via needle stick injury. Only .3%-.4% of those who are exposed via this route will contract the disease. H.I.V. is a fragile virus that doesn’t live long outside of the body. But precautions still must be taken when handling the body fluids of these patients. Hepatitis B (HBV) infects roughly 8,700 healthcare workers every year. 6%-30% of healthcare workers who are exposed to HBV via a needle stick injury will develop the disease. The virus can live on dried surfaces for up to a week. The HBV vaccine is very effective. Hepatitis C (HCV) is the most common bloodborne infection in the United States. More than 4 million people are infected with the virus and many aren’t even aware of it. 3%-10% of those who are exposed to HCV via a needle stick injury or blood spatter to the eyes or an open wound will develop the disease. There is no vaccine against HCV. OSHA has mandated bloodborne pathogen training for all U.S. workers who are at risk for exposure. It also mandates that employers provide personal protective equipment and HBV vaccine free of charge to all employees. The best method of protecting yourself from bloodborne pathogens is to use standard precautions when providing care to your patients. You must treat ALL body fluids and substances as if they were infectious. You must wear the appropriate personal protective equipment with all patient contact.


PPE includes:

• Goggles • Masks • Impermeable gown • Gloves

Hand washing is the beginning of infection control. It can prevent potentially fatal infections from spreading from patient to patient, from patient to health care worker and vice-versa. You must cleanse your hands before and after all patient contact. After applying soap, you must rub your hands together making lather and continue rubbing for 15-20 seconds. To wash for the correct time, sing “Happy Birthday to you” twice! If soap and water are not available, you can use an alcohol based hand rub to clean your hands. These foam gels significantly reduce the number of germs on the skin and are fast acting. But be aware, they do not kill ALL germs, the most prominent being C-diff. In some community hospitals over the last two years, the rate of hospital acquired C-diff infections was 25% higher than MRSA infections. All needles and other sharps (glass ampules, scalpels, etc.) must be disposed of in an approved sharps container. Sharps disposal containers should be:

• Functional – durable, closeable, leak/puncture resistant • Accessible – close to where work is being done • Visible – properly labeled and color coded • Accommodating – conveniently located, easy to reach, and with an opening large

enough for all needles and sharps Never overfill a sharps container or you increase your chances of getting stuck accidentally. Fill only to the indicated line or ¾ of the container, whichever comes first. Tape, bloody gauze, dressings and IV tubing do not belong in the sharps container. These items must be disposed of in an appropriate RED biohazard bag or waste receptacle. In November 2001 the Needle stick Safety Act was passed by Congress. This law mandates that all health care institutions use needles and other sharps that have engineering controls and design features to help prevent accidental needle stick or sharps injury. Even with these controls in place there are 600,000-800,000 sharps injuries every year. The majority of needle stick injuries occur when healthcare workers:

• Dispose of needles • Give injections • Draw blood • Recap needles • Handle trash and dirty linens

This law also requires that healthcare institutions get input from those using the device. Be aware when new needles are being introduced on your unit. Evaluate the needle based on its’ ease of activating the safety device, ease of use, and patient comfort. There are many different safety needles on the market. Become familiar with those used in your institution. Most safety devices will require you to activate the safety feature. These must be used properly, conscientiously, and every single time to prevent injury. Make sure you have read and understand your institutions policy regarding needle stick injury and prevention.


What if you stick yourself with a contaminated needle?

1.) Remove your gloves and dispose of them properly. 2.) Squeeze puncture site to promote bleeding. 3.) Wash the area well with soap and water. 4.) Record the patient’s name and identification number. 5.) Report the incident to your supervisor and follow your institution’s guidelines regarding

treatment and follow-up procedures.

What if you splash blood on your skin or into your eyes or mouth?

1.) Wash the area with generous qualities of water or follow policy and procedure of facility on exposures. Do not use bleach on the eyes or open mucous membranes.

2.) Once stable, wipe up any spilled blood/bodily fluids with towels, using proper standard precautions. This should be done with hospital approved cleaning agents (as per facility policy).

3.) Discard used towels in an appropriate biohazard waste container. 4.) Record the patient’s name and identification number. 5.) Report the incident to your supervisor and follow your institution’s guidelines regaurding

treatment and follow-ups.

