1. Assisting in Phlebotomy
Chapter 53

2. Learning Objectives
Define, spell, and pronounce the terms listed in the vocabulary.
Apply critical thinking skills in performing patient assessment and care.
List the equipment needed for venipuncture.
Explain the purpose of a tourniquet.
Explain how to apply a tourniquet and three consequences of improper application.
Explain why the stopper colors on evacuated tubes differ.

3. Learning Objectives
State the correct order in which various types of tubes should be collected.
Describe the types of sharps used in phlebotomy.
Explain why a syringe is used for blood collection rather than an evacuated tube.
Discuss the use of sharps with engineered sharps injury protection.
Summarize postexposure management of needlesticks.
Detail patient preparation for venipuncture that displays sensitivity to patient rights and feelings.

4. Learning Objectives
Describe and name the veins that may be used for blood collection.
List, in order, the steps of a routine venipuncture.
Collect a venous blood sample using the syringe method.
Collect a venous blood sample using the evacuated tube method.
Explain the reasoning behind choosing a winged infusion set (butterfly) over an evacuated tube.
Perform a venipuncture using a winged infusion set.

5. Learning Objectives
Summarize typical problems that may be associated with venipuncture.
Identify the major causes of hemolysis during a venous blood collection.
List situations in which capillary puncture would be preferred over venipuncture.
Discuss proper dermal puncture sites.
Describe containers that may be used to collect capillary blood.

6. Learning Objectives
Explain why the first drop of blood is wiped away when a capillary puncture is performed.
Perform a capillary puncture.
Differentiate whole blood, serum, and plasma, and give an example of a test performed with each.
Describe handling and transport methods for blood after collection.

7. Phlebotomy The practice of drawing blood.
The most common method of obtaining blood is by venipuncture.
What are some reasons that a physician would perform blood work for a patient?

8. Venipuncture Equipment
Venipuncture chair – adjustable locking armrest to protect fainting patient
Gloves:
Glove use during venipuncture is mandated by OSHA.
Caution with latex products
Tourniquet
Tied 3 to 4 inches above elbow immediately before venipuncture; a tourniquet on for longer than 1 minute may alter test results
When is it appropriate to ask a patient if he or she prefers to lie on a table to have blood drawn?
Why should you ask each patient if they have a latex allergy?
Explain the procedure for applying a tourniquet.

9. Venipuncture Equipment
Identify each of the items in this phlebotomy tray.
From Stepp CA, Woods MA: Laboratory procedures for medical office personnel, Philadelphia, 1998, Saunders.

10. Venipuncture Equipment
Tourniquet
Prevents venous flow out of the site, causing veins to bulge.
Makes veins easier to locate and puncture.
From Flynn JC Jr: Procedures in phlebotomy, ed 3, Philadelphia, 2005, Saunders.
What types of tourniquets are available? How long can a tourniquet be left in place?
What happens if the tourniquet is left on the arm too long?

11. Venipuncture Equipment
Antiseptics
70% isopropyl alcohol most commonly used
Alcohol does not sterilize skin; inhibits reproduction of bacteria that might contaminate the sample.
To be most effective alcohol should remain on skin 30 to 60 seconds.
Should not be used when drawing blood alcohol test. Sterile soap pads, benzalkonium chloride, or povidone-iodine (Betadine) can be used.
Cleansing before blood culture collection requires more vigorous cleansing with Betadine.
Give an example of when it would be best to use Betadine to cleanse a puncture site.
What is the procedure for cleansing a puncture site?

12. Evacuated Collection Tubes (Vacutainers)
Tubes of various sizes with color-coded tops indicating tube contents
Volumes range from 2 to 15 ml
Match needle gauge to tube size; the larger the tube, the greater the vacuum and more likely blood will hemolyze if a high-gauge, small-lumen-sized needle is used
Each test requires a specific amount of blood; refer to the laboratory manual to ensure you are drawing the right amount of blood for the test
Tests may be combined to reduce the number of tubes
Blood is about half cells and half liquid; for a test requiring 3 ml of serum 6 ml of blood must be collected
Why is it important to use the appropriate size needle with a vacutainer?
How will you know how much blood is needed for each test ordered?
How much blood would you have to draw to get a 2-cc sample of plasma?

