The most important step in venipuncture is positive identification (ID) of the patient. Insertion depth and width The depth of the insertion depends on the site and the patient ( Table 10-2.
NEW TO THIS EDITION
The temperature of the device should not exceed 42°C and it should be applied for 3 to 5 minutes. Finally, a Mock Certification Exam allows students to test themselves at the end of the course as they prepare for certification.
ANCILLARIES For the Instructor
- UNIT 1 Introduction to Phlebotomy
- UNIT 2 Phlebotomy Basics
- UNIT 3 Specimen Collection
- UNIT 4 Specimen Handling
- UNIT 5 Professional Issues
- UNIT 1
Competency Checklists: All the competency checklists from the book are available as PDFs to be used in print and electronically. The Occupational Safety and Health Administration (OSHA) standards must be followed when performing most of the procedures presented in this text.
ASCP American Society of Clinical Pathology ASPT American Society of Phlebotomy Technicians CEU Continuing Education Unit.
OUTLI N E
OBJ ECTIVE S
WHAT IS PHLEBOTOMY?
MODERN PHLEBOTOMY
WHAT WOULD YOU DO?
The phlebotomist is a member of the health care profession and must exhibit professional behavior at all times (Figure 1-2). The phlebotomist plays a crucial role in the healthcare setting and is dependent on performing that role skillfully, efficiently and without constant supervision.
PROFESSIONAL ORGANIZATIONS AND STANDARDS
Some of the organizations listed in Table 1-1 publish journals with useful articles or sponsor workshops or seminars. If you fall into one of the categories for exemption in the board's rules, you do not need a state license to practice phlebotomy.
LEGAL ISSUES IN PHLEBOTOMY
For the phlebotomist, this means that information about a patient should never be discussed with a colleague who is not involved in the patient's care. As a phlebotomist, you will have access to some elements of a patient's PHI, and you are responsible for helping to protect the confidentiality of that information.
REVIEW FOR CERTIFICATION
All information related to a patient's condition, including the types of tests ordered or the results of those tests, is confidential medical information. Under HIPAA, healthcare facilities must have procedures in place to actively protect the confidentiality of patients' protected health information (PHI).
CERTIFICATION EXAMINATION PREPARATION
STUDY QUESTIONS
The various departments within the clinical laboratory are all involved in the analysis of patient samples. CLIA '88 Clinical Laboratory Improvement Act of 1988 CLSI Clinical and Laboratory Standards Institute CMP Comprehensive Metabolic Panel.
HOSPITAL ORGANIZATION
This branch is responsible for admissions and medical records, as well as billing, accounting and other financial aspects of the hospital. This branch includes all aspects of the hospital's physical facility, such as cleaning, maintenance, and security, as well as food service and procurement.
INTRODUCTION TO THE CLINICAL LABORATORY
FUNCTIONS OF THE CLINICAL PATHOLOGY LABORATORY
It is also used to diagnose and classify malignancies, aiding in the development of treatment plans. You will learn much more about all these responsibilities in the coming chapters.
STANDARDS AND ACCREDITATION FOR THE CLINICAL LABORATORY
The reagents (test chemicals) embedded in the pads change color, indicating the results of the test. These are usually newer tests that may require special equipment or training not available in the laboratory.
OTHER HEALTH CARE SETTINGS
Globally Harmonized System (GHS) of Classification and Labeling of Chemicals Irritant Contact Dermatitis Latex Sensitivity. The Occupational Safety and Health Administration (OSHA) is the government agency responsible for workplace safety.
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
TYPES OF SAFETY HAZARDS
Bleach is used as a disinfectant in the laboratory, which causes irritation of the mucous membranes and skin. The National Fire Protection Association (NFPA) mark (Figure 3-6) is a design recognized by firefighters that indicates the location of hazardous materials in the event of a fire.
QUICK CARD TM
If you cannot turn off the electricity, break the contact between the source and the victim using a non-conductive material, such as a wooden broom handle. Fires or explosions in the laboratory may occur as a result of chemical or electrical accidents or carelessness with flames or other sources of fire.
EMERGENCY FIRST-AID PROCEDURES
These correspond to the type of extinguisher that should be used to fight the fire, as shown in Table 3-2. Health care workers must be trained in CPR techniques and must refresh their skills twice a year.
DISASTER EMERGENCY PLAN
If you are not trained in rescue breathing or cannot give rescue breaths, you should perform compressions (“Hand-only CPR”) only after determining that the victim is unresponsive and not breathing normally. If the victim is unresponsive and not breathing or only gasping, begin chest compressions immediately.
SENSITIVITY TO LATEX AND OTHER MATERIALS
Define the Occupational Safety and Health Administration (OSHA) and explain its role in infection control. The goal of infection control is to develop and maintain an environment that minimizes the risk of acquiring or transmitting infectious agents to hospital staff, patients and visitors.
