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CongratulationsMercedes!!Skills USA
1st Texas
Championship Nurse
Assisting
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Blood Composition:
Formed elements (~45%)– RBC– WBC– Platelets
Fluid component (~55%)– Water (~92%)– Protein (~7%)– etc
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Blood Collection Tubes:• Contain a vacuum
• Used with
Vacutainer and
Syringe systems
• Stoppers universal
color coded: indicates contents
• Have an expiration date
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Safety: Engineering Controls
• PPE• Sharps containers• Safer medical devices
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Safer Medical Devices:
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Equipment:
1. PPE: gloves, lab coat, mask
2. Cleaning agent– Alcohol pads: routine– Povidone iodine: blood culture collection and
blood gases– Soap and water: alcohol testing, allergies
3. Cotton balls, gauze
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Equipment: 4. Bandage, tape (use caution with children)
5. Sharps container: – Discard needles,
lancets– Biohazard marking– Puncture resistant
– NEVER recap, bendbreak needles
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Equipment:
6. Tourniquets:– Slows venous blood flow down– Causes veins to become more prominent– NEVER leave on for >1 minute – AVOID rigorous fist clenching or hand
pumping (potassium, lactic acid, LD)– Latex allergy
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Tying on the Tourniquet:
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Equipment:
7. Needles– NEVER reuse a needle– NEVER use if shield is broken– NEVER recap, cut, bend or break
– Drop immediately into sharps container after venipuncture
– Size of needle is indicated by gauge:• Larger gauge number indicates smaller needle diameter• 21, 23 gauge needles routinely used for phlebotomy
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Needles:
Used with syringe system Used with vacutainer system
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Multi-sample Needle:
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Butterfly Needle:
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Butterfly Needle:• Most often used with
syringe
• Expensive, thus not used for routine draws
• Used for small, fragile veins
• Increased risk of needle stick injury
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Equipment:
8. Tube holder/
vacutainer adapter
– Threaded– Flanges
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Equipment:
9. Syringe
10. Black
water proof
pen
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Syringe Safety Device:
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Labeling Blood Collection Tubes:• Black indelible marker (water proof)
– Never pencil– Legal document– Print legibly
• Required information: 5 items– Patient name– Identification number– Date of draw (mm,dd,yyyy)– Time of draw (military time)– Phlebotomist initals
Labeling
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Last Name, First NamePatient ID: 1234-56June 5, 2005 8:10 AM Initials: SM
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Vacutainer or Syringe?
• Vacutainer– Most often used– Most economical– Quick– Least risk of accidental needle stick
• Syringe– More control– Reposition easily– Will see ‘flash’ of blood in syringe hub when
vein successfully entered
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The Patient:
• Approach• Communication• Empathy• Handling special situations• Patient identification
– Arm band– Legal document
• Prepare patient for blood draw– Latex allergy?
Great QUESTIONS TO ASK YOUR PATIENT
• Have you ever had blood drawn before?• Have you had problems during a
venipuncture? • If yes—
–Did you have pain, bruising or bleeding?–Did you have chest pain, dizziness,
fainting or nausea?
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Necessary Equipment for Venipuncture
Equipment
• PPE• Alcohol swabs• Gauze pads• Tourniquet• Needles- sterile
disposable• Blood collection tubes• Pediatric collection
tubes
Equipment • Winged infusion sets• Vacutainer• Lancets
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Patient Preparation 1. Patient education
1. Do not make it lengthy
2. Tell the steps of the procedure
3. Instruct patient to let you know right away if they are having pain
4. Explain possible complications1. Bruising, hematoma, infection, prolonged
bleeding, excessive pain
5. Ask if they have questions
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Selecting the Site
1. Begins with hand washing
2. Must be done before and after procedure
3. Don gloves
4. Ask patient to extend arm with palm facing up
5. Search for a vein using visual examination and palpation
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Selecting the Site:• Antecubital area most
often accessed– “ the bend of the
arm”– Preferred site – There are 3 veins
that are preferred for blood draw in this location
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The 3 Preferred Veins• Medial Cubital
– 1st choice– In center of AC fossa– Usually does not move– In obese patient- not seen by can be palpated
• Cephalic Vein – 2nd choice– Located in lateral aspect of AC fossa– Large vein and can be seen – *** tends to ROLL and difficult to stabilize
• Brachial Vein – Last choice– Located in medial aspect of AC fossa– ** very close to brachial artery– Not visible and tends ROLL
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Examine the Patients AC FOSSA!!