Some Common Reasons Why Phlebotomist get Injured

1.) Speeding, rushing or hurrying to complete a task. 2.) Not being mindful of surrounding environment or equipment. 3.) Not foreseeing patient’s actions by looking for cues of anxiety and fear. 4.) Using improper body mechanics. 5.) The use of improper PPE or not using any at all. 6.) Improper disposal of PPE and sharps. 7.) Not following guidelines and the facilities policies.

Phlebotomy

l Phlebotomy, also known as Venipuncture, literally means collecting blood from the veins, therefore a Phlebotomist, by definition, is one who collects venous blood. A phlebotomist is a medical professional who:

– Collects blood and other specimens.

– Prepares specimens for testing.

– Interacts with patients & health care professionals.

An experienced phlebotomist should be knowledgeable in the collection of:


- Venous blood specimens

- Capillary blood specimens

- Blood culture specimens

- Urine specimens

- Throat cultures

- Medico legal specimens requiring chain of custody.

He or she should also know how to:

- Process specimens

- Perform bleeding times, and

- Collection specimens from IV lines and central venous lines, under appropriate supervision.

The phlebotomist collects blood and other specimens which ultimately provide doctors and nurses with laboratory test information critical to patient care. He or she therefore plays a vital role in any health care system.

Phlebotomists work in a variety of settings including:

– Hospitals

– Physician Offices

– Nursing Homes

– Home Health Care

– Clinics, and

– Military facilities.

A well trained phlebotomist will therefore have a variety of job opportunities available. Other medical professionals, including nurses, respiratory therapists, and medical assistants may also be trained to collect blood specimens.


Anatomy and Physiology Review

The skin is the first barrier to a successful venipuncture. The skin acts as a barrier between the outside environment and internal organs. When the barrier is broken, the risk for infection increases. An infusion access device perforates the skin, interrupts the integrity of the barrier, and increases the risk for infection. Any infection in this tissue can spread throughout the body. Strict aseptic technique for venipuncture, care and maintenance of the site is mandatory.

The skin serves multiple functions:

• Acts as a mechanical barrier to microorganisms • Sensory and temperature regulation • Aids in fluid and electrolyte balance

The skin consists of layers:

Epidermis: Composed of squamous cells that are less sensitive than underlying structures, the epidermis is the first line of defense against infection.

Dermis: Much thicker than the epidermis. This layer consists of blood vessels, hair follicles, sweat glands, sebaceous glands, collagen fibers, lymphatic vessels and nerves. The dermis reacts quickly to painful stimuli as well as to temperature changes and pressure sensation. This is the most painful layer during a venipuncture.

To help decrease pain during a venipuncture, penetrate these layers quickly!

The vascular system is made up of blood vessels, which include arteries, arterioles, capillaries and veins. These vessels vary in size and function.

• Arteries carry oxygenated blood away from the heart. The aorta is the largest artery, emanating from the heart. Arteries branch off the aorta. As they branch off the aorta, they decrease in size and become arterioles. Arterioles subdivide into capillaries.

• Capillaries provide nutrients to the tissue and take wastes away. Capillaries connect with venules, which are the smallest veins. The venules connect with larger veins, eventually leading to the vena cava, which is the largest vein and connects directly to the heart.

• Veins carry deoxygenated blood back to the heart. The deoxygenated venous blood is carried to the right atrium through the superior vena cava (SVC) and the inferior vena cava (IVC). The blood enters the right ventricle, exiting through the pulmonary artery to the lungs, where it is oxygenated and carried to the left atrium through the pulmonary veins.


NOTE: The pulmonary artery carries deoxygenated blood and the pulmonary veins carry oxygenated blood; these are the only exceptions to the rule that an artery contains oxygenated and a vein deoxygenated blood.

The vein is the second barrier to successful venipuncture and consists of three layers:

• Tunica adventitia--outer coat, made of connective tissue, which is the support.

• Tunica media--muscle and elastic tissues which causes contraction and dilation.

• Tunica intima--endothelial lining of the vein; a single layer of smooth flat cells lying along the length of the vein, allowing for smooth blood flow; disruption of this layer exposes the basement membrane and the clotting process is immediately begun. Also, when solutions with extremes of osmolarity are infused,fluids shift into or out of these cells, which can cause the inflammatory process to occur. This can lead to phlebitis or thrombophlebitis.