13. Tube Additives Red-topped tube Ethylenediaminetetraacetic acid (EDTA)
No additive
Ethylenediaminetetraacetic acid (EDTA)
Lavender-topped tube
Prevents platelet clumping and preserves appearance of blood cells for microscopic examination
Clot activators promote clotting of blood
Silica particles
Thrombin quickly promotes clotting; used in tubes drawn for stat chemistry testing or for patients taking anticoagulants
Without a clot activator, blood will clot in 30 to 60 minutes, after which it must be centrifuged
Discuss the different additives placed in tubes and their associate tube top colors.

14. Tube Additives Anticoagulants prevent blood from clotting
Whole blood sample – CBC and blood typing
Centrifuge sample to separate plasma from blood cells – plasma used for stat chemistry testing and coagulation studies
Thixotropic gel
SST and the PST green-gray marbled topped tubes
Forms a barrier between red cells and plasma when centrifuged
When are each of these vacutainer types appropriate?

15. Critical Thinking Application
Melissa Machen has been assigned to orient Leah to the clinic and her duties as a certified medical assistant. Melissa takes Leah to the laboratory in the clinic. There is a small room with a blood collection chair and a table. What supplies should be on the table to perform venipuncture?
What else might Leah find in this room?
Discuss the scenario.

16. Order of Collection
Order applies to the filling of tubes when blood is
collected in a syringe.
1. Blood culture tubes.
2. Red-topped tubes.
3. Light blue-topped tubes with sodium citrate.
Serum tubes without (red stopper) or with (red-gold or speckle stopper) clot-activator.
5. Green-topped tubes.
Lavender-topped tubes follow.
Red/gray marble-topped tubes are next.
8. Gray-topped tube.
Explain the importance of following the proper order of collection.
What is meant by carryover?
What might happen if the appropriate order of collection is not followed?

17. Needles
The venipuncture needle has a shaft with one end cut at an angle (bevel).
The other end attaches to the syringe or to an adaptor (hub).
Gauge is designated by a numeric value.
The higher the number, the smaller the lumen.
Describe safety needle devices.
Explain the relationship between gauge numbers and lumen size.

18. Syringes
Used when there is concern that the strong vacuum in a stoppered tube will collapse the vein.
The syringe needle fits on the end of the barrel and comes in different gauges.
It must be transferred immediately to another tube because the blood will clot in the syringe barrel.
When might a syringe be used to draw blood rather than a vacutainer?

19. BD Vacutainer Blood Transfer Device
Courtesy Becton, Dickinson & Company, Franklin Lakes, NJ.

20. Winged Infusion Sets (Butterfly Needles)
Designed for use on small veins such as those in the hand or in pediatric patients.
Needle size is 23 gauge.
Needle is ½ to ¾ inch long with a plastic, flexible butterfly-shaped grip attached to a short length of tubing.
When is it appropriate to use a winged infusion set?
What is the typical needle size?

21. Winged Infusion Set (Butterfly Needle)
Courtesy Becton, Dickinson & Company, Franklin Lakes, NJ.

22. Needle Holders Translucent cylinders.
Cylinders have a ring that indicates how far the tube can be pushed onto the needle without losing the vacuum.
Needles are not removed from the needle holder, and the safety feature must be activated before disposal.
Explain the purpose of needle holders.
What is done with them after the blood is drawn?

23. Needle Safety Never recap a needle. Use safety needles and shields.
Self-sheathing safety devices
How would you implement this safety needle cover?

24. Needle Safety Retractable safety device
Needle blunting SESIP for the needle holder
With retractable needles, after the needle is used, pushing the plunger automatically retracts the needle into the syringe or needle holder.

