1. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Chapter 40 Phlebotomy: Venipuncture and Capillary Puncture

2. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Why Collect Blood? Phlebotomy: for diagnostic purposes or bloodletting as therapeutic measure Bloodletting dates to ancient Egyptians Phlebotomy historically used to cure patients with “bad” blood Also called venipuncture

3. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. The Medical Assistant’s Role in Phlebotomy To collect blood as efficiently as possible for accurate and reliable test results Role varies Direct contact with patient Provide high-quality care Must act professionally

4. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Anatomy and Physiology of the Circulatory System Blood forms in body’s organs and bone marrow Blood carries oxygen and nutrients to cells and removes waste products and carbon dioxide Please refer to the animations library in the StudyWARE to view video “The Blood.”

5. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Anatomy and Physiology of the Circulatory System Heart: pumps blood through body Arteries: blood flows away from heart Veins: blood flowing back to heart Capillaries: connecting most arteries and veins

6. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Anatomy and Physiology of the Circulatory System Arteries –Carry blood from heart, carry oxygenated blood (except pulmonary artery) –Normally bright red in color –Elastic walls that expand with surge of blood –No valves –Can feel a pulse

7. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Anatomy and Physiology of the Circulatory System Veins –Carry blood to heart, carry deoxygenated blood (except pulmonary vein) –Normally dark red in color –Thin walls/less elastic –Valves –No pulse

8. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Anatomy and Physiology of the Circulatory System Body contains about 6 liters of blood 45% of blood is formed elements –Erythrocytes –Leukocytes –Thrombocytes (platelets)

9. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Anatomy and Physiology of the Circulatory System 55% of blood is liquid 2.5 milliliters (mL) blood will yield about 1 mL serum Liquid part of blood is plasma Clotting converts fibrinogen into fibrin

10. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Anatomy and Physiology of the Circulatory System Centrifuge separates serum from blood Vacuum collection tubes showing serum and plasma Anticoagulant prevents blood from clotting Buffy coat: leukocytes and thrombocytes

11. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Blood Collection Most laboratory tests performed on serum, plasma, or whole blood Serum sample: serum separator vacuum tube with thixotropic gel used Do not use serum separator tubes for therapeutic drug monitoring (TDM) or toxicology studies

12. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Blood Collection Plasma and whole-blood collection –Tubes containing anticoagulants used –Preparing plasma specimen for transport or testing similar to serum preparation

13. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Blood Collection Collection of blood specimens –Venipuncture commonly used method –Antecubital area –Median cubital vein –Superficial veins in hands or wrist –Veins in feet or legs –Arteries of arms

14. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Syringes and needles –Syringes usually made of plastic –Vary in size from 1 mL to 10 mL; Luer-Lok tip –Needles attach to syringes

15. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Syringes and needles –Needles vary in gauge and length –Special needle; multidraw needle –Winged infusion set (butterfly) with safety needle

16. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Safety needles and blood collection systems –OSHA requires safety needles –Prevent on-the-job needlestick injuries –Needlestick prevention devices (NPDs)

17. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Vacuum tubes and adapters/holders –Vacuum tubes: vacuum-packed test tubes with rubber stoppers Plain or with added chemicals or substances necessary for appropriate test to be run –Plastic holders or tube adapters used in conjunction with vacuum tubes

18. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Anticoagulants, additives, and gels –Different tests require different types of blood specimens –Additive: Anticoagulant to prevent clotting of blood Chemical to help preserve blood Substance to accelerate clotting process

19. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Anticoagulants, additives, and gels –Gel plugs: act as separators between blood cells/clot and serum/plasma –Anticoagulant: chemical substance that prevents clotting; identified by tube color –Clot activators: silica particles on sides of the tubes that initiate clotting process

20. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Anticoagulants, additives, and gels –When centrifuged, gel changes to liquid –Gel forms solid plug and separates cells/clot from plasma/serum Separator thixotropic gel tube>>

21. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Order to draw –Revised Order of Draw published in 2003 by CLSI and is still the standard –Sterile collection bottles need to be filled first to prevent any contamination –After sterile culture tubes drawn, order for other tubes is related to additives in them

22. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Tourniquets –Constrict flow of blood in arm –Make veins more prominent –Rubber or elastic strip 1 inch wide by 15–18 inches long –Blood pressure cuff may be used instead

23. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Equipment Specimen collection trays –Hold all equipment necessary –Portable

24. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Approaching the patient –Social skills –Technical skills –Administrative skills

25. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Preparing supplies and greeting the patient –Prepare before venipuncture –Place all tubes within easy reach –Keep spare tubes

26. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Patient and specimen identification –Ask patient to state full name –Check wristband if applicable –Label specimen tubes before leaving examination room –Check paperwork against tubes

27. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Patient and specimen identification Computer label >> Aliquot specimen>>

28. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Positioning the patient –Comfortable for patient and health care professional Selecting the appropriate venipuncture site –Antecubital –Back of hand –Back of wrist (can be painful) –Ankle or foot (provider permission needed)

29. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Applying the tourniquet –Applied 3 to 4 inches above intended puncture site –Tightly enough to slow flow of blood in veins but not so tightly as to prevent flow of blood in arteries –On arm no longer than 1 minute –Remove as soon as blood flow established

30. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Performing a safe venipuncture –Find site that will give best blood return –Palpate vein with tip of index finger –Differentiating between veins, tendons, nerves –Use tourniquet appropriately –Avoid scars and compromised arms

31. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Venipuncture Technique Please refer to the video library on the Instructor Resources CD to view video “Venipuncture.”

32. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection Hand washing critical step Tie tourniquet Select a vein Cleanse site firmly with alcohol pad Allow area to air dry Put on gloves Palpate vein

33. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection The syringe technique –Ideal for collecting small volumes of blood from fragile, thin, or “rolling” veins –Blood placed in appropriate containers –Order of filling the tubes important –Use a safety system

34. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection The syringe technique Proper hand position to hold syringe >>

35. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection The syringe technique –After drawing blood into syringe, activate needle’s safety mechanism, then remove needle and dispose –Connect needleless syringe to transfer device –Insert vacuum tube to device –Allow blood to transfer from syringe to tube –After filling, mix any tubes containing additives

36. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection Vacuum tube specimen collection –Improvement over syringe method with only slight variations –Vacuum already in tube <<Proper hand position

37. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection Butterfly needle collection system –Combines benefits of syringe and vacuum tube methods –Used for small and fragile veins that are difficult to puncture –Winged needle inserted at 5- to 10-degree angle then threaded into vein –Works well on children

38. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection Blood cultures –Use surgical solution rather than alcohol –Use sterile techniques –Blood collected into special transport bottles Aerobic bottle filled first, then anaerobic

39. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection Patient reactions –Vary –MA must anticipate reactions and respond appropriately –If pain persists, discontinue venipuncture

40. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection The unsuccessful venipuncture –Stimulate the vein –Change position of needle by rotating needle half a turn –Advance further into vein –Pull back a little –Try another tube

41. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection The unsuccessful venipuncture –Withdraw needle slowly –Probing of site not recommended –After two attempts, have someone else try –Notify patient’s provider if two MAs unsuccessful

42. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection Criteria for rejection of a specimen –Quality-assurance controls for specimen collection and processing –Retesting specimen or collecting another sample

43. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Specimen Collection Factors affecting laboratory values –Improper specimen handling and storage –Patient physiologic factors may contribute to inaccurate results –Special handling requirements not met –Patient alters results by certain actions

44. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Capillary Puncture Method of obtaining one to several drops of blood Tests that use blood obtained by capillary puncture –CBC, RBC, and WBC –Hemoglobin and hematocrit –Glucose testing –Phenylketonuria testing

45. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Capillary Puncture Capillary blood collection sites

46. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Capillary Puncture Preparing capillary puncture site –Promoting circulation Cleaning and disinfecting >>

47. © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Capillary Puncture Performing the puncture –Wear appropriate PPE Perform puncture in one quick, steady movement >> –Wipe away first drop of blood Collect in capillary tubes or other capillary collection device >>