1. Mr. Abdulaziz.M. Biochemistry Department Laboratory Lessons
Phlebotomy
Mr. Abdulaziz.M.
Biochemistry Department
Laboratory Lessons

2. Objectives Theory and practice of phlebotomy
How to interact professionally with patients
Occupational health hazards and appropriate precautions
Related anatomy and physiology
Phlebotomy equipment and supplies
Phlebotomy procedures
Complications of venipuncture and how to handle them.

3. Theory and Practice of Phlebotomy

4. What is phlebotomy
The term phlebotomy refers to the ancient practice of bloodletting
Now the term phlebotomy is used for the withdrawal of blood from a vein, artery, or the capillary bed for lab analysis or blood transfusion.

5. Who is a phlebotomist Collects blood and other specimens
Prepares specimens for testing
Interacts with patients & health care professionals
plays a vital role in any health care system

6. Who is a phlebotomist
Other medical professionals, including doctors, nurses, technologists, and medical assistants must also be trained to collect blood specimens.

7. Laboratory work flow cycle

8. Laboratory Workflow Cycle

9. Laboratory Workflow Cycle

10. Laboratory Workflow Cycle

11. Professionalism

12. Professionalism

13. Confidentiality
All employees are responsible for maintaining confidentiality of medical information

14. Attitude
Tone of voice and facial expression will determine how patients respond to you.
Always be polite, friendly, calm, and considerate.

15. Appearance
Your personal appearance will also affect the impression you make.
Comply with your facility’s dress code and personal appearance policies.

16. Safety

17. Blood-Borne Pathogens
Infectious micro-organisms which live in the bloodstream.
You can be exposed to bloodborne pathogens if you are injured with a contaminated needle.
You can also be exposed if your mucous membranes, including eyes, mouth, or the inside of your nose come into contact with contaminated body fluids.

18. Blood-Borne Pathogens
Diagram of Hepatitis C Virus

19. Occupational Health and Safety Administration of the federal government has mandated bloodborne pathogen training for all workers who are at risk of exposure.

20. OSHA Training Standard Precautions Personal Protective Equipment
Hand Washing
Hazardous waste disposal
Needle sticks and prevention act

21. Standard Precautions

22. Standard Precautions
Standard Precautions means treating all body fluids and substances as if they were infectious.

23. Standard Precautions
Potentially infectious body fluids include: Blood, Semen, Vaginal Secretion, Peritoneal, pericardial and pleural fluids, and Saliva
Sweat and tears are not generally considered infectious.

24. Personal Protective Equipment

25. Personal Protective Equipment
lab coat
Gloves
Face masks ( certain types of isolation)

26. Hand Washing
Hand washing is the single most important infection control measure.
Wash hands thoroughly before, after, and between all patient contacts.
Be sure to turn off faucets using a paper towel to avoid contamination.

27. Hand washing Remove rings Stand by the sink but do not touch it
Apply soap and rub hands together
Both sides of the hand, between fingers, around knuckles, under fingernails
Rinse hands in a downward motion
Dry hands with a clean paper towel
Turn off water with another paper towel

28. Hand Washing

29. Hazardous waste disposal
All needles & other sharps must be disposed of in approved sharps disposal containers.
Other contaminated waste must be discarded in an appropriate biohazard bag or waste receptacle.

30. Needlestick

31. Needle sticks and prevention act
Safety Devices should always be encouraged

32. Anatomy & Physiology

33. Anatomy & Physiology
Anatomy is the branch of science concerned with the study of the structure of the body.
Physiology is the branch of science concerned with the study of the function of the body.

34. Anatomy & Physiology
The cardiovascular system consists of the Heart, and Blood Vessels.
Its main function is circulate oxygenated blood from the lungs to various organs, and return blood depleted of oxygen to the lungs, where it is reoxygenated.

35. Anatomy & Physiology

36. Blood Collection sites

37. Anatomy & Physiology

38. Anatomy & Physiology

39. Blood Components

40. Blood Components Circulating whole blood is a mixture of:
Plasma (which contains fluid, proteins, and lipids), and
Formed elements, consisting of red cells, white cells, and platelets.