INFECTION
BLOODBORNE PATHOGENS
Contact with mucous membranes (eyes, nose and mouth) through splashing or touching the eyes, nose or mouth with an infected glove or hands. Laboratory equipment such as centrifuges or quality control products that use human blood or body fluids should be handled with appropriate precautions.
CHAIN OF INFECTION
Environmental agents that can cause airborne disease include Aspergillus (fungus) and anthrax (bacteria). Some infectious agents are transmitted by agents such as arthropods (eg insects and ticks) that are not harmed by their presence.
BREAKING THE CHAIN OF INFECTION
Hand hygiene includes (1) washing your hands with regular or antimicrobial soap and water and (2) rubbing your hands with an alcohol-based hand sanitizer. Wearing gloves reduces, but doesn't rule out, your hands carrying infectious agents.
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION’S
Pull the gloves tight and stretch the ends of the gloves over the cuffs of the dress. Employers must provide free medical follow-ups to workers in case of accidental exposure.
ISOLATION CONTROL MEASURES
For used needles, the safety device must be activated and disposed of in the needle box in the room. There should be a special tourniquet in the patient's room, or the tourniquet should be thrown away.
CLEANING UP A SPILL
UNIT 2
HOW TO USE THIS CHAPTER
PARTS OF A WORD
For example, antecubital includes the suffix -al, meaning "pertaining to"; prefix ante-, meaning "before". Hence the word means "pertaining to the area in front of the elbow." Tables 5-1 through 5-3 list commonly used prefixes, suffixes, and roots.
Hemat o logy ven i puncture
The body's tissues, organs, and systems work together to create and maintain homeostasis, the integrated control of body function that is characteristic of health. Describe the eight major body cavities and list at least one organ contained in each.
LEVELS OF ORGANIZATION
Smooth muscle, or nonstriated involuntary muscle, lines blood and lymph vessels within the
The three main parts of the neuron are the dendrite, cell body, and axon (Figure 6-4). It also includes the muscles that inflate the lungs, such as the diaphragm, the rib muscles and the muscles of the neck.
ANATOMIC TERMINOLOGY
After a brief discussion of anatomical terminology, we review the structure and function of the body systems, discuss how they may be involved in disease, and indicate what tests may be ordered to monitor their function. The elbow is distal to the shoulder, and the hand is distal to the wrist.
SKELETAL SYSTEM
Synarthrosis (fixed): Fixed or fixed joints include the sutures of the cranial and facial bones. Diarthrosis (free range of motion): Appendicular joints such as the shoulder, elbow and knee move freely.
MUSCULAR SYSTEM
Scoliosis: curvature of the spine from one side to the other; it can be congenital or develop during the teenage years. Lyme disease: inflammation of the synovial membrane caused by a bacterial infection; transmitted by tick bites.
INTEGUMENTARY SYSTEM
NERVOUS SYSTEMS
The CNS controls movement by sending commands to the muscles. the motor part of the PNS. Sensory neurons, called afferents, receive stimulation from specialized cells in their sense organs—eyes, nose, mouth, ears, skin, and subcutaneous tissue such as joints, muscles, and internal organs.
DIGESTIVE SYSTEM
Diseases of the central nervous system are most commonly diagnosed with imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT). Disorders of the digestive system Disorders affecting the digestive system include infections, inflammation, chemical injuries, and autoimmune diseases (Box 6–5).
URINARY SYSTEM
Blood pressure forces fluid out of the glomerulus, into Bowman's capsule, and then into the renal tubule. Renal failure - the inability of the kidneys to maintain blood homeostasis - is life-threatening and must be treated with dialysis or transplantation.
RESPIRATORY SYSTEM
Respiratory Disorders Disorders affecting the respiratory system include infection, inflammation, obstruction, inadequate ventilation, developmental disorders, and neoplastic disease (Box 6-7). Diseases of the upper respiratory tract are usually treated by a primary care physician or an ear, nose, and throat (ENT) specialist.
ENDOCRINE SYSTEM
The thymus gland sits behind the sternum and plays a key role in the early development of the immune system. Disorders of the endocrine system Disorders affecting the endocrine system are most commonly related to hypersecretion or hyposecretion (Boxes 6-8).
REPRODUCTIVE SYSTEMS
A separate but related circulatory system, the lymphatic system, redistributes intercellular fluid and provides an important transport route for cells of the immune system. The structure of each type of blood vessel is adapted to its function in the system.
CIRCULATORY SYSTEM
The four chambers of the heart are the left and right atria (singular: atrium) and the left and right ventricles (Figure 7-1). Contraction of the left atrium forces blood through the mitral valve into the left ventricle.