• If you see a good vein it is time to palpate!• Touch the vein with you fingers• Vein should feel
– Soft– Flexible – Non- tender– The vein SHOULD NOT BE HARD,
INFLEXIBLE OF TENDER
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Conditions• The following conditions cause veins to be unsuitable for
venipuncture– Sclerosis
• HARD, INFLEXIBLE,NARROW– Tortuous veins
• TWISTED, TURN EASILY– Thrombotic veins
• BLOOD CLOT(S) IN THE VEIN– Fragile veins
• THIN, DARK, CLOSE TO SURFACE, COLLAPSE EASILY
– Phlebitis• INFLAMMED BLOOD VESSELS, TENDER TO
TOUCH 32
Complications
• If performed on any of the aforementioned categories– Vein will be difficult to access– Impossible to puncture– Painful – Easily damaged– Blood supply through the vein will be POOR
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Troubleshooting to Locate a Vein
• Place the arm below the level of the heart for several minutes
• Place a warm compress• *** The best technique is to slow down and
take your time • Ask someone else to try• Notify supervisor• Notify Physician
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Other Veins
• Hand and wrist veins• Dorsum area of the hand• Easily seen--- *** are more fragile!!• ** ROLL easily– superficial,small and
painful• Short length– difficult to to angle needle• Vein on underside of wirst
– CLOSE to Artery and Nerves– Physically challenging to access
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Hand Vein Draw
NO BLOOD DRAW
•On arm with IVF•Dialysis Shunt•Mastectomy side
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Collection Site Problems:
• Intravenous line– NEVER draw above
an IV
– Draw from other arm
– Draw from hand
on other arm
– Draw below the IV
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Draw Below IV site:
Cleaning the SITE• Invasive procedure• Scrub with isopropyl alcohol 70%• Other germicides include- chlorhexidine and
iodine • Alcohol preferred
– Dries fast– No residue– Not highly irritating– Does not obscure– Not drying to the skin
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Proper Venipuncture Technique• Introduce self• Identify the patient • Check laboratory requisition form • Have patient sit or lie down- NEVER STANDING• Assemble equipment – check expiration• Wash hands• Don gloves• Locate vein • Apply tourniquet
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STEPS• Do not touch area after prepping site• Use your fingers to spread the skin & make tight• Uncap and inspect the needle tip• Discard if defective or if sterility was compromised • Insert the needle at 15-30 °angle – BEVEL UP• This angle
– Allow room to work– Reduces pushing the needle through the vein – Allow best blood flow
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Needle Position:
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Releasing the Tourniquet
• Once the needle has entered the vein and you have attached the 1st tube to the infusion set or vacutainer
• RELEASE the tourniquet• The tourniquet should NOT be left on for
more than 1 minute
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Complications of Leaving Tourniquet Applied Too Long
1. Hemolysis1. Destruction of blood cell
2. Will cause abnormal electrolyte readings
2. Petechiae1. Very tiny hemorrhages-appear in red and
purple spot on the skin
3. Hemoconcentration1. Tourniquet application can force fluids out of
cells and leak into blood volume46
Attach the Collection Tubes• After you have successful accessed the vein • Attach the blood collection tubes to vacutainer or
infusion set• Tubes will fill in about 5 seconds• Tubes must be filled in the correct sequence• Tubes must be handled correction after filling• At most– if you fill 6 tubes with blood– 30 ml or
cc’s will be the amount of blood removed
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Order of the DRAW
1. Blood cultures or sterile specimens
2. Blue top
3. Red top
4. Gold or Green top
5. Lavender or Purple top
6. Gray top
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Fill Tubes:• Use correct order of draw:
– Sterile/Blood cultures-----------SALLY– Blue------------------------------------BRINGS – Red-------------------------------------REALLY– Gold/Green---------------------------GOOD GREASE
»and– Purple/ Lavender-------------------LEAVES
» the – Gray------------------------------------GRAVEY
Inverting the Tubes
• Once filled– tubes must be inverted• Invert by holding it in your hand and
turning your wrist• Blue top- 3-4 inversions• Lavender and Green top- 8-10 inversions• Serum separator tubes ( SST, red tops)
and serum tubes ( red tops without the separating gel) 5 inversions
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Removing the Needle• Place gauze over the needle• Quickly remove needle and apply firm
pressure to site• Always use gauze pad and wear gloves• Allow patient to apply pressure ( if
