Sometimes, problems with the sample cannot be identified until after testing. In this case another
sample will have to be collected. Some of the rea- sons for recollection are shown in Box 11-5.
REVIEW FOR CERTIFICATION
Complications of routine venipuncture may occur from a variety of causes. If the patient is not in the room, locate him or her if possible, especially if the collection is a stat request or for a timed test. Con- tact the nursing station for missing or improper ID bands. Apprehensive patients may need calming.
If the antecubital fossa is not appropriate due to scarring, burning, or other skin disruptions, use an alternative site such as the dorsal hand. Be aware of the potential for complications from improper tour- niquet application. During the collection, remain aware of the patient’s status, and be ready to cope with syncope, seizures, nausea, pain, and other re- sponses to the procedure. Keep extra supplies handy in the event of defective tubes or needles. Specimen rejection, or redrawing and retesting, may be neces- sary due to improper collection, labeling, transport, or other errors.
FLASHBACK
You learned about nerves in the antecubital area in Chapter 7.
Box 11-4 Reasons for Specimen Rejection
• Clotted blood in an anticoagulated specimen
• Collection in the wrong tube
• Contaminated specimens and containers
• Defective tube
• Hemolysis
• Improper special handling
• Incompletely or inadequately filled tube
• No requisition form
• Unlabeled or mislabeled specimens
Box 11-5 Reasons for Specimen Recollection
• Clots in an anticoagulated specimen
• Contaminated specimens and containers
• Hemolysis
• Improper special handling
• Incomplete drying of antiseptic
• Quantity not sufficient (QNS)
• Unlabeled or mislabeled tube
• Use of the wrong antiseptic
BI BLIOG R AP HY
CLSI: Procedures for the collection of diagnostic blood speci- mens by venipuncture; Approved standard—sixth edition. CSLI document GP41-A6 (formerly H03-A6). Wayne, Pa., 2007, Clinical and Laboratory Standards Institute.
CLSI: Procedures for the handling and processing of blood specimens for common laboratory tests; Approved guideline—
fourth edition. CSLI document GP44-A4 (formerly H18-A4).
Wayne, Pa., 2010, Clinical and Laboratory Standards Institute.
Lusky K: Safety net: Juggling the gains, losses of phlebotomy routines. CAP Today, 2004.
Masoorli S: Caution: Nerve injuries during venipuncture, Nurs Spectr, 2006. Retrieved from ews.nurse.com/apps/pbcs.dll/
article?AID52005505010320.
Roberge RJ, McLane M: Compartment syndrome after simple venipuncture in an anticoagulated patient, J Emer Med 17:
647–649, 1999.
WHAT WOULD YOU DO?
When a physician enters a patient’s room to consult with the patient, you should leave until they are done. The physician may be brusque or hurried, but he or she is in charge of the patient’s care and the phlebotomist must comply with the request. If the needle is already in place, you may ask the physician for a few minutes to finish up because this will likely be more comfortable and safer for the patient than redrawing a second time. Even then, the physician may choose to have you leave and return later.
AVOID THAT ERROR!
AVOID THAT ERROR!
Kevin likely damaged the vein while withdrawing the needle. This can happen if the needle is accidently pushed in at first, or if the tube is lifted away from the skin before the needle is completely removed. The damage causes pain and accumulation of blood, forming a hematoma. Kevin needed to pay as much attention to withdrawing the needle as he did to inserting it. Now, he should apologize, contact his supervisor, and make sure that Mr. Robinson gets treatment for the hematoma.
Maria may not have done anything wrong in her first two attempts—some patients are harder than others to draw from. But two attempts is the limit at most institutions; after that, she should have stopped and called her supervisor or a more experienced phlebotomist to complete the draw.
STUDY QUESTIONS
See answers in Appendix F.
1. What must be done if the patient is not in the room when you come to collect a specimen?
2. What hospital protocol is followed when you are supposed to draw blood from a patient who is not wearing an ID bracelet?
3. How is an unconscious patient approached for blood collection?
4. Name six potential barriers to communicating with a patient.
5. Define hemolysis.
6. Define occluded, and describe what occluded veins feel like.
7. Describe where the tourniquet is applied when performing a dorsal hand stick.
8. What antiseptic must be used when collecting for a blood alcohol test?
9. List four things that can cause hemoconcentration.
10. What symptoms might a patient exhibit immediately before syncope?
11. How can you correct the position of a needle whose bevel has stuck to the vein wall?
12. What can cause a vein to collapse during a blood draw?
13. How many venipuncture attempts by a phlebotomist are usually considered acceptable?
14. How can a phlebotomist prevent reflux of an additive during collection?
15. List five reasons specimens may be rejected.
CERTIFICATION EXAMINATION PREPARATION
See answers in Appendix F.
1. If a stat test is ordered and the patient is not in his or her room, you should
a. wait in the patient’s room until he or she returns.
b. leave the request at the nurse’s station for the nurse to perform the draw.
c. locate the patient.
d. postpone the collection.
2. Which laboratory department may require special patient ID?
a. Microbiology b. Chemistry c. Hematology d. Blood bank
3. Collapsed veins can be caused by a. too large a needle for the vein.
b. too much vacuum asserted on the vessel.
c. the plunger being pulled too quickly.
d. All of the above.