41. Whole Blood

42. Plasma

43. Plasma

44. Blood cells

45. Blood Clot
When a blood sample is left standing without anticoagulant, it forms a coagulum or blood clot.
The clot contains coagulation proteins, platelets, and entrapped red and white blood cells.

46. Serum
Serum contains all the same substances as plasma, except for the coagulation proteins, which are left behind in the blood clot.

47. Equipment

48. Trays Trays should be sanitized daily using appropriate disinfectant
Kept Organized and well-stocked.

49. Blood Collection tubes
glass or plastic tube with a rubber stopper.
It has a vacuum so that blood will flow into the tube.
anticoagulants and/or other chemical additives.

50. Blood collection tubes
Rubber stoppers of blood collection tubes are color coded.
Each type of stopper indicates a different additive or a different tube type.

51. LAVENDER EDTA to prevent clotting hematology studies.
Should be completely filled
Must be inverted after filling

52. LIGHT BLUE sodium citrate. coagulation (clotting) studies.
must be completely filled
must be inverted immediately after filling

53. GREEN sodium or lithium heparin
for tests requiring whole blood or plasma such as ammonia

54. RED No additives Blood bank tests, toxicology, serology
Must not be inverted after filing

55. GRAY Inhibitor for glycolysis + anticoagulant
Sodium Fluride +potassium oxalate.
glucose levels.

56. YELLOW Acid citrate dextrose Inactivates complements
DNA studies, paternity testing

57. ROYAL BLUE heparin or Na EDTA anticoagulants
Tube is designed to contain no contaminating metals
Trace element and toxicology studies

58. Blood Culture Bottles
Different blood culture bottles are used for aerobic, anaerobic, and pediatric collections.

59. Blood collection tubes: Safety
The rubber stopper is positioned inside the plastic shield

60. Sizes Adult:3 - 10 ml Pediatric 2 - 4 ml.
Tubes for fingersticks or heelsticks ½ or less

61. Expiration Dates

62. Holders
A plastic holder must be used with the evacuated tube system.

63. Needle holders with built-in protection devices

64. Syringes

65. Syringes with built-in safety devices

66. Needles

67. Needles Different sizes. size =gauge.
The larger the needle, the smaller the gauge number.
21 or 22 gauge needle is mostly used.

68. Needle Components

69. Single Draw Needle
Single draw needles are of the type that fit on a syringe, and can be used only to fill the syringe to which they are connected.

70. Multiple Draw Needle Used with vacuum collection tubes.
They have a retractable sheath over the portion of the needle that penetrates the blood tube.

71. Needles with built-in safety devices
An internal blunt needle that is activated with forward pressure on the final blood tube prior to withdrawal of the needle from the vein.

72. Butterfly Needle Winged infusion set
Difficult venipunctures including pediatric draws
with a syringe or a holder and vacuum collection tube system.
21, 23, or 25 gauge.

73. Butterflies with built-in safety features
number-one cause of needlestick injuries, so proper use of their safety devices is critical.

74. Butterflies with built-in safety features

75. Lancets
Lancets are used for difficult venipunctures, including pediatric draws.

76. Tourniquets
Vein easier to SEE, FEEL, and PUNCTURE

77. Sterilization

78. Bandaging Material

79. Gloves
Gloves must be worn for all procedures requiring vascular access.
Non-powdered latex gloves are most commonly used;

80. Sharp Disposal Container

81. Marking Pen

82. Collecting Blood

83. Greeting Always greet patient in a professional, friendly manner.
A good initial impression will earn the patients trust, and make it easier and more pleasant to draw a good specimen.
Knock on the patient’s door before entering.
Identify yourself by name and department.
Explain the reason for your presence.

84. Technical Tip
The more relaxed and trusting your patient, the greater chance of a successful atraumatic venipuncture.

