Phlebotomy - WV HOSA

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Dec 14, 2013 (3 years and 7 months ago)

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Phlebotomy

For

Health Care Workers


Phlebotomy

Phlebos is Greek for “Vein”

Tome means to “cut”


Phlebotomy means to cut a vein

Phlebotomy is a term used to describe the specialized technique of blood
collection by a venipuncture


“Veni” is a prefix which means vein

Puncture
refers to the penetration of the vein for any

reason, including the administration of IV’s and other

medications. (Venipuncture)


Phlebotomy is an invasive procedure that invades the body
through cutting or puncture, and is performed by

professionals known as a:
Phlebotomists


History of Phlebotomy

First documented in Egypt around 1000 BC


Removing blood from the veins dates back as far as 1400 BC


Leeches
: Were used in 1800s


Venesection
: Vein was pierced with a sharp object to drain blood


Cupping
: Produced a vacuum effect by pulling blood to the
capillaries under a heated glass cup


Phlebotomy profession emerged as a result of technology and

expansion of lab function in the late 1980s and 1900s


Bloodletting as a profession is believed to have originated with
Barber Surgeons in the 12
th

Century
, in Italy.


The Barber Surgeon carried a red and white staff or cane crowned
with a ball as a symbol of his skills in bloodletting and his role in the
health care of the day.


The
red stripe
of his staff or cane
stood for the blood of the patient


The
white stripe
was
for the bandages of the procedure


The
ball on the top was for the cup
which was
used to catch the
blood flow


The
Barber Surgeon
could perform surgeries, administer enemas, let
blood, pull teeth, and even cut hair.


A
blue and white
staff signified
patriotism

Following developments in the history of
phlebotomy in chronological order




Hippocrates’ theory on the relationship between excess body fluids


and disease




Appearance of the barber pole symbol




Collection of blood for diagnostic testing




Development of structured phlebotomy training programs




Certification of phlebotomists

Two behaviors that represent negative body


language:




Shuffling into the room



Avoiding eye contact



Demonstrate good telephone communication skills



By making sure the call is not an emergency before


placing them on hold



Providing instructions to a patient



Explain you are going to transfer their call


Why is the appearance and personal hygiene

of the phlebotomists important to the patient?

Patients feel that the quality of care they receive is
reflected by the appearance and cleanliness of the
caregiver


Five
barriers
to effective
verbal communication
and
means to overcome each:



Hearing Impairment: Speak slowly and look directly at the person



Emotions: Use a calm tone of voice and demonstrate confidence &


concern



Age: Use age
-
appropriate phrases and words



Educational Level: Use terminology appropriate to the educational


level



Language Proficiency: Attempt to locate a translator; use basic


words and sign language

Clinical and Laboratory Standards Institute (CLSI)

Established the techniques and principals for

the phlebotomy profession.

Primary role

of the phlebotomist is: To obtain blood
specimens and transport specimens for diagnostic testing.

Representative of the laboratory to the patient and the
health care staff of the institution. Requires a
professional, courteous, and understanding manner in all
contacts with the patient.


Two methods
for collecting blood is:

1.
Venipuncture

2.

Microtechnique (dermal/capillary puncture)

Sometimes arterial blood is collected by phlebotomists.




Functions of a phlebotomist

1.
To obtain venous blood specimens for
diagnostic testing

2.
To remove blood from donors for blood



transfusions

3.
Collect and properly package urine
specimens

4.
Accept incoming specimens

5.
Route specimen to the proper
departments to be tested and analyzed







Phlebotomist
is a valuable member of the
health care team



Responsible
for:


1.
Collection

2.
Processing

3.
Transportation of specimens


Duties of the phlebotomist



Demonstrate professional attire, attitude



and communications


Know facility’s policies and procedures


Properly identify patients


Collect both venous and capillary blood
specimens


Select the appropriate and accurate
specimen container for the specified
tests


Properly label, handle, and transport



specimens following department policies


Sort specimens received and process



specimens for delivery to laboratory
departments


Perform computer operations and/or



update log sheets where required


Perform point
-
of
-
care testing



Perform quality control checks


Observe all safety regulations

Cont’d



Phlebotomy Programs



Require high school diploma or GED


Offered in hospitals, technical and
private schools and community
colleges


Clinical training is from 120/200 hours


Courses vary from a few weeks to
months




Phlebotomy Organizations


ASCP: American Society of Clinical Pathologist


PBT (ASCP)


ASPT: American Society of Phlebotomy Technicians


CPT (ASPT)


AMT: American Medical Technologist


RPT (AMT)



NPA: National Phlebotomy Association


CPT (NPA)


Entering the Room

Should greet the patient and identify themselves and the
procedures that will take place. Put the patient at ease.