Also in the tunica intima layer are the semi-lunar valves, which are directed toward the heart and prevent blood from flowing toward the extremities. Therefore, the direction of the IV needle should always be toward the heart with the flow of the circulation.

Systemic veins are in two sets: deep and superficial. Deep veins accompany the corresponding arteries and are called venae comites or venae comitantes. The superficial veins commence as a network of small veins just under the skin. Superficial veins in the hand and forearm are the ones most utilized for the initiation of IV therapy. However, upper arm veins can be and frequently are accessed as venipuncture sites.


Functions of the Blood

1.) Transport: to and from tissue cells • Nutrients to cells: amino acids, glucose, vitamins, minerals, lipids (as lipoproteins). • Oxygen: by red blood corpuscles (oxyhemoglobin - 4 x O2 molecules/hemoglobin).

• Wastes from cells: urea, CO2 (mainly as HCO3

- in solution in the plasma).

2.) Temperature Regulation: by altering the blood flow through the skin. 3.) Immunity: protection against pathogens — blood clotting; phagocytes, lymphocytes and antibodies

distributed in blood. 4.) Communication: hormones distributed to all parts of the body in the blood. 5.) Defense: clotting following a wound Composition of Blood Plasma: pale yellow sticky liquid; 55% of blood volume. Components: water 92%, dissolved protein 8%, glucose, amino acids, vitamins, minerals (mainly NaCl), urea, CO2, hormones, antibodies.

Composition of Blood Plasma: pale yellow sticky liquid; 55% of blood volume. Components: water 92%, dissolved protein 8%, glucose, amino acids, vitamins, minerals (mainly NaCl), urea, CO2, hormones, antibodies. Blood Cells Red Blood Cells

• Tiny (8µ) biconcave disc-shaped cells (thus large SA). • Do not have nucleus, mitochondria, ribosomes. • Cell full of haemoglobin – binds O2 (and CO). • Made in the bone marrow – live about 120 days. • Destroyed and recycled by the liver.

White Blood Cells (leucocytes)

• These are colourless cells and possess a nucleus. • They function in defending the body against pathogens. • Phagocytes - ‘granulocytes’ ‘feed’ on pathogens by phagocytosis. • Monocytes are one form of phagocytes. • Lymphocytes – ‘agranulocytes’ - produce antibodies, the specific defence proteins. • Made in bone marrow and lymphatic tissue.

Platelets

• Responsible for clotting of the blood • Responsible for repair of damaged tissue – releasing the hormone platelet growth factor. • Short life – under 7 days. • Made in bone marrow


Blood Vessels Artery v. vein

• The wall of the artery is thicker: thicker connective tissue layer, thicker mixed layer of muscle and elastic tissue.

• The lumen of the artery is much narrower. • Arteries do not have valves along their length, veins do. • Valves in the veins prevent the backflow of blood so the flow is in one correct direction

towards the heart. • Blood flows away from the heart in arteries; blood flows towards the heart in veins. • Blood pressure in arteries is higher and so also the speed of blood flow • Pulsed flow in an artery, steady flow in a vein. • Many tissues, thus both are organs

Arterioles have muscular walls which control how much blood flows to a particular organ – e.g.

• guts after meal, • skin for temperature regulation • muscle when working hard Note: Blood supply to brain is constant!

Capillaries

• Capillaries are the link between arteries and veins – where exchange with tissues occurs. • The capillary wall is one cell thick and somewhat porous — ideal to allow materials to pass

in and out. • All tissue cells very close to a capillary so exchange is very efficient. • Exchange at the capillaries is by diffusion, mass flow and active transport. • Blood flow in capillaries is slow giving enough time for effective exchange. • One type of cell, thus a tissue.

Common Laboratory Tests

There are many lab tests available; however there are a few that you will become familiar with. The most common of these tests are panels or profiles that are each composed of several different lab tests.

A few of the frequently encountered tests are as follows:

CBC (Hemogram) Also known as Complete Blood Count (CBC)

l Blood is tested for quantity and quality of different blood cell types, including:

– White Blood Cells (WBC Count)

– Red Blood Cells (RBC Count)

– Platelets (Platelet Count)


l Blood is also tested for hemoglobin & hematocrit (H&H).