85. Technical Tip
Good verbal, listening, and nonverbal skills are very important for patient reassurance

86. Patient Identification
Make sure the name, medical record number, and date of birth on your order/requisition match those on the patient’s armband.
Verify the patient’s identity by politely asking them to state their full name.

87. Patient Identification
Properly identifying patients and specimens is probably the single most critical part of your job.
The consequences of misidentifying a specimen can be life threatening.

88. Patient Identification
Never rely on the patient name on the door or above the bed. Patients are frequently moved from room to room.

89. Technical Tip
A hospitalized patient must always be correctly identified by an ID band that is attached to the patient.

90. Standard Precautions

91. Wash hands

92. Apply gloves

93. Technical Tip
Patients are often reassured that proper safety measures are being followed when gloves are put on in their presence.

94. Position the Patient Comfortable position
Turn the arm so that the wrist and palm face upward, and the antecubital area is accessible

95. Technical Tip
When supporting the patient’s arm, do not hyperextend the elbow. This may make vein palpation difficult.

96. Applying the tourniquet
Tie the tourniquet just above the elbow.
The tourniquet should be tight enough to stop venous blood flow in the superficial arm veins.
The tourniquet should be applied a maximum of 1 – 2 minutes.

97. Applying the tourniquet

98. Applying the tourniquet

99. After applying the tourniquet, you may ask the patient to make a fist to further distend the arm veins.

100. Technical Tip
Patients often think they are helping by pumping their fists
This is an acceptable practice when donating blood, but not in sample collection as this can lead to hemoconcentration

101. Choose a site The median cubital vein
If not accessible: Cephalic vein, or the Basilic vein.
If not accessible: veins on the back of the hand.
Use a much smaller needle for these hand veins.

103. Technical Tip
Using the nondominant hand routinely for palpation may be helpful when additional palpation is required immediately before performing the puncture.
Often, a patient has veins that are more prominent in the dominant arm.

105. Never draw from these areas Scarred, abraded, or inflamed skin
Arms containing IV catheters
Edematous arms
Occluded Veins
Shunts

106. Cleansing the site Isopropyl alcohol swab
Outward expanding spiral starting with the actual venipuncture site.
Allow the alcohol to dry:-
1-disinfect the site
2-prevent a burning sensation

107. Cleansing the site

108. Technical Tip
Patients are quick to complain about a painful venipuncture. The stinging sensation caused by undry alcohol is a frequent, yet easily avoided, cause of complaints.

109. Attach needle to holder

110. Place tube into holder

111. Hold vein in place

112. Insert needle
the needle bevel up

113. Push tube into holder
Gently push the tube onto the needle holder so that the catheter inside the needle holder penetrates the tube.
Blood flow should be visible at this point.

115. Technical Tip
Allow tubes to fill until the vacuum is exhausted to ensure the correct blood to anticoagulant ratio.

116. Blood won’t flow If you do not see blood flow, the tip of the needle:
May not yet be within the vein.
May have already passed through the vein.
May have missed the vein entirely.
May be pushed up against the inside wall of the vein.

117. TROUBLESHOOTING

118. Incomplete collection or no blood is obtained:

119. Incomplete collection or no blood is obtained:
Change the position of the needle. Move it forward (it may not be in the lumen)

120. Incomplete collection or no blood is obtained:
or move it backward (it may have penetrated too far).

121. Incomplete collection or no blood is obtained:
Adjust the angle (the bevel may be against the vein wall).

122. Incomplete collection or no blood is obtained:
Loosen the tourniquet. It may be obstructing blood flow.
Try another tube. There may be no vacuum in the one being used.
Re-anchor the vein. Veins sometimes roll away from the point of the needle and puncture site.

123. Other Problems
A hematoma forms under the skin adjacent to the puncture site - release the tourniquet immediately and withdraw the needle. Apply firm pressure.

124. Other Problems
The blood is bright red (arterial) rather than venous. Apply firm pressure for more than 5 minutes

125. Multiple Tube Collection
If you are drawing more than one tube:
Keep a firm grip in the needle holder while pressing down on the patients arm.
Use your other arm to interchange tubes.