Effective communication is essential. Both verbal and nonverbal.


Inpatient

Proper identification of the patient is mandatory. Ask for full
name, and check armband. Hospital identification number is the
primary means for identifying the patient.


Outpatient (OPD)

Use the requisition as a reference. Birthday and social security

Number is a source of information about the patient and a
method of communication between the phlebotomist and the
laboratory staff. Today OPD patients also are given an armband.


Post Venipuncture

Thank the patient after the procedure and excuse yourself

courteously, leaving the patient with a positive impression of

you and the laboratory you represent. (Clean up work areas)

Equipment and Supplies for Venipuncture



Collection Tray with Test Tube Racks



Evacuated Tubes



Needles



Holders



Tourniquets



Safety Disposal Unit (biohazard with symbol)



Alcohol Wipes (70 % isopropyl alcohol)



2” X 2” Gauze Sponges



Bandages



Ammonia



Gloves



Requisition Forms


Common Errors



Identification of patient



Not labeling the tubes



Wrong name of the patient on tubes



Improper selection of tubes



Improper site cleansing



Improper specimen collection



Not properly mixing the tubes



Improper transportation of specimens


Problem Patients

1.
Fainting

2.

Refusal

3.

Nausea or Vomiting

4.

Convulsions

5.

Excessive Bleeding

6.

Cessation of Breathing

7.

Unconsciousness

8.

Obesity

9.

Tremors

10.

Disruptive Behavior

11.

Deaf or Hearing Impaired

12.

Communication Barriers

13.

Special Precautions

14.

Special Instructions at the Bedside

15.

Blind or visually Impaired

16.

Hematoma






Laboratory Departments



Hematology



Coagulation



Urinalysis



Immunohematology/Blood Bank



Immunology/Serology



Chemistry

1.

Toxicology

2.

Biochemistry



Microbiology

1.

Bacteriology

2.

Virology

3.

Parasitology

4.

Mycology

5.

Rickettsiology



OPD/Collection & Transportation


Hematology Department

Tube
:
Lavender/purple

Anticoagulan
t: K3 Ethylenediaminetetraacetic Acid
(EDTA)

Invert:

8 Times

This anticoagulant
binds

calcium

Tests
:

CBC= Complete Blood Count

WBC
= White Blood Cell

RBC
=Red Blood Cell

Plt
=Platelet Count

HGB=
Hemoglobin

HCT=
Hematocrit

Diff=Differential Cell Count
(Identify 100 WBCs, RBC Morphology, Platelet estimation)

Red Cell
Indicies=MCV, MCH, MCHC

RDW=
Red Cell Distribution Width

MPV
=Mean Platelet Volume

Other Test performed in this department are:

Reti=
Reticulocyte

Sed Rate, or ESR=
Erythrocyte Sedimentation Rate


Coagulation Department

Tube:

Light Blue

Anticoagulant
: Sodium Citrate

Invert
: 8 Times

Anticoagulant
binds
calcium

Tests:

PT =(Prothrombin Time)

PTT= (Partial Prothrombin Time)

APTT= (Activated Partial thromboplastin Time)

D
-
Dimer

Fibrinogen

TT=(Thrombin Time)

Coagulation Factors

FDP= (Fibrin Degradation Products)

FSP=(Fibrin Split Products)


Blood Bank/Immunohematology

Tube:

Plain Red (Glass)
other tube:
Pink
/
Lavender

Anticoagulant:

None
EDTA

Invert:
None

Tests:



Type & RH



Crossmatch (x
-
match)



Antibody Screen (ABS)



Direct Coombs (DAT)



Antibody Identification Panel



RhoGam



Cold Agglutins


Blood Unit Components:

Packed Cells, Platelets, Fresh Frozen Plasma, Cryoprecipitate



Urinalysis Department

Collection Containers:

(urine)Plastic; Paper; or Metal

(stool) Plasic

(sperm) Plastic tube

Tests:

Urinalysis



Physical (color, appearance, volume, odor)



Chemical (Sp.Gr., pH, Protein, Glucose, Ketones, Blood, Bilirubin, Urobilinogen,


Nitrite, Leukocyte esterase WBC)



Microscopic (WBCs, RBCs, Epithelial Cells, Casts, Crystals, Bacteria, etc.)


