1. CHAPTER 17
Phlebotomy

2. Introduction to Phlebotomy
Purpose of phlebotomy: collect blood for laboratory analysis
Phlebotomy: incision of a vein for the removal of blood
Phlebotomist: individual who collects the blood sample

3. Introduction to Phlebotomy
Types of blood collections
Arterial puncture
Venipuncture
Skin puncture
Venipuncture is the puncturing of a vein for the removal of a venous blood sample and is performed when a large blood specimen is needed for testing

4. Introduction to Phlebotomy
Methods of Venipuncture
Vacuum tube – uses an evacuated tube and is the fastest, most convenient, and most often used method
Butterfly and syringe – used for difficult draws such as small or sclerosed veins

5. General Guidelines for Venipuncture
Patient preparation
Fasting
Avoidance of medications
Special preparation required by outside laboratories

6. Collection and Handling Requirements
Collection Supplies
Type of specimen required
Amount of specimen required
Techniques for collecting specimen
Proper handling and storage of specimen

7. Assembling Equipment and Supplies
Appropriate blood tubes
Ensure tubes are not broken, cracked or expired
Label each blood tube
Unique patient identifiers, such as name and date of birth
Date and time of collection as well as collector’s initials
Laboratory requisition

8. Supplies and Equipment
Venipuncture needle
Double pointed needle with threaded hub that attaches to vacutainer
Has a bevel that facilitates easier insertion into the skin and vein
Gauge sizes are 20 to 22 with 21 G being the most common size used
Length is 1 to 1 ½ inches

9. Supplies and Equipment, cont.
Vacutainer/Plastic Holder
Used to secure the needle and hold the evacuated tubes
Evacuated tubes
Glass or plastic tubes with rubber stopper on one end
Tubes have a vacuum that assists in drawing the blood into the tube
Evacuated tubes have different colored stoppers which indicate the type of additive in the tube

10. Supplies and Equipment, cont.
Tourniquet
Makes patient veins stand out; they are easier to see and palpate
Different types of tourniquets
Velcro closure
Rubber
Latex and non-latex

11. Reassuring the Patient
Explain the procedure
Instruct the patient to remain still
Tell patient there will be a small amount of pain associated with the procedure
Make sure patient is ready for procedure; tell them they will “feel a small stick”

12. Venipuncture – Vacuum Tube Method
Review requirements and tubes from order
Sanitize your hands
Greet and identify patient; discuss previous draw experiences
Assemble equipment
Tubes, vacutainer, needle, tourniquet, gloves, alcohol pads, gauze, cotton, co-ban
Check for expirations on all equipment

13. Venipuncture – Vacuum Tube Method, cont.
Prepare equipment
Place tube loosely in vacutainer
Apply tourniquet to assess veins
Take tourniquet off, clean area with alcohol
Put tourniquet back on, position arm
Anchor vein using thumb and first finger of non-dominant hand

14. Venipuncture – Vacuum Tube Method, cont.
Insert needle at a 15 degree angle
Stabilize the tube, never change hands during the procedure
Fill each tube to exhaustion
As last tube fills to 3/4 s full, remove tourniquet and remove tube
Place gauze or cotton at site and apply pressure

15. Venipuncture – Vacuum Tube Method, cont.
Apply co-ban
Place tubes in upright position after labeling
Remove gloves and sanitize
Chart the procedure
Appropriate sites for antecubital
vacuum tube method of
venipuncture

16. Butterfly Method of Venipuncture
Called the Butterfly method because of the “wings” located between the tubing and needle

17. Butterfly Method of Venipuncture, cont.
Used when veins are smaller, have a thin wall or are more likely to collapse
Gauge of needle is 21 to 23
Length of needle is ½ to ¾ inch
After collecting equipment and supplies:
Seat patient
Assess veins and locate vein for venipuncture

18. Butterfly Method of Venipuncture, cont.
Follow procedure used for antecubital draw
Compress plastic wings together with bevel up
Insert at 15 degree angle to skin
After inserting, decrease angle to 5 degrees
Follow order of draw