Run on whole blood

Electrolytes panel (Lytes) Blood is tested for the most important electrolytes (salts):

– Sodium (Na)

– Potassium (K)

– Chloride (Cl)

– Carbon dioxide (CO2).

l Can be run on serum or plasma.

Basic metabolic panel (BMP) Consists of an electrolyte panel, plus:

– Blood urea nitrogen (BUN), which a measure of renal function.

– Creatinine (Creat), which also measures renal function

– Glucose, the most important blood sugar, and

– Calcium.

l Run on serum or plasma

Comprehensive metabolic panel (CMP) Consists of a basic metabolic panel, plus:

l Albumin (Alb)

l Bilirubin (Bili)

l Alkaline Phosphatase (Alk Phos)

l Total protein (TP)

l Alanine aminotransferase (ALT)

l Aspartate aminotransferase (AST)

l Lipid Panel is known as a Lipid profile and consists of:

– Cholesterol

– High density lipoprotein


– Low density lipoprotein

– Triglycerides

l Lipid profile is run on serum or plasma.

l It requires a 14 hour fast prior to collection.

Acute hepatitis panel:

– Hepatitis A antibody (IgM)

– Hepatitis B core antibody, IgM (HBcAb)

– Hepatitis B surface antigen (HBsAg)

– Hepatitis C antibody

There are many more lab tests run at various times, and over time you will become familiar with the most common run within your environment. Regardless of the tests that are ordered by the physician, the tubes will remain a constant. Here is a look at the most common tubes used in phlebotomy.

Light Blue top

ADDITIVE

Sodium Citrate either 3.2% or 3.8% Citrate, theophylline, adenosine, dipyridamole (CTAD)

ACTION

Citrate is an anticoagulant which binds calcium in the blood. Calcium is required for blood clotting. Since it is bound up the blood cannot clot resulting in a whole blood sample, red blood cells and PLASMA. Coagulation tubes are filled with buffered tri-sodium citrate solution. Citrate concentrations of either 0.109 mol/l (3.2 %) or 0.129 mol/l (3.8 %) are available. The choice of the concentration depends upon the policies of the laboratories. The mixing ratio is 1 part citrate to 9 parts blood. CTAD tubes contain besides the buffered citrate solution, theophylline, adenosine and dipyridamole.

These tubes MUST BE COMPLETELY FILLED due to the amount of additive in the tube. Short draw tubes will be rejected.

TESTS PERFORMED


• Routine coagulation tests include: o Prothrombin Time (PT) o Partial Thromboplastin Time (PTT) o Thrombin Time (TT) o Fibrinogen o Fibrin degradation products (FDP) o D-dimer

• Many special coagulation tests can be performed to diagnosis various bleeding disorders, these are usually sent out to reference labs:

o Factor activity assays (II, V, VII, VIII, IX, X, XI, XII) o Factor antigen assays (VII, X) o Factor inhibitor assays (II, V, VII, VIII, IX, X, XI, XII) o von Willebrand factor assays (vWF Ag, Ristocetin cofactor, Multimers, RIPA) o Platelet aggregation studies (collagen, ADP, epinephrine, arachidonic acid,

risocetin) o Lupus Inhibitor assay (DRVVT) o Thrombophilia assays (protein C, protein S, antithrombin) o Activated Protein C Resistance/Factor V o DNA screening o Fibrinolysis assays (t-PA activity and antigen, PAI-1 activity, plasminogen,

antiplasmin)

Red top tube - Serology and Immuno-hematology

ADDITIVE

Glass - NONE Plastic - clot activators to enhance the clotting of blood, tube inversions are necessary to ensure mixing of clot activator with blood. Blood clotting time 30 minutes.

For serum determinations in chemistry, serology and Immunohematology (blood banking). Chemistry will be covered on another page.