25. Needle Safety Needle blunting SESIP for winged infusion sets
Hinged or sliding safety SESIP
How do these needle covers work?
Why is it important for employers to provide safety needle systems?
Modified from Garrels M, Oatis C: Laboratory testing for ambulatory settings, ed 2, St Louis, 2011, Saunders.

26. Needle Safety Postexposure management of needlesticks
Care of the exposure site
Evaluation of the exposure
Follow-up care and testing
Discuss postexposure follow up for a needlestick.

27. Protection Against Needlesticks
Avoid the use of needles when safe and effective alternatives are available.
Help your employer select and evaluate devices with safety features.
Use devices with safety features provided by your employer.
Never recap a contaminated needle.
Plan for safe handling and disposal before beginning any procedure using needles.
Summarize a variety of methods for preventing needlesticks.

28. Protection Against Needlesticks
Dispose of used needles and needle holders promptly in appropriate sharps disposal containers.
Report all needlestick and other sharps-related injuries promptly to ensure that you receive appropriate follow-up care.
Tell your employer about hazards from needles that you observe in your work environment.
Participate in blood-borne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination.
What microorganisms are of most concern for phlebotomists who have experienced an accidental exposure?

29. Critical Thinking Application
During her lunch break, Leah meets some of her co-workers. The conversation in the lunchroom involves an accident that occurred several years ago when a former employee was performing venipuncture on a recovering intravenous drug addict and was accidentally stuck with the needle. Describe the procedure for follow up of an accidental needlestick incident.
What measures are available to prevent accidental needlesticks?
Discuss the case.

30. Routine Venipuncture
Prepare the patient – greet and identify the patient; obtain verbal consent; ask if the patient has had problems with venipuncture in the past
Prepare for the venipuncture – examine both antecubital spaces for site; place tourniquet 3 to 4 inches above the patient's elbow making sure it is not twisted; ask patient to make a fist and palpate for an acceptable vein
What is an acceptable method for identifying the patient in the ambulatory care setting?
How do you establish informed consent for patients who are ordered venipunctures?
When is it acceptable to touch the venipuncture site with your finger?
Review Standard Precautions that should be used for each blood draw.

31. Routine Venipuncture
Perform the venipuncture – after locating a vein remove the tourniquet; it can remain in place for 1 minute; after removal must wait 2 minutes before reapplying; apply gloves and cleanse area with alcohol in a circular motion; do not touch after cleansing; patient should make a fist; anchor the vein and swiftly insert the needle at a 20- to 30-degree angle; unclench fist when blood enters tube
Complete the procedure – gently invert tubes several times; when last tube fills release tourniquet and quickly remove needle; apply direct pressure to site with gauze, do not bend arm; properly dispose of materials; monitor patient and label tubes
Summarize Procedures 53-1 and 53-2.
Explain the step-by-step procedure for drawing blood.
How many times should vacutainers be inverted immediately after the tube fills?
Explain how you would take care of the patient after the procedure is completed.

32. Phlebotomy Requisitions
Must have the following information:
Patient name
Date of birth
Identification number
Name of physician making the request
Type of test requested
Test status (timed, fasting, stat, and so forth)
Summarize the information that must be included on a laboratory form for phlebotomy procedures.

33. Problems Associated with Venipuncture
Failure to obtain blood
Hematoma
Syncope
Refer to Table 53-4
Review Table 53-4 and discuss.
How can a hematoma form?
What should you do if the patient has a history or vertigo or syncope during past venipunctures?

34. Critical Thinking Application
During her second week at the clinic, Leah is confident that she can perform phlebotomy on her own. Melissa has been a good mentor, and Leah has done quite a few successful “sticks” without any problems. Today, however, she is just having a bad day. Mr. Godfrey Lawrence has come to the clinic with numerous problems, and Dr. Gupta has ordered several blood tests. Mr. Lawrence is uncooperative when he sees that Leah must draw four tubes of blood. He angrily tells her that she cannot take that much blood out of him; she is a vampire and she will drain him. How should Leah deal with this problem?
Discuss the scenario.