19. Alternate Venipuncture Sites
Inner forearm
Wrist area above the thumb
Back of the hand
Top of the foot

20. Types of Blood Specimens
Clotted Blood – has no additives in tubes
Serum – required for most blood chemistry studies
Obtained from clotted blood which is obtained from tubes with no anticoagulants
Whole blood – required for blood hematology studies such as a complete blood count
Plasma – obtained from tubes that have anticoagulants to prevent clotting

21. OSHA Safety Precautions
To avoid exposure to bloodborne pathogens:
Wear gloves
Avoid hand-to-mouth contact while working with blood specimens
Wear a face shield or mask and eye protection
Perform all procedures in a manner to minimize the splashing, spraying, or splattering of blood
Bandage cuts before gloving

22. OSHA Safety Precautions, cont.
Sanitize hands after removing gloves
If exposure to blood occurs, wash with soap and water immediately
If mucous membranes come in contact with blood flush with water immediately
Do not break, bend, or shear contaminated venipuncture needles
Do not recap contaminated venipuncture needles

23. OSHA Safety Precautions, cont.
Locate sharps containers and keep close
Place blood specimens in containers that prevent leakage during collection, handling, processing, storage, transport, and shipping
Handle lab equipment and supplies properly
Do not store food in refrigerator where testing supplies and specimens are stored
If exposed to blood – report incident to physician or employer immediately

24. Order of Draw for Multiple Tubes
Tubes must be drawn in a specific order as to not contaminate specimens

25. Problems Encountered with Venipuncture
Failure to obtain blood
Can occur with obese or elderly patients
After two attempts ask for assistance
Reasons for not getting blood:
Needle not inserted far enough
Needle inserted too far
Bevel lodged against the wall of vein

26. Hemolysis Hemolysis is the breakdown of blood cells
This can occur due to rough handling and can cause inaccurate test results
To prevent hemolysis:
Store tubes at room temperature
Allow alcohol to air dry completely
Do not use small gauge needles to collect specimen
Handle tubes carefully
Do not shake or handle tubes

27. Fainting Some patients do not do well with venipuncture
Protect patient from injury
Place patient in a position that will promote blood flow to brain
Notify provider for further treatment

28. Inappropriate Puncture Sites
When not to use a potential site:
Scarred areas or sclerosed veins
Bruised areas
Burned skin
Adjacent to areas of infection
Edema
Avoid the arm on the same side of a radical mastectomy

29. Preparation of Specimen
If centrifuging is required:
Allow tube to stand upright 20 to 30 minutes at room temperature
Do not let blood stand for more than one hour as this causes leaching and will lead to inaccurate test results
Centrifuge specimen for 10 minutes
Hold tube up to light to look for intact red blood cells or hemolysis
If so, re-centrifuge specimen

30. Skin Punctures Used to obtain capillary blood specimens
Also known as a capillary puncture
Example of tests:
Hemoglobin
Hematocrit
Blood glucose
Prothrombin time

31. Skin Punctures, cont. Puncture sites:
Finger tip is preferred for adults
Earlobe as a back-up
Plantar surface of heal for infants, birth to one year

32. Skin Puncture Devices
Disposable semiautomatic retractable lancet devices
Disposable lancets recommended by OSHA
Reusable semiautomatic retractable lancet device

33. Skin Puncture Devices, cont.
Depth of puncture
Adults: no deeper than 3.1 mm
Infants and children: no deeper than 2.0 mm
If puncture is too deep, may penetrate bone
Could result in osteochondritis or osteomyelitis

34. Micro-collection Devices
Specimens can be collected on various devices:
Reagent strips
Capillary tubes
Micro-collection tubes

35. Performing a Finger Puncture
Use lateral part of tip of third or fourth finger
Do not use index finger because it is too callused
Do not use little finger because the amount of tissue is not deep enough and could cause injury to bone
Cleanse site with antiseptic wipe
Ask patient to remain still
Firmly grasp finger, select site, firmly press lancet against site, and perform puncture

36. Performing a Finger Puncture, cont.
Wipe away the first drop of blood, it is not suitable for testing
Allow large drop to form
Can massage the finger, but do not squeeze, this can cause inaccurate readings
Collect specimen
Apply pressure to ensure bleeding stops; apply bandaid