possible) so you can invert tubes• You can place pressure for 30 seconds
and apply adhesive bandage over the gauzes
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Recheck Draw Site:
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Labeling the Tubes Immediately:
• In sight of patient• Patient name• Identification number• Date of draw• Time of draw
(military time)• Your initials
• **This is a critical step• **Mislabeling can lead to
serious consequences
Handling and Transporting Specimens
• All specimens must be handled correctly • Most have a standard # of inversions• Most can be stored at room temp• **** There are exceptions!!!• Learn the proper transport policy of the
facility
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Finishing the Procedure
• Discard the needle in sharps container• NEVER REUSE!!!• NEVER RECAP!!• Remove gloves and wash your hands!!!
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Recheck Draw Site:
Reporting Test Results
• There may be occasions in which you will be asked to transmit lab results
• The keys to doing this accurately and correctly are repetition and confirmation
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After the Venipuncture
• Check the patient for:• Excessive bleeding• Excessive pain• Lack of sensation• Excessive bruising• Signs of infection• How the patient feels
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Troubleshooting Technical Problems during Venipuncture
• Most are done quickly and with ease• What do you do if the blood flow stops?
– *** This occurs when the vacuum is not enough
– ***Patency of the system has been compromised
– Try another tube– check to see if you have released the
tourniquet– Needle is in too far or not far enough
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Collection Site Problems:Complications
• Nerve damage• Hematomas• Phlebitis• Petechiae• Thrombus• Physical Reactions• Collection or processing errors • Edematous area
Collection or Processing• Misidentification of patient• Improper site selection and preparation • Incorrect order of the draw• Under filling of tubes• Failure to invert tubes• Failure to document when a specimen was
obtained and when it was received• Mislabeling of the specimen
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Needle Sticks and Contact with Body Fluids and Secretions
• Good technique and PPE is KEY!!• If you have contact with skin– WASH
Immediately with soap and water • EYE contact= Eye wash for 15 minutes
with lukewarm water • Inhalation of body fluid=leave area and
seek fresh air• ** Report exposure soon after you finish
basic first aid measures 63
Needlesticks
• Milk and wash the area with soap and water • Cover with dressing • Report the incident ASAP• Any break in the skin can be a portal of entry!!• Risk of HIV, Hepatitis B & C
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First Aid, Medical Emergencies and the Phlebotomy
You must be prepared to deal with medical emergencies• excessive bleeding- apply direct pressure
& call for help• Patient faints-call for help – try to prevent patient
injury- check for breathing and pulse• Know how and when to start CPR• Know who and what to do quickly
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Finger and Heel Stick Phlebotomy
• If blood is needed and venipuncture is contraindicated
• Heel or finger stick may be used• These are NOT venipuncture- because
you are not drawing from veins• You are drawing from capillaries• There are differences between a HEEL
and FINGER sticks•
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Capillary Blood• Mixture of arterial, venous, capillary blood
and fluid from surrounding tissues
• Fluid from surrounding tissues may interfere and/or contaminate the specimen
• Warming skin puncture site increases arterial blood flow to the area
• Reference ranges often differ from venous
Fingersticks
• Done when only a small amount of blood is needed
• When venous access is difficult• Commonly done on children• Commonly done on adults who need very
frequent blood checks• Can be used to check for lead,
hemoglobin and other blood components including blood glucose
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Fingerstick Procedure• Infection control• Assemble equipment• AIDET-• Position patient• wash hands• Don gloves• ID site- middle and ring finger
are best • Use side of the finger
– Avoid cold, cyanotic, scarred, fingers
• Clean site with alcohol 70%• Gently massage- milk finger
puncture fingertip with lancet• Wipe away first drop• Allow blood to drip into collection
tube• Cap when filled• Position and massage site as
needed- careful not to over milk/massage may damage cells
• Cap filled tube• Label specimen • Check patient• Discard equipment • Remove glove & wash hands 69
Heelstick Procedure• Assemble equipment• Choose correct lancet-
will puncture the skin to a specific depth– If infant <2.2 lb.