126. Order Of Draw

127. Order of draw

129. Removing the Needle
Gently release the tourniquet before the last tube of blood is filled
Remove the last tube from the needle
Withdraw the needle in a single quick movement

130. Apply Pressure
Quickly place clean gauze over the site, and apply pressure.
You may ask the patient to continue applying pressure until bleeding stops.

131. Apply Adhesive bandage

132. Technical Tip
The practice of quickly applying tape over the gauze without checking the puncture site frequently produces a hematoma

133. Needle disposal
Remove the needle from the holder if appropriate, and properly discard it in an approved sharps disposal container.
Discard all waste and gloves in the appropriate biohazardous waste container.
Wash hands.

135. Specimen Labeling
Label specimens at the bedside according to your institution’s standard procedures, or apply preprinted labels.
Proper labeling is the single most critical task you are asked to perform.

136. Proper labeling generally includes:
Patient’s first and last name
Hospital identification number
Date & time
Phlebotomist initials
Your institution may provide bar coded computer generated labels that contain this information.

137. Summary Of Venipuncture Technique
requisition form.
Greet the patient.
Identify the patient.
Reassure the patient and explain the procedure.
Prepare the patient.
Select equipment and supplies.
Wash hands and apply gloves.
Apply the tourniquet.
Select the venipuncture site.
Release the tourniquet.
Cleanse the site.
Assemble equipment.

138. Summary Of Venipuncture Technique
Reapply the tourniquet.
Confirm the venipuncture site.
Examine the needle.
Anchor the vein.
Insert the needle.
Push the evacuated tube completely into adapter.
Gently invert the specimens, as they are collected.
Remove the last tube from the adapter.
Release the tourniquet.
Place sterile gauze over the needle.
Remove the needle, and apply pressure.
Activate needle safety device.

139. Summary Of Venipuncture Technique
Dispose of the needle.
Label the tubes.
Examine the patient’s arm.
Bandage the patient’s arm.
Dispose of used supplies.
Remove and dispose of gloves.
Wash hands.
Complete any required paperwork.
Thank the patient.
Deliver specimens to appropriate locations.

140. Syringe Specimen Collection
Small or delicate veins that might be collapsed by the vacuum of the evacuated tube system.
May also be used to collect blood culture specimens.

141. Finger stick-Specimen collection
A safety Lancet, which controls the depth of incision
Finger-sticks should not be performed on children under one year of age.

142. Finger stick
If possible, use the fourth (ring) finger or the middle finger.
Many patients prefer that you use fingers on their nondominant hand.
Choose a puncture site near the right or left edge of the finger tip.
Clean the site as you would for routine venipuncture.

143. Finger stick
Select a safety lancet appropriate for the size of the patient’s finger.
You may warm the finger prior to puncture to increase blood flow.
Make the puncture perpendicular, rather than parallel, to the finger print.

144. Finger stick
Wipe away the first drop of blood using gauze to remove tissue fluid contamination.

145. Finger stick Collect blood into an appropriate tube.
Label specimens appropriately.
Make sure bleeding has stopped. Apply an adhesive bandage if necessary.
Discard sharps appropriately.

147. Heel stick
Veins of small children and infants are too small for venipuncture;
Butterfly needles may be used to collect venous blood in older children.

148. Heel stick neonatal blood collection
These devices are designed to control the depth of incision, since going too deep into an infant’s heel could injure the heel bone, and cause osteomyelitis (bone infection).

149. Heel stick Firmly grasp the infants foot. Do not use a tourniquet.
The heel may be warmed with a cloth to help increase blood flow.
Wipe the collection site with an alcohol prep pad, and allow the alcohol to dry.
Wipe the site with sterile cotton or gauze, to be sure all the alcohol has been removed.

150. Heel stick
Puncture the left or right side (outskirt) of the heel, not the bottom of the foot.
Wipe away the first drop of blood since it may contain excess tissue fluid or alcohol which could alter test results.