4. When an artery is inadvertently stuck during collection, which of the following statements is not true?
a. The sample should be labeled as usual.
b. The blood may be bright red.
c. The blood may spurt or pulse into the tube.
d. Pressure should be applied for 10 minutes.
5. Which of the following could be a cause of hemolysis?
a. Vigorously mixing the tubes
b. Allowing the blood to run down the side of a tube when using a syringe to fill the c. Drawing blood too slowly into a tube
syringe
d. Using a needle larger than 23 gauge 6. Reasons for specimen recollection include all
of the following except:
a. incomplete drying of the antiseptic.
b. using the wrong antiseptic.
c. prolonged bleeding after needle withdrawal.
d. contamination by powder from gloves.
7. To avoid reflux of an anticoagulant, you should do all of the following except:
a. keep the patient’s arm elevated above the heart.
b. allow the tube to fill from the bottom up.
c. remove the last tube from the needle before removing the tourniquet.
d. remove the last tube from the needle before removing the needle.
8. Conditions that may alter the quality of a spec- imen or cause harm to the patient during a blood draw include the following:
a. edematous tissue.
b. mastectomies.
c. hematomas.
d. All of the above
9. When performing a butterfly draw using a hand vein,
a. place the tourniquet on the patient’s arm above the antecubital fossa.
b. place the tourniquet on the patient’s arm below the antecubital fossa.
c. place the tourniquet on the patient’s wrist.
d. a tourniquet is not required.
10. Povidone–iodine is not recommended for a. blood alcohol draws.
b. dermal punctures.
c. blood gas draws.
d. blood cultures.
11. Hemolysis is
a. the flow of blood from the collection tube back into the needle and the patient’s vein.
b. alteration in the ratio of elements in the blood.
c. lack of lymph fluid movement.
d. destruction of blood cells.
12. Which test result is not affected by patient position?
a. Albumin b. Blood alcohol c. Cholesterol d. Enzymes 13. Lymphostasis is
a. the flow of blood from the collection tube back into the needle and the patient’s vein.
b. alteration in the ratio of elements in the blood.
c. lack of lymph fluid movement.
d. destruction of blood cells.
14. To enhance vein prominence, you can a. elevate the arm in an upward position.
b. tap the antecubital area with your index and middle finger.
c. squeeze the patient’s wrist.
d. apply a cold pack.
15. Hemoconcentration is
a. the flow of blood from the collection tube back into the needle and the patient’s vein.
b. alteration in the ratio of elements in the blood.
c. lack of lymph fluid movement.
d. destruction of blood cells.
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OBJ ECTIVE S
1. Describe two physiologic differences between children and adults that should be considered when collecting blood from infants and children.
2. Describe steps that can be taken to help reduce a child’s anxiety and make the venipuncture experience more pleasant.
3. Explain how blood collection supplies and the venipuncture procedure are modified for infants and children.
4. List the steps in dorsal hand venipuncture in children.
5. Define bilirubin, explain its significance, and describe precautions that must be observed when collecting blood for bilirubin testing.
6. Explain the usual procedure for collecting blood for neonatal screening tests, and list five tests that may be done.
7. Explain physical changes that may occur with aging that should be considered when collecting blood.
8. List conditions that may require blood draws for an extended period and alternative collection sites for patients with such conditions.
9. Define vascular access device, and describe eight types.
10. Describe how blood should be collected from a vascular access device.
11. List steps to be followed when collecting blood from a patient with an intravenous line in place.
After completing this chapter, you should be able to:
Pediatric Patients
Special Physiologic Consider- ations
Special Psychological Consid- erations
Involvement of Parents and Siblings
Identification of Newborns Supplies
Anesthetics
Immobilization of Infants and Children
Pediatric Dermal Puncture Venipuncture in Newborns Geriatric Patients
Physical Changes Common Disorders Mental Impairment Special Considerations for
Blood Collection
Patients Requiring Blood Draws for Extended Periods
Special Equipment Used in the Intensive Care Unit and Emer-
gency Room
Types of Vascular Access De- vices
Drawing from a Vascular Ac- cess Device (VAD) Working with IV Lines Review for Certification
OUTLI N E
CHAPTER 12
Blood Collection in Special Populations
sites commonly used for drawing blood may become damaged from overuse. Patients in the ER or ICU may have vascular access devices or intra- venous (IV) lines in place. Only specially trained personnel can draw blood from these devices on a physician’s order, but the phlebotomist may be called on to assist in the draw or handle the samples during and after collection. Each of these special populations requires approaches and equipment beyond those needed for routine blood collection.
By understanding these special requirements, you will gain the skills you need to collect blood from the widest possible patient population.
F
our special populations—pediatric patients, geriatric patients, patients requiring chronic blood draws, and patients in the emergency room/emergency department (ER/ED) or intensive care unit (ICU)—have special needs and require special knowledge and procedures to collect blood safely and considerately. In young children, loss of blood volume and the child’s fear of the procedure are paramount concerns. In geriatric patients, skin changes and the possible presence of hearing loss or mental impairment are important considerations.
Patients with certain diseases require regular blood tests for an extended or indefinite period, and the