choose lancet which punctures depth of 0.65mm
• Positon patient • Apply heel warmer for 3-
5 minutes • Wash hands and don
gloves
• Select site– Best sites are lateral and medial sides
of the heel– DO NOT USE back of heel– Clean site– Puncture skin with lancet– Use your thumb and fingers to gently
squeeze heel – Wipe away first drop of blood– Allow blood to drip into collection tube– Do not over squeeze– Cap tube when filled– Label specimen– check patient – discard equipment– remove gloves & wash hands
–
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Recheck Draw Site:
SPECIAL COLLECTIONS
• This refers to any collection that is different from the standard blood draw
• Uses techniques that are a bit more complicated
• You may be required to perform or assist in a special collection
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Peripheral Blood Smears
• A peripheral blood smear is a blood collection that is used most often to diagnose a hematologic disorder
• The smear is used to examine different types of white blood cells ---WBCs
• This is call checking the DIFFERENTIAL• Peripheral blood smears also are used to
detect malarial parasites in the blood
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Peripheral Blood Smears• Can be done using capillary or venous
blood• It can be collect at the bedside or using
blood from an EDTA collection tube• You will need the following equipment:
– Lens cleaner– Lens paper– glass slides– gloves– EDTA tube
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Peripheral Smears• Take 2 glass slides• Apply drop of lens cleaner on each slide and use the lens paper to rub
the slides until they are dry • Invert the EDTA tube 8-10 times • Open the stopper & use a stick or other pipette to remove a small
amount of blood• Place a drop of blood 2mm in diameter onto the slide just in front of
frosted area • Drop of blood should be in the center of the slide & approximately ¼ inch
from the back edge of the slide • Smear immediately after the blood is applied** a delay will affect the test • Do this by using the end of the other slide, hold at 30° just in front of the
blood and then pull the slide until it just touches the blood
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Peripheral Smears• The blood will begin to spread towards the edge of the
bottom slide• Wait until the blood has almost reached the edges of the
bottom slide• Maintain a 30°- push the spreader slide rapidly across
the bottom slide• Do not press down• The smear should be across ¾ of the bottom slide• There should be a smooth appearance and no holes or
lines• It should have rainbow sheen when reflected in light • Allow smear to air dry and label correctly
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How to Prepare a Peripheral Blood Smear Slide
•Peripheral Blood Slide Preparation
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Blood Culture Collection• Obtained to detect the presence of
microorganisms in the blood= bacteremia• Blood Culture or Blood C & S requires a
specific collection procedure
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Blood Culture Collection • Assemble equipment• Blood Culture Bottles
2( anaerobic & aerobic)• Tourniquet • Gloves• Alcohol 70 % swabs • Gauze pads• Chlorhexidine• Syringe & winged infusion set• 79
Blood Culture Collection • Clean top of bottles with alcohol ( NOT with
CHOLORHEXADINE OR IODINE allow to dry for 30 seconds
• Find suitable site and clean with chlorhexidine --------scrubbing firmly a 5 cm area for 30 seconds
• Allow to dry and DO NOT TOUCH the area once prepped • Perform venipuncture and remove 20 ml of blood using
butterfly device with special BC vacutainer device • Transfer the blood to the bottles filling the aerobic 1st then
the anaerobic bottle• Divide blood amounts evenly between the 2 bottles • *** it is helpful to mark off the fill level on the bottles for
filling accuracy
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Blood Culture Collection Procedure
•Blood Culture Collection Procedure
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Recheck Draw Site:
Blood Samples for Inborn Errors of Metabolism
• Genetic disorders that affect the way the body metabolizes certain nutrients
• Will affect the enzyme systems• Diagnosed by blood tests• 3 common blood tests are:
1. Serum Ammonia
2. Serum Lactate
3. Serum Pyruvate
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Blood Samples for Inborn Errors of Metabolism
• Use the standard venipuncture procedure• DO NOT use a tourniquet or have the patient
make a fist • Patient should be fasting for the serum pyruvate
level • These specimens are collected in special tubes• MUST BE PLACED ON ICE & immediately
transported to the lab for processing
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Phlebotomy for Blood Donation
• Collecting specimens for blood donation follow the same principles
• Patient ID• Patient assessment• Site preparation • Vein access• Infection control
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Phlebotomy for Blood Donation• Screening for BLOOD donation includes:
– Age– weight – Blood- borne disease exposure– ** Today guidelines are very specific and extensive – Maximum amount of blood that is taken is 525 ml– American Academy of Blood Banks recommendation is
10.5 ML per kg of body weight– assuming a minimum weight of 110 lb or 50 kg
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Draw Below IV site:
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No Needle Movement!