151. Heel stick Collect the blood into the appropriate tube.
Do not: Squeeze the infant’s foot too tightly and wipe with alcohol during the collection.

152. Heel stick
After collection is completed, apply pressure to the puncture site with a sterile gauze pad until bleeding has stopped.
Do not apply an adhesive bandage to an infant’s foot since it may injure its delicate skin.

153. Heel stick

154. Heel stick

155. Heel stick

156. Heel stick

157. Butterfly Butterfly needles (winged infusion set)
are available in smaller gauges, and are used to draw venous blood from children, and adults with difficult veins.

158. Butterfly
Butterfly needles come attached to a small tube which may be connected to:
An evacuated tube holder, or A syringe.

159. Butterfly

160. Special situations

161. Patients refusing blood work
If someone hesitates to let you collect a blood specimen, explain to them that their blood test results are important to their care.
Patients have a right to refuse blood tests
If the patient still refuses, report and document patient refusal

162. Fainting Rarely, patients will faint during venipuncture.
It is therefore important that patients are properly seated or lying in such a way during venipuncture so that if they do faint, they won’t hurt themselves.
self-limited

163. Fainting; what to do?
Gently remove the tourniquet and needle from the patients arm, apply gauze and pressure to the skin puncture site. 
Call for help. 
If the patient is seated, place his head between his knees. 
A cold compress on the back of the neck may help to revive the patient more quickly.

165. Unsatisfactory Specimens
They can cause misleading laboratory results
Must be rejected by the laboratory.
The patient must then undergo another venipuncture to get a better specimen. 
It costs time & money to redraw the specimen.
The credibility of the laboratory is reduced if too many unsatisfactory specimens are drawn.

166. Causes of Unsatisfactory Specimens

167. Hemolysis

168. Hemolysis
Hemolysis means the breakup of fragile red blood cells within the specimen, and the release of their hemoglobin and other substances, into the plasma.
A hemolyzed specimen can be recognized after it is centrifuged by the red color of the plasma.

169. Causes of Hemolysis
Using a too small needle for a relatively bigger vein
Pulling a syringe plunger too rapidly
Expelling blood vigorously into a tube,
Shaking a tube of blood too hard.

170. Hemolysis

171. Hemolysis

172. Hemolysis
Hemolysis can cause falsely increased potassium, magnesium, iron, and ammonia levels, and other aberrant lab results.

173. Clots

174. Clots
Blood clots when the coagulation factors within the plasma are activated.
Blood starts to clot almost immediately after it is drawn unless it is exposed to an anticoagulant.
Clots within the blood specimen, even if not visible to the naked eye, will yield inaccurate results.

175. Causes of Clots Inadequate mixing of blood and anticoagulant
Delay in expelling blood within a syringe into a collection tube

176. Insufficient volume

177. Insufficient volume
short draws will result in an incorrect ratio of blood to anticoagulant, and yield incorrect test results.
Short draws can be caused by:
A vein collapsing during phlebotomy.
The needle coming out of the vein before the collection tube is full.
Loss of collection tube vacuum before the tube is full.

178. Labeling Errorrs
Labeling errors are the most common cause of incorrect laboratory results.
If detected, the incorrectly labeled specimen will be rejected.
If undetected, it will produce incorrect results which might adversely affect your patient’s care.

179. Causes Failure to follow proper patient identification procedure.
Failure to label the specimen completely and immediately after collection.

180. Ten Commandments I. Thou shalt protect thyself from injury
I. Thou shalt protect thyself from injury 
II. Thou shalt identify thy patients 
III. Thou shalt stretch the skin at the puncture site
IV. Thou shalt puncture the skin at about a 15 degree angle 
V. Thou shalt glorify the median vein 
VI. Thou shalt invert tubes containing anticoagulants immediately after collection 
VII. Thou shalt attempt to collect specimens only from an acceptable site 
VIII. Thou shalt label specimens at the bedside 
IX. Thou shalt know when to quit  
X.Thou shalt treat patient's like they are family

181. Healthcare in the new millennium

182. THE END