TESTS - BLOOD BANK

ABO/D type aka ABO/Rh Testing Antibody Screen AKA Indirect Antiglobulin Test (IAT) Type and Screen (T&S) Crossmatch or Type and Cross (T&C) Rh Immune Globulin AKA Rhogam Antibody Titer Antigen Typing


Blood Component Requests:

Packed Red Blood Cells (RBC) PLATELETS CRYOPRECIPITATE (CRYO) FRESH FROZEN PLASMA (FFP)

Red top tube – Chemistry

ADDITIVE

Glass - NONE Plastic - clot activators to enhance the clotting of blood, tube inversions are necessary to ensure mixing of clot activator with blood. Blood clotting time 30 minutes.

For serum determinations in chemistry, serology and Immunohematology (blood banking). Chemistry will be covered on another page.

TESTS - BLOOD BANK

ABO/D type aka ABO/Rh Testing Antibody Screen AKA Indirect Antiglobulin Test (IAT) Type and Screen (T&S) Crossmatch or Type and Cross (T&C) Rh Immune Globulin AKA Rhogam Antibody Titer Antigen Typing

Blood Component Requests:

Packed Red Blood Cells (RBC) PLATELETS CRYOPRECIPITATE (CRYO) FRESH FROZEN PLASMA (FFP)

SEROLOGY OR IMMUNOLOGY - originally, the study of the in vitro reactions of immune sera, e.g., precipitin, agglutination, and complement fixation reactions. Currently, the term is used to refer to the use of such reactions to measure serum antibody titers in infectious disease (serologic tests), to the clinical correlations of the antibody titer (the serology of a disease), and to the use of serologic reactions to detect antigens (e.g., "serologically defined" HLA antigens).

TESTS -SEROLOGY


• Infectious Mononucleosis such as Monotest or Monospot • Rheumatoid Arthritis (RA) AKA Rheumatoid Factor (RF) • Syphilis testing such as Rapid Plasma Reagin (RPR), Venereal Disease Reserach

Lab (VDRL) or Fluorescent Treponemal Antiody Test (FTABS) • Rubella titer • Strep testing such as Streptozyme or Anti-streptolysin O (ASO) Titer • Pregnancy test • Cold Agglutinins (CAG) - Keep sample warm after collection • Haptoglobin (HP) • C-Reactive Protein (CRP)

Light Green top or Green top

ADDITIVE

Sodium Heparin Lithium Heparin Ammonium Heparin

ACTION

The interior of the tube wall is coated with lithium heparin, ammonium heparin or sodium heparin. The anticoagulant heparin activates antithrombins, thus blocking the coagulation cascade and producing a whole blood / plasma sample instead of clotted blood plus serum. Plasma separator tubes (PST) are tubes with lithium heparin and gel contain a barrier gel in the tube. The specific gravity of this material lies between that of the blood cells and plasma. During centrifugation the gel barrier moves upwards providing a stable barrier separating the plasma from cells. Plasma may be aspirated directly from the collection tube, eliminating the need for manual transfer to another container. This barrier allows for the stability of certain parameters in the primary tube under the recommended storage conditions for up to 48 hours. Check the heparin additive before use. Do not use heparin plasma tubes for TDM measurements, lithium heparin for lithium determinations, sodium heparin for sodium determinations, ammonium heparin for ammonia determinations or any type of heparin for blood banking procedures.

TESTS

For plasma determinations in the chemistry department. Many institutions use red stoppered tubes for routine chemistry tests and green stoppered tubes for STAT chemistry tests.


Lavender top

ADDITIVE

EDTA K2 EDTA K3

ACTION

The interior of the tube wall is coated with either EDTA K2 or EDTA K3. The tube is also available with an 8% liquid EDTA solution. The EDTA binds calcium ions thus blocking the coagulation cascade. EDTA tubes can be used in direct sampling analysers without actually being opened. Erythrocytes, leukocytes (white blood cells) and thrombocytes (platelets) are stable in EDTA anticoagulated blood for up to 24 hours. Preparation of blood smears should be done within 3 hours after blood collection. EDTA tubes are used for testing whole blood in the clinical laboratory. EDTA K2 tubes are used for testing whole blood in molecular diagnostics.

EDTA K2/gel tubes are used for testing plasma in molecular diagnostics and viral load detection. HIV and HCV are stable for up to 72 hours in a non-centrifuged sample at room temperature (20–25°C). However centrifugation for EDTA K2/gel tubes should be done within 6 hours after blood collection for best results. Mid- term storage (up to 2 weeks) in primary tubes is recommended at –20°C. For long-term storage (over 2 weeks) at –70°C or at lower temperatures please store aliquots in cryo vials.