• You must anchor the blood-drawing equipment on the patient’s arm to minimize chance of injury
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Withdraw Needle:
• First release tourniquet• Disengage tube• Place cotton directly over needle, without
pressing down• Withdraw needle in swift, smooth motion• Immediately apply pressure to wound• Do not bend arm
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You should try again
• Look at alternate site– Other arm– Hand
• Use clean needle• Use fresh syringe if
contaminated
• Only try twice
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Venipuncture Procedure:
• Wash hands• Put on gloves• Identify patient• Latex allergy?• Position arm• Apply tourniquet
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Venipuncture Procedure:
• Locate vein• Release
tourniquet• Cleanse site in
outward rotation– Allow to air dry
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Mark your spot
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Venipuncture Procedure:
• Reapply tourniquet– Do not contaminate
site• Anchor vein• Insert needle• Fill tubes
– Quick mix additive tubes
• Release tourniquet• Withdraw needle
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Venipuncture Procedure:
• Engage safety device• Dispose of needle
immediately• Apply pressure to
puncture site• Label tubes• Recheck puncture
site• Thank patient• Remove gloves,
wash hands
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Syringe draw
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Be careful not to:
• Push needle further into vein when engaging evacuated tube
• Pull needle out of vein when disengaging tube
• Pull needle out of vein as you pull back on the plunger
• Pull up or press down when needle in vein• Forget to mix additive tubes 8-10 times
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Syringe Safety Transfer Device
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Skin Puncture Procedure:1. Wash hands
2. Approaching the patient
3. Patient identification
4. Latex allergy?
5. Bedside manner
6. Site selection
7. Cleanse site: DO NOT use providone- idodine
8. Perform puncture: Wipe away first drop of blood
9. Label the specimen
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Skin Puncture:
• Method of choice for infants, children under 1 year
• Adults– Scarred – Fragile veins– Hardened veins– Home glucose monitoring (POCT)– Patients with IV
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Skin Puncture Procedure:• Hold finger between your index finger and thumb
• Puncture the finger using a quick, smooth motion
• Wipe away the first drop of blood
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Skin Puncture Site Selection:
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Skin Puncture Equipment:
1. PPE
2. Cleaning agent– Alcohol pads: routine– Soap and water: alcohol testing, allergies– DO NOT use providone iodine
3. Cotton balls, gauze
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Skin Puncture Equipment:
4. Bandage/tape
5. Sharps container
6. Warming device– Commercial warmer– Warm wet washcloth
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Skin Puncture Equipment:
7. Lancet – Always use
standardized equipment
– NEVER use a surgical blade
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Skin Puncture Equipment:8. Micro-specimen
containers– Capillary tubes– Microtainers– Capillary blood gas
tubes– Micropipet diluting
system
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Skin Puncture Equipment:
9. Glass slides:
used to prepare
blood smears
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Skin Puncture Procedure:• Collect sample
– DO NOT touch collecting device to skin surface– DO NOT scrape collecting device across skin surface– DO NOT scoop blood into collecting device
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Skin Puncture Procedure:• Order of draw is critical: platelets accumulate at
puncture site causing clot formation– Blood smear– EDTA– Heparin– Serum
• Apply pressure to puncture site
• Label specimen in sight of patient (indelible marker)
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Specimen Processing Essential
Knowledge
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Labeling and Transporting Specimens
• Each facility has a protocol for transporting specimens– The time from collection to transport– Storage requirements for the specimen during
transport– Most can be transported on room Air– Some require traveling on ice
