Chapter 8 Venipuncture Equipment

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Learning Objectives  List the equipment that should be available for venipuncture.  Describe the purpose of a tourniquet; list types that may be used to locate a vein.  Differentiate between an antiseptic and a disinfectant. List those that may be used for blood collection.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 Learning Objectives  Locate the bevel, shaft, hub, and point of a needle. Describe safety features that may be included.  Define gauge.  Name the parts of a syringe, and describe how the syringe system differs from the evacuated tube system.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 Learning Objectives  Explain when a syringe system or winged infusion set (butterfly) is used in blood collection.  Describe the proper use of the tube holder (needle adapter).  Differentiate whole blood, serum, and plasma. List at least one use for each.  Describe at least nine additives, including their mode of action and uses.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Learning Objectives  List at least 10 different colors for tube stoppers. Identify the additives(s) in each, and state one use for each.  State the correct order in which various types of tubes should be collected.  Describe the proper disposal of a used needle.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6 Phlebotomy Equipment  Equipment needed includes: needles, tubes, sharps disposal container, needle holders, syringes, winged infusion sets, pens, gloves, tourniquets, antiseptic, gauze, and bandages.  Phlebotomists will carry equipment in a tray or a cart to draw blood on inpatients. Never place the tray on a patient’s bed.  Outpatients will come to a drawing station and use a phlebotomy chair with a locking armrest.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7 Phlebotomy Equipment

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Tourniquet  A tourniquet is the most common way to locate a vein.  A tourniquet prevents venous blood flow which causes the veins to bulge.  A tourniquet may be latex or nonlatex.  A tourniquet may be used only once and disposed of or cleaned before use on another patient. Follow your facility’s policy regarding tourniquet reuse.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 The Puncture Site  Use 70% isopropyl alcohol, an antiseptic, to cleanse the skin before a venipuncture.  Alcohol left to dry on the arm is bacteriostatic.  Disinfectants are used on work surfaces to kill microorganisms and are not safe for use on the skin.  For allergic patients, use iodine, chlorhexidine gluconate or benzalkonium chloride.  Apply a 2 in. by 2 in. gauze square to apply pressure to the puncture site after needle removal.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Needles  All needles have a point, bevel, and shaft.  The shaft can differ in length and gauge.  The gauge describes the diameter or lumen of the needle.  The larger the gauge number, the smaller the lumen of the needle.  You will learn to pick the correct gauge depending on the patient’s veins.  For adults use a 20 to 21 gauge; for children or adults with small veins use a 22 to 23 gauge.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11 Parts of a Needle

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12 Multisample Needles  This needle is double- ended with one tip used on the patient’s arm and the second end used to pierce tube stopper.  There is a retractable rubber sleeve that covers the second tip when tubes are changed to prevent blood from leaking into the holder.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13 Syringes and Syringe Needles  A syringe has a plunger, a barrel and a syringe needle (Figure 8-4, p. 117).  Syringes are used on small, fragile veins to control the pull of vacuum on the veins.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14 Syringes and Syringe Needles  You will see a flash of blood in the hub of the needle when you are in the vein.  Blood must be transferred to evacuated tubes.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15 Winged Infusion Sets (Butterflies)  Butterflies are used on pediatric or elderly patients for small veins such as in the hand.  The butterfly has a ½ to ¾ inch, 23 gauge needle with wings and plastic tubing.  The syringe or tube holder can be attached at the end. From Bonewit-West K: Clinical Procedures for Medical Assistants, 6th ed. Philadelphia, Saunders, 2004.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16 Needle Safety  OSHA and the Needle Safety and Prevention Act requires the use of safety devices when collecting and transferring blood.  There are many kinds of safety needles and safety holders available for use.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17 Evacuated Tube System (ETS)  The ETS uses a multisample needle, an evacuated tube and an adapter.  The needle and holder are used once and then disposed of “intact” into a sharps container.  It is best to use tubes, holders, and needles from the same manufacturer for best fit.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18 Evacuated Tube System

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19 Evacuated Collection Tubes  Tubes are color coded and come in assorted sizes in either plastic or glass.  The tube size selected depends on the patient, his vein size and the amount of blood needed.  Each tube contains an “additive” or chemical added to the tube to prevent or promote changes in the blood sample.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20 Types of Blood Specimens  Whole blood is mixed with an anticoagulant to prevent clotting and is for hematology cell counts.  Serum is the fluid portion of blood after clotting and is used for chemistry testing such as glucose.  Plasma is the fluid portion of blood containing an anticoagulant and is used for stat chemistry testing.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21 Tube Additives  Any tube with an additive must be inverted 5 to 8 times after collection.  Tube additives are identified by the stopper color.  Many tubes are coated with silicone to prevent blood from sticking to the sides.  Only the red glass tube contains NO additives.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22 Anticoagulants  Anticoagulants prevent blood from clotting.  The choice of anticoagulant varies with the test being done.  Different anticoagulants work in different ways to prevent clotting and yield plasma: - EDTA, citrate and oxalate bind calcium. - EDTA, citrate and oxalate bind calcium. - heparin inhibits conversion of prothrombin to thrombin. - heparin inhibits conversion of prothrombin to thrombin.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23 Antiglycolytic Agents  Sodium fluoride is an additive in the gray stopper tube used for glucose.  Sodium fluoride inhibits glycolysis, or metabolism of glucose, for accurate testing.  Lithium iodoacetate is an acceptable alternative also available in the gray stopper tube for glucose testing.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24 Clot Activators  Thrombin is an additive that promotes coagulation.  Glass or silica promote clotting by providing more surface area for platelet activation.  Tubes with clot activators must be inverted to allow blood to come into contact with the activator.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25 Thixotropic Gel  An inert, synthetic substance with a density between that of cells and plasma or serum.  When a blood tube with gel is centrifuged, spun at high speed, the gel becomes liquid and forms a layer upon hardening between the cellular and liquid layer.  Example: SST (Serum Separation Tube)