LYMPHATIC SYSTEM
You should not discuss the purpose of a test with a patient - that is the role of the doctor. Lymphatic fluid is also important for the transport of fat - terminal lymphatics in the intestine absorb dietary fat and keep it out of the capillary circulation.
IMMUNE SYSTEM
UNIT 3
Methicillin-resistant Staphylococcus aureus MRSA Occupational Safety and Health Administration PST Plasma Separator Tubes.
PHLEBOTOMY EQUIPMENT
ORGANIZING AND TRANSPORTING EQUIPMENT
You may need them during a draw; for example, you may need to replace a tube while the needle is still in the patient's arm (which can happen if you get a defective tube). The armrest locks to prevent the patient from falling out in case of fainting.
LOCATING VEINS
A trolley is sometimes used to transport large quantities of supplies when you plan to collect samples from many patients, but the trolley should stay in the hospital corridor to reduce the risk of spreading infection from one patient to another. Once in the patient's room, do not place your tray on the patient's bed, where it can easily tip over, or on the patient's nightstand that is used for eating.
CLEANING THE PUNCTURE SITE
A blood pressure cuff can also be used as a tourniquet when veins are difficult to find. When such a device is placed correctly, veins are visible as dark lines in the tissue.
PROTECTING THE PUNCTURE SITE
Using the cuff requires special training in addition to your normal phlebotomy training and should only be done with the approval of your supervisor.
NEEDLES
The gauge describes the diameter of the needle lumen, the hollow tube inside the shaft. While one tip of the needle penetrates the patient's skin, the other tip pierces the rubber cap of the drained collection tube.
NEEDLE ADAPTERS
To respond to this problem, the OSHA issued a directive in November 2000, emphasizing the use of safety devices to reduce the number of sharps injuries. Federal law mandates the use of safety devices, and many states have passed legislation related to safety devices.
NEEDLE SAFETY
The Needlestick Safety and Prevention Act specified types of "technical controls" mentioned in OSHA's Bloodborne Pathogens Standard to increase needle safety. Adapters come in different sizes for different diameter pipes, and it is important to choose an adapter that fits the pipe you are using.
EVACUATED COLLECTION TUBES
For example, for a simple metabolic panel, the minimum sample size is 0.5 ml of serum or plasma. However, you can choose a 2.7 ml tube for a pediatric patient or someone with small veins, knowing that the minimum testing requirements would be met, as this would give you approximately 1.5 ml of plasma.
TYPES OF BLOOD SPECIMENS
You may choose to draw a larger volume, however, perhaps because smaller tubes are more expensive or because the test equipment works better with a particular tube size. When stocking supplies, the tubes should be rotated by date so that the oldest tubes are in front and used first and the newest tubes are in the back.
TUBE ADDITIVES
Notes: Fill the tube completely to maintain the ratio of nine parts blood to one part sodium citrate (e.g. 4.5 ml blood to 0.5 ml citrate). Additives: Antiglycolytic (iodoacetate or sodium fluoride) that preserves glucose, perhaps the anticoagulant potassium oxalate or heparin Specimen: Plasma.
ORDER OF DRAW
These tubes are always withdrawn before tubes containing other types of anticoagulants or coagulation activators because other additives can contaminate this tube and interfere with coagulation testing. Other colored tubes are usually drawn after these six, but you should check the manufacturer's packaging instructions and your laboratory's procedures manual for specific information.
NEEDLE DISPOSAL CONTAINERS
You ask his name and he replies, "I'm Tommy Phelps." Then check the identification band on your wrist—the number matches the number on the application form.
REQUISITIONS
Third, it allows you to collect the necessary equipment for the collection before meeting the patient. If you have obtained an ABN for a patient, it is therefore very important that the patient signs the form before you provide the service.
PATIENT IDENTIFICATION
If the service (such as a blood draw) is performed without an ABN and Medicare rejects the reimbursement claim, your facility is not allowed to bill the patient for the service. At a minimum, you will need to ask the patient to state his or her name and date of birth.
ROUTINE VENIPUNCTURE
- Greet and identify the patient
- Position and prepare the patient
- Perform hand hygiene, and put on gloves
- Apply the tourniquet
- Select the site
- Palpate the vein
- Assemble your equipment
- Clean the site
- Reapply the tourniquet
- Examine the needle
- Perform the venipuncture
- Fill the first tube
- Advance and change the tubes
- Remove the tourniquet
- Prepare for needle removal
- Withdraw the needle
- Dispose of the entire used needle collection system in the needle collection container
- Label the tubes
- Attend to the patient
- Deliver the specimen
Do this examination out of the patient's line of sight, as the sight of the needle can cause anxiety. Pull the needle assembly straight out of the patient's arm at the same angle as it was inserted.