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CLIA Quality Control
• Clinical Laboratory Improvement Amendments– Federal regulatory standards for labs that
perform testing of human samples– CLIA standards stipulate that certain simple,
low risk lab tests may be waived– There does not have to be any direct routine
oversight of the labs in regards to how they perform these tests
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Good Lab Practices • Include:
– Using recent package insert from the kits manufacturer
– Doing quality control or calibration on equipment
– Documenting quality control– Storing and handling according to
manufacturer– Provide personnel with training and document
training– Using OSH regulations that pertain to labs
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Non-Blood Specimen Collection Transport
• Include;–Semen–Sputum–Stool –urine
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Collection
• All will require a simple collection• This means the patient is given a cup and
the specimen is placed in the cup• The only exception is
– Sterile urine
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Sterile Urine Collection• Wait 2-3 hr. for urine to be in the bladder• wash hands• Men- clean head of penis with sterile wipe• Women- must separate labia and wipe front to
back – use a second wipe to clean area around the urethra
• Void for several seconds• STOP urine stream • Urinate in the sterile cup• DO not touch inside of cup• Seal cup and properly label
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Pre-Analytical Errors• Common errors include:
– Insufficient specimen– QNS– Hemolysis
• The destruction of red blood cells which leads to the release of hemoglobin from within the red blood cells into the blood plasma.
– Hemoconcentration• Decrease in the volume of plasma in relation to the
number of red blood cells; increase in the concentration of red blood cells in the circulating blood
– Specimen contamination – Allergic reactions 122
Chain of Custody• The process through which specimens must be obtained,
processed and transported for legal purposes• Refers to the documentation that must be done when
these specimens are obtained, processed and transported
• Examples;– Bld ETOH levels– Test for illicit drug– Workplace drug testing– Specimens that may be part of a crime-
• ie sexual assault
123
Chain of Custody• The following must be carefully
documented– When, how and by whom specimen was
collected– When, how and by whom specimen was
transported – Who received the specimen and when; where
and how it was stored– How and when the specimen was processed– When, by whom and to whom the results were
reported 124
Chain of Custody
• Most labs will have specific forms and a protocol in place to handle chain of custody
• Refer to handout for more information on Chain of Custody
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Communication and Specimen Collection and Processing
• Communication during specimen collection and processing is very important
• Accurate communication is vital• The best way to ensure accurate
communication is to use repetition and confirmation
126
Entering and Retrieving Laboratory Values
• Lab values must be entered correctly• You must pay special attention to the
values and the units that are used to report
• You must also have basic knowledge of normal and abnormal values
• Entering or retrieving values incorrectly could have serious consequences
127
Reporting Routine and Critical Values
• When you are reporting routine and critical lab values --- use repetition and confirmation
• You must document to whom you report the values and when
• Doing this especially when you are reporting critical lab values
128
Summary• Basic venipuncture• Proper venipuncture technique• Proper
– patient ID– Preparation – Troubleshooting– Potential complications– Finger stick– Heel stick – Special collections– Processing of specimens 129
Tubes and Tests• Gray top- fbs, gtt, bld etoh, lactic acid• Lavender top- CBC, H&H, ESR, Sickle
Cell screening• Light Blue top- PT, PTT, Fibrinogen
Degradation Product FDP, • Red top- Blood bank, immunohematology• Red/gray(speckled)- most chemistry tests
130
Practice Skills• The following is a more simply stated order of the
draw. Keep in mind that other, less frequently used tubes, will be placed in the order below based on the additive present. MEMORIZE!
• blood cultures• light blue • red• green• purple• gray • Other.
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