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26 Color Coded Tube Stoppers  Tube: Red (glass) Allow 30 min. to clot. Allow 30 min. to clot.  Additive: None  Specimen: Serum  Tests: Chemistry (glucose) Serology (rubella) Serology (rubella) Blood Bank (group and Rh) Blood Bank (group and Rh)

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27 Color Coded Tube Stoppers  Tube: Red (plastic)  Additive: Clot Activator  Specimen: Serum  Tests: Chemistry (glucose) Serology (rubella) Serology (rubella) NOTE: Do not use for Blood Bank testing.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28 Color Coded Tube Stoppers  Tube: Light Blue  Additive: Sodium citrate (anticoagulant)  Specimen: Plasma  Tests: Coagulation tests PT (prothrombin time) PT (prothrombin time) NOTE: Tube must be filled to its correct level to maintain a 9:1 ratio of blood to anticoagulant.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29 Color Coded Tube Stoppers  Tube: Lavender  Additive: K 2 or K 3 EDTA (anticoagulant)  Specimen: Whole blood  Tests: CBC (complete blood count) Hgb (hemoglobin) Hgb (hemoglobin)

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30 Color Coded Tube Stoppers  Tube: Pearl  Additive: K 2 EDTA plus gel  Specimen: Plasma  Tests: Viral Loading

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31 Color Coded Tube Stoppers  Tube: Gold Hemogard TM Closure Red/Gray Stopper  Additive: Clot activator/ thixotropic gel  Specimen: Serum  Tests: Chemistry (glucose, BUN) Both tubes referred to as SSTs for serum separation tube.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32 Color Coded Tube Stoppers  Tube:Gray Additive: sodium fluoride or iodoacetate to preserve glucose; may be combined with potassium oxalate or heparin (anticoagulants).  Specimen: Serum or plasma  Tests:Fasting blood sugar/alcohol levels

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33 Color Coded Tube Stoppers  Tube: Black  Additive: Sodium citrate (anticoagulant)  Specimen: Whole blood  Tests: ESR (erythrocyte sedimentation rate) NOTE: Tube must be filled to its correct level to maintain a 4:1 ratio of blood to anticoagulant.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34 Color Coded Tube Stoppers  Tube: Green  Additive: Heparin (anticoagulant)  Specimen: Plasma  Tests: Stat chemistry tests – glucose, electrolytes, ammonia.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35 Color Coded Tube Stoppers  Tube: Light green or green/gray stopper  Additive: Heparin/thixotropic gel  Specimen: Plasma  Tests: Stat chemistry tests – glucose, potassium, BUN. This tube is referred to as a PST or plasma separation tube.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36 Color Coded Tube Stoppers  Tube: Orange or yellow/gray stopper  Additive: Thrombin (clot activator)  Specimen: serum  Tests: Chemistry tests when serum is required on patients on anticoagulant therapy. This tube will clot the blood in 5 minutes.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37 Color Coded Tube Stoppers  Tube: Royal blue  Additive: Heparin/EDTA or none  Specimen: Plasma or serum  Tests: Toxicology trace metals, lead This tube is specially cleaned and has special stoppers to prevent specimen contamination.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38 Color Coded Tube Stoppers  Tube: Tan  Additive: Heparin  Specimen: Plasma  Tests: Lead Tube is formulated to contain less than 0.1microgram/mL (ppm) of lead.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39 Color Coded Tube Stoppers  Tube: Yellow (Sterile)  Additive: SPS (sodium polyethanol sulfonate) to inhibit complement and phagocytosis and keep blood from clotting.  Specimen: Whole blood  Tests: Blood culture to recover organisms that cause blood infection.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40 Color Coded Tube Stoppers  Tube: Yellow (Nonsterile)  Additive: ACD (acid citrate dextrose)  Specimen: Whole blood  Tests: Paternity testing, tissue typing The dextrose nourishes and preserves RBCs and the citrate is an anticoagulant.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41 Color Coded Tube Stoppers  Tube: Pink  Additive: K 2 EDTA  Specimen: Whole blood or plasma  Tests: Blood bank compatibility testing and antibody screening. This tube, similar to the lavender, meets labeling standards for Blood Bank. This tube, similar to the lavender, meets labeling standards for Blood Bank.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42 Order of Draw 1. Blood culture tubes  yellow sterile  to prevent cross contamination from other tubes. 2. Lt. Blue tubes for coagulation tests to prevent contamination from other additives that can interfere with testing. 3. Red, glass or plastic, gold, red-gray, SST which, except for red-glass, contain clot activators that could interfere with other samples for testing.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 43 Order of Draw 4. Green or Lt. green tubes because the heparin will not interfere with EDTA tubes. 5. Lavender tubes with EDTA which can affect calcium and potassium levels if drawn before other tubes. 6. Gray tube is last to avoid contamination of tubes for electrolyte and enzyme testing. All other colors are typically drawn after these.

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 44 Needle Disposal  Activate the needle safety device immediately after removing the needle from the arm.  Dispose of the needle and tube holder intact into a closable, sealable, puncture resistant, leakproof container clearly marked for biohazard disposal.