TESTS PERFORMED

• Routine hematology tests include: o Hemoglobin o Hematocrit o White blood cell (WBC) count o Red blood cell (RBC) count including MCV, MCH, and MCHC which are

calculations used to determine size and shape of RBCs o Platelet Count o Differential - the microscopic examination of blood o Complete Blood Count - the complete blood count includes ALL of the following

tests: red blood cell count, platelet count, white blood cell count, hemoglobin and hematocrit.

o Reticulocyte count o Eosinophil count

• Other special tests can be performed in the hematology department: o Erythrocyte sedimentation rate AKA Sed Rate or ESR o Sickle cell test

• Body fluid counts - Cerebrospinal Fluid (CSF), pleural fluid, pericardial fluid, peritoneal fluid, and synovial fluids may be submitted for cell counts.


Chemistry

Hemoglobin A1C

Pink top tube (Blood Bank EDTA)

Gray top

ADDITIVES

Potassium Oxalate and Sodium Fluoride Sodium fluoride/Na2 EDTA Sodium Fluoride (no anticoagulant, will result in serum sample)

ACTION

Sterile blood collection tubes for laboratory procedures requiring plasma or whole blood chemistry procedures where glycolytic inhibition of specimen is required. The anti-glycolytic properties prevent the blood cells from using the glucose in the sample. Used instead of red top when there will be a delay in getting blood to the lab for a glucose level.

Oxalate and EDTA are anticoagulants which will prevents the blood from clotting, sodium fluoride is a stabilizer. The resulting supernatant fluid is PLASMA. Sodium fluoride is an anti-glycolytic only, resulting fluid is SERUM.

The tube must be inverted 4-5 times after collection to allow adequate mixing of the blood with the additive. Failure to mix may result in the sample clotting. Clotted tubes will be rejected.

TESTS PERFORMED

Glucose Levels Blood Alcohol Levels Lactate Bicarbonate

Yellow top tube (ACD solution A) or (ACD solution B)

Royal Blue top; serum, no additive or sodium heparin


OrderoftheDraw

TopreventcontaminationoftubeswithadditivesfromothertubesitisimportanttodrawthetubesinaSPECIFICordercalled"theorderofthedraw".Forexample,iftheadditiveinthepurplestoppertubecontaminatesthegreenstoppertubethiswouldcausefalselydecreasedcalciumandincreasedpotassium.Please,JUSTDOIT.Thesequenceofcollectionofevacuatedtubesinamulti-drawshouldbeinthisorder:

1. Sterile/Bloodcultures(yellowstopperorbottles,mostinstitutionsusebottles)2. LightBluecoagulationtube-NOTE:IfcoagulationtestsonlyareorderedANDyouareusing

abutterfly,drawadiscardtubetocollecttheairinthetubingintothediscardtube.Failuretodosowillresultinashortdrawwhichwillberejectedbythelab.

3. Red-Non-Additive-hasclotactivator4. RedGelseparatortube(speckledor“tiger”toporgold)5. Green(heparin)6. Green/GraymottledPlasmaSeparatorTube(PST)withheparin7. Lavender/purpleand/orpink(EDTA)8. Graytop(PotassiumOxalate/sodiumfluoridetube)

Order of tube collection

• Blood culture bottles; blue; yellow, Red glass, red plastic, green; lavender and pink; and finally gray (see order below)


VENIPUNCTURE PROCEDURE

The venipuncture procedure is complex, requiring both knowledge and skill to perform. Each phlebotomist generally establishes a routine that is comfortable for her or him. Several essential steps are required for every successful collection procedure:

1. Identify the patient. 2. Assess the patient's physical disposition (i.e. diet, exercise, stress, basal

state). 3. Check the requisition form for requested tests, patient information, and

any special requirements. 4. Select a suitable site for venipuncture. 5. Prepare the equipment, the patient and the puncture site. 6. Perform the venipuncture. 7. Collect the sample in the appropriate container. 8. Recognize complications associated with the phlebotomy procedure. 9. Assess the need for sample recollection and/or rejection. 10. Label the collection tubes at the bedside or drawing area. 11. Promptly send the specimens with the requisition to the laboratory.