ROUTINE VENIPUNCTURE WITH A SYRINGE
- Follow the beginning steps for a routine venipuncture
- Prepare the syringe and perform the venipuncture
- Fill the syringe
- Withdraw the needle, and transfer the blood to evacuated tubes
- Dispose of the syringe and transfer device together in the appropriate container
- Complete the procedure
- CHAPTER 10 Capillary Collection
Pushing the plunger causes hemolysis and increases the risk of an aerosol spray being created when the needle is removed. A moment later he blows on the spot to remove the last bits of fluid and then inserts the needle.
REASONS FOR PERFORMING CAPILLARY COLLECTION
EQUIPMENT FOR CAPILLARY COLLECTION
DIFFERENCES BETWEEN VENOUS AND CAPILLARY BLOOD
They are also available with a plastic capillary tube fitted inside the container to aid in the collection of the sample. These tubes are used primarily for collecting samples for CBG determinations.
SITE SELECTION
In adults and children older than 1 year, dermal punctures are almost always performed on the fingertips of the non-dominant hand. The best sites are the palmar surface of the distal segments of the third (middle) and fourth (ring) fingers (Figure 10-4).
CAPILLARY COLLECTION
- After documenting on the requisition that you are performing a capillary collection,
- Assemble your equipment
- Select and clean the site
- Position and hold the area
- Make the puncture, and dispose of the blade properly
- Prepare to collect the sample
- Collect the sample
- Complete the procedure
Massaging the finger proximal to the injection site (closer to the palm) can help increase blood flow. Gently touch the drop of blood with the scoop of the test tube and let the blood flow into the test tube.
OTHER USES OF CAPILLARY PUNCTURE
- Assemble your equipment
- Prepare the patient
- Position the arm, select the site, and clean the site
- Apply the blood pressure cuff
- Position the device
- Make the incision, and start timing
- Wick the blood away every 30 seconds
- Complete the test
- Attend to the patient
- CHAPTER 11 Venipuncture Complications
The blade is placed perpendicular to the antecubital crease on the volar surface of the forearm. Touch the edge of the filter paper to the surface of the blood drop without touching the skin or incision.
FACTORS THAT PREVENT ACCESS TO THE PATIENT
When the ID band is missing, contact the nursing station so one can be attached by the nurse on duty. Even if an ID band is in the room, unless it is on the patient, you should not draw blood.
BARRIERS TO COMMUNICATING WITH THE PATIENT
Most establishments use a commercial identification system in which the ID belt has the appropriate markings for the samples. If you are collecting a blood bank sample and your institution uses this system, make sure you have the appropriate labels.
PROBLEMS IN SITE SELECTION
The steps for collecting blood from the back of the hand are similar to those for routine venipuncture, as described in Chapter 9. A syringe allows you to control the suction to slowly draw blood from the veins, which is especially important is for elderly and pediatric patients.
PROBLEMS ASSOCIATED
For this reason, you must use a winged infusion set (WIS), or butterfly, with a smaller gauge needle and tubing or a syringe. A butterfly is ideal for a hand draw because the tube allows for a lower insertion angle than a standard needle and tube holder.
WITH TOURNIQUET APPLICATION Hemoconcentration
PROBLEMS ASSOCIATED WITH CLEANING THE SITE
- Position the patient’s hand, and apply the tourniquet
- Insert the needle
- Collect the sample
- Finish the collection
- Attend to the patient
- Dispose of the WIS
Insert the needle into the vein with the slanted side up and aligned in the direction of the vein. When the needle enters the vein, a flash of blood should appear in the tube.
COMPLICATIONS DURING COLLECTION
Withdraw the needle slightly, palpate to reposition the vein, and redirect the needle (Figure 11-5). Remove the tourniquet, withdraw the needle slightly, palpate to reposition the vein, and redirect the needle.
FACTORS THAT AFFECT SAMPLE INTEGRITY
Accidental Puncture of the Artery Puncture of the artery produces bright red blood and may cause blood to spurt or pulse into the tube.
PROBLEMS IN COMPLETING THE PROCEDURE
To prevent reflux, hold the patient's arm down so that the probe is always below the site, allowing it to fill from the bottom up. Also, after removing the tourniquet, disconnect the tubing from the needle before removing the needle from the patient's arm.
LONG-TERM COMPLICATIONS ASSOCIATED WITH VENIPUNCTURE
SPECIMEN REJECTION
SPECIMEN RECOLLECTION
Patients in the emergency room or intensive care unit may have vascular access devices or intravenous (IV) lines placed. Four special populations – pediatric patients, geriatric patients, patients requiring chronic blood draws, and emergency room patients/.
PEDIATRIC PATIENTS