Stool (Feces)



WBC



Observe for Parasites (O & P)



Occult Blood


Spermatozoa



Sperm count



Motility


Types and Collection:

Random, First Morning, Timed, Midstream Clean
-
Catch, Catheterized


Serology/Immunology Department


Tube:
SST
/
Gold


Plain
RED

Evacuated Tubes: (SST/Gold): Gel & Clot Activator


Plain Red: None

Invert: SST/Gold mix 5 Times

Tests:

Mono

RA/RF

Lupus

ASO TITER

CRP (C
-
Reactive Protein)

ANA (antinuclear Antibody)

HCG (Human Chorionic Gonadotropin) Pregnancy Tests

Anti
-
HIV

Hepatitis B Surface Antigen (HBsAG)

Rapid Plasma Reagin (RPR)

VDRL (Venereal Disease Research Laboratory)


Chemistry Department

Tubes:
Gold/
SST


Red


Green/
Mint Green


Gray


Lavender


Royal Blue


Clot Activator/Plain tunes:


Gold
/
SST
: Gel & Clot Activator


Red
: None

Anticoagulant tubes:


Green
: Heparin (Sodium, Lithium, Ammonia)


Mint Green
: Gel & Plasma Activator


Gray
: Sodium Fluoride & Potassium Oxlate


Lavender
: EDTA


Royal Blue: Red: None; Lavender: EDTA; Green: Heparin

Invert: 5
-
8 Times except for the Red which is none






Chemistry Cont’d

Tests:

Electrolytes: Cardiac:

Sodium CK
-

MB (Creatine Kinase)

Potassium SGOT/AST

Chloride LDH/LD (Lactic Dehydrase)

Carbon Dioxide ALT/SGPT


Tropin

Kidney:

BUN
Liver:

Creatinine SGOT/AST (Aspartate Aminotransferase)

Creatinine Clearance ALT (Alanine Aminotransferase)


ALP (Alkaline Phosphatase)

Bone:
Bilirubin (Total & Direct)

Calcium GGT (Gamma Glutamyl Transferase)

Phosphous


Amylase


Lipase

Lipids:
Vitamin B12

Cholesterol (HDL, LDL, VLDL) Lactic Acid

Triglycerides Folate


Ammonia

Glucose (2 Hr PC, GTT, Fasting)



Microbiology Department

Procedures

in this department are: Cultures, Stains, Microscopic
examinations

Biochemical Reactions

Specimens

are:

Blood

Urine

Feces

Sputum

Genitourinary Tract

Vaginal

Eye

Ears

Nose

Throat

Wounds (Anaerobic, aerobic)


Special Handling Requirements

Chilled Specimens Warmed Specimens

Acetone Cold Agglutinin Test

Ammonia

Blood Gases

Catecholamine

Corticotropin

Fibrinogen

Ketones

Lactic Acid

Serum
Gastrin

(
Chilled specimens are cooled immediately following collection to slow down metabolic
processes that may alter some chemical values.)

Light
-
Sensitive Specimens

Bilirubin

Carotene

Erythrocyte Protoporphyrin

Vitamine

B12

Folate

To protect from light wrap the collection containers in aluminum foil., or place in a dark

container.


Special Procedures

GTT: Glucose Tolerance Test

(Diabetes Mellitus)

A multiple
-
timed glucose test that evaluates the metabolism of carbohydrates over
time

2 hour PC/PP:
A type of glucose specimen collected 2 hours after the ingestion of
food

Fasting:

Nothing to eat or drink for 8
-
14 hours




Forensic or Chain of Custody Specimens

Forensic specimens
, which may be required for law enforcement agencies or

litigation, must follow a special protocol called chain of custody.

Chain of Custody
: is a process of in
-
depth documentation that accounts for every
personnel contact with the specimen from time of collection through

Recording of the final results

Blood Alcohol
: Must carefully follow institutional procedure when collecting these

specimens. Use a non alcohol antiseptic or soap and water for cleansing .