EQUIPMENT NEEDED:

THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE:

• 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. • Alcohol Wipes - 70% isopropyl alcohol. • Povidone-iodine wipes/swabs - Used if blood culture is to be drawn. • Gauze sponges - for application on the site from which the needle is withdrawn. • Adhesive bandages / tape - protects the venipuncture site after collection. • Needle disposal unit - needles should NEVER be broken, bent, or recapped.

Needles should be placed in a proper disposal unit IMMEDIATELY after their use.

• 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.


VENIPUNCTURE SITE SELECTION:

Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a last resort because of the higher probability of complications.

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.

• 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:

o Turn off the IV for at least 2 minutes before venipuncture. o Apply the tourniquet below the IV site. Select a vein other than the

one with the IV. o Perform the venipuncture. Draw 5 ml of blood and discard before

drawing the specimen tubes for testing. • 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.

PROCEDURE FOR VEIN 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 15 to 30 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.

PHLEBOTOMY PROCEDURE ILLUSTRATED:

The tourniquet is applied and the phlebotomist palpates for a suitable vein for drawing blood.

The area of skin is cleaned with a disinfectant, here an alcohol swab.

The vein is anchored and the needle is inserted.


The vacutainer tube is depressed into the needle to begin drawing blood.

PERFORMING 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.

• 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 non-dominant 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.

• 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.

• 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.

• 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.


FINGERSTICK PROCEDURE ILLUSTRATED:

The proper location on the 3rd or 4th finger of the non-dominant hand for performing a finger stick is outlined here between the green lines. The puncture should be made just off center and perpendicular to the fingerprint ridges. (A puncture parallel to the ridges tends to make the blood run down the ridges and hamper collection.)

The lancet is placed over the proper location on the finger and the puncture is made quickly.

ADDITIONAL CONSIDERATIONS:

To prevent a hematoma:

• Puncture only the uppermost wall of the vein • Remove the tourniquet before removing the needle • Use the major superficial veins • Make sure the needle fully penetrates the upper most wall of the vein.

(Partial penetration may allow blood to leak into the soft tissue surrounding the vein by way of the needle bevel)

• Apply pressure to the venipuncture site


To prevent hemolysis (which can interfere with many tests):

• Mix tubes with anticoagulant additives gently 5-10 times • Avoid drawing blood from a hematoma • Avoid drawing the plunger back too forcefully, if using a needle and

syringe, and avoid frothing of the sample • Make sure the venipuncture site is dry • Avoid a probing, traumatic venipuncture

Indwelling Lines or Catheters:

• Potential source of test error • Most lines are flushed with a solution of heparin to reduce the risk of

thrombosis • Discard a sample at least three times the volume of the line before a

specimen is obtained for analysis

Hemoconcentration: An increased concentration of larger molecules and formed elements in the blood may be due to several factors:

• Prolonged tourniquet application (no more than 2 minutes) • Massaging, squeezing, or probing a site • Long-term IV therapy • Sclerosed or occluded veins

Prolonged Tourniquet Application:

• Primary effect is hemoconcentration of non-filterable elements (i.e. proteins). The hydrostatic pressure causes some water and filterable elements to leave the extracellular space.

• Significant increases can be found in total protein, aspartate aminotransferase (AST), total lipids, cholesterol, iron

• Affects packed cell volume and other cellular elements


Bibliography

"Blood Collection Tubes." Austin Community College - Start Here Get There. Web. 07 Oct. 2010. <http://www.austincc.edu/kotrla/phb_tubes>. Infusion Nurses Society et. al. Infusion Nursing: An Evidence-Based Approach, 3rd edition, Saunders, 2009.

"Phlebotomy." EHSL - Spencer S. Eccles Health Sciences Library Home Page. Web. 07 Oct. 2010. <http://library.med.utah.edu/WebPath/TUTORIAL/PHLEB/PHLEB.html#1>. Potter, P., Perry, A. Fundamentals of Nursing, 6th ed. St. Louis: Mosby, 2006. Weinstein, S. Plumer’s Principals & Practice of Intravenous Therapy, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2007.

Phlebotomy Course - Avalon Medical Educators€¦ · 10:50 – 12:30 Phlebotomy a. Electrolyte...

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