35. Specimen Recollection
Unlabeled or mislabeled specimen
Quantity not sufficient
Defective tube
Incorrect tube used for test ordered
Hemolysis
Clotted blood in an anticoagulated specimen
Improper handling
Discuss reasons that phlebotomy must be repeated.
How can these problems be averted?

36. Critical Thinking Application
Leah next must draw a sample from Ms. Danielle Rollins. Ms. Rollins indicates that she has a history of bruising after venipuncture, and sure enough a hematoma begins to rise shortly after Leah inserts the needle. She then notices that Ms. Rollins has become pale and is perspiring. What should Leah do first?
What other steps should Leah take? Can she still obtain the sample?
Discuss the case.

37. Capillary Puncture Older patients
Pediatric patients (especially under the age of 2 years)
Patients who require frequent glucose monitoring
Patients with burns or scars in venipuncture sites
Obese patients
Patients receiving intravenous therapy
Patients who have had a mastectomy
Patients at risk for venous thrombosis
Patients who are severely dehydrated
Tests that require a small volume of blood
When venous blood and capillary blood are not identical
Why might you need to perform a capillary puncture on an elderly patient?
Where are pediatric capillary sticks performed?

38. Equipment Skin puncture device Lancet
Courtesy Becton, Dickinson & Company, Franklin Lakes, NJ.

39. Equipment
Collection containers

40. Equipment
Manufacturers also provide various collection devices designed to obtain small quantities of blood for “point-of-care” testing for analytes such as glucose, hemoglobin A1c, and cholesterol
Paper cards
Discuss the equipment needed to perform a capillary stick.

41. Capillary Puncture Site selection Patient preparation
Collection of the specimen
Specimen handling
Discuss Procedure 53-4.
What sites might be used?

42. Critical Thinking Application
Melissa calls the first patient into the room. Mrs. Cara Miata is visiting the doctor today to have coagulation studies done. She is a pleasant, talkative woman, 88 years of age. Melissa begins to organize her supplies. She examines Mrs. Miata’s arms and decides that it would be best to draw from the hand. Why do you think she makes this decision?
What supplies will she need to draw from the hand? What tubes will she collect?
Discuss the scenario.

43. Pediatric Phlebotomy
Performed only by personnel trained in the techniques for pediatric phlebotomy.
Tactfully determine if the parent is comfortable with assisting in restraining an uncooperative child.
Refer to Table 53-7.
Collect blood by dermal puncture for those under 2 years of age; may use dorsal hand vein with 23-gauge winged infusion set
Discuss Table How could you gain the cooperation of a child ordered to have a phlebotomy?
Refer to Table What is it important to limit the amount of blood drawn from pediatric patients?
What equipment is used to perform pediatric phlebotomy?

44. Critical Thinking Application
As much as Leah likes children, performing capillary puncture on little fingers is not one of her favorite things to do. Mrs. Spix brings her son Garrett in for a hemoglobin and hematocrit test. Garrett is 3 years old. Mrs. Spix nervously asks Leah about the procedure and the tests that Garrett must have. How can Leah adequately answer Mrs. Spix’s questions and make Garrett and his mother feel at ease about this procedure?
What supplies will she need? Explain how she will perform the capillary puncture.
Discuss the scenario.

45. Handling Specimens Most samples are centrifuged
Should be refrigerated and tested within 72 hours
Blood may be drawn for drug and alcohol testing, DNA analysis, or parentage testing
Samples must be handled according to special procedures to prevent tampering, misidentification, or interference with the test results
Follow chain of custody procedures
Correctly handling and storing samples is crucial to laboratory results.
Describe guidelines for proper handling and storage.
Why are most blood samples centrifuged before transport to a referral lab?
Explain the meaning of chain of custody procedures.
What antiseptic should you use when doing phlebotomy for alcohol screening?

46. Patient Education
The medical assistant must maintain a professional attitude and still be sympathetic to the fears and apprehensions of the patient.
Use the patient’s suggestion in choosing the site for the removal of a blood specimen.