Use a vacuum tube with sodium fluoride




Toxicology


Specimens evaluated for the presence of drugs


Therapeutic Drug Monitoring (TDM):

Collection and testing of blood to evaluate and manage medication therapy

effectively and safely

Important to the diagnosis and safe management of drug treatment of the client


Peak Level
: A drug level in the blood collected 15 to 30 minutes after the dosage

has been administered or when the highest serum concentration is expected


Trough Level:
A drug level in the blood collected when the lowest serum concentration
is expected, which is usually immediately before administering the next dosage


Coagulation



Primary
Hemostasis


1. Vascular Platelet Phase


2. Platelet Plug


3. Bleeding time



Secondary
Hemostasis


1. Stable fibrin clot


a. Extrinsic System


b. Intrinsic System


c. Common Pathway


2. Laboratory Assessment


a. Prothrombin Time


b. Activated Partial Thromboplastin Time


Fibrinolysis


1. Breakdown of clot


2. Fibrin degradation Products of D
-
dimers


Blood




Plasma



Formed Elements


1.
Red Blood Cells (Erythrocytes)


a. Function (Transports O2 and CO2)


b. Production


c. Destruction


d. ABO Blood Type Groups


e. Rh Blood Type (positive or negative)


2.
White Blood Cells (Leukocytes) Body Defense


a.
Neutrophils (most numerous of WBC’s)


b.
Lymphocyts


c.
Monocytes


d.
Eosinophils


e.
Basophils


3.
Platelets

(
Thrombocytes
) Blood Clotting



Three Major Types
of Blood Vessels


Arteries:

(Oxygenated Blood)

Are muscular and carry blood
away

from the
heart


Veins:
(Deoxygenated Blood)

Have
valves

and carry blood
to the heart


Capillaries:

(
Resembles more Oxygenated Blood
)

Have walls only one cell thick for exchange of

substances between the blood and tissues



Flow of Blood through the heart


Vena cava

Right Atrium

Right Ventricle

Pulmonary Artery

Lung

Pulmonary Vein

Left Atrium

Left Ventricle

Aorta


Types

of Needles

1. Multi
-
sample (evacuated method)

2.
Hypodermic (syringe)


Parts
of Needles

1. Hub

2.

Shaft

3.

Beveled Point


Size

of Needles

1.
16
-
Gauge (Blood Donor Collection)

2.
21
-

Gauge (Routine Venipuncture)

3.

23
-
Gauge (Patient with small veins, butterfly)


Order of Draw



Blood Cultures (Sterile) SPS/
Yellow



Coagulation Tubes (Sodium Citrate)
Light Blue



SST/
Gold ,
Plain Red



Green

(Heparin)/

(PST)
Mint Green



Lavender

(EDTA)



Gray
(Sodium Fluoride, Potassium Oxalate)



Yellow

(ACD)

Information that must be on a patient’s ID band



Patient’s Name



Patient’s ID Number



Date of Birth



Requesting
Physician



Tests requested



Date and Time


Where to look for ID Band on the patient



Wrist



Ankle


3 Reasons
for requiring a requisition




Authorization to perform the procedure




Collection of appropriate equipment




Patient location and identification





Three Major Veins




Median
Cubital

(middle)




Cephalic (outer side)




Basilic

(Inside)


Tourniquet

Length of time to leave on the arm is:


One Minute


Why use a tourniquet?

To permit arterial flow and to block


venous flow


Placement of tourniquet

3 to 4 inches above the bend of elbow


Four test results that are affected by prolonged tourniquet application are:

Proteins, Lipids, Enzymes, and Potassium



3 Reasons for vein palpation


1. Determining the
direction

of the vein


2.

Determining the
depth

of the vein


3.

Determining the
size

of the vein



Reasons to allow the
alcohol to dry
on the patient’s arm before venipuncture


1.
Maximum
bacteriostatic

action


2.

Preventing a stinging sensation for the patient


3.

Prevention of
hemolysis



Alcohol + Blood =
Hemolysis

Two tests seriously affected by
hemolysis

are:

1.
Potassium

2.

LD


Hemolysis
:
Red Cell destruction (Pink)

Lipemic
:

Fats in Blood (Milky)

Jaundice:

Yellow Color of plasma or serum (eyes, skin)

Reasons why blood may not be obtained

1.
Collapsed vein

2.

Occluded vein

3.

Bevel of the needle resting on the wall of the vein

4.

Defective evacuated tube


Causes of hematomas

1.
Removing the needle before removing the tourniquet

2.
Enadequate

pressure or bending the arm

3.
Excessive probing

4.
Needle not fully inserted through the vein

5.

Needle inserted through the vein



Specimen Rejection

1.
Unlabeled specimen

2.
Mislabeled specimen

3.
Inadequate Volume

4.
Wrong Tube

5.
Hemolysis

6.
Clotted
Anticoagulated

Tube

7.
Improper Transport

8.
Missing Requisition Form

9.
Contaminated Specimen Container

What is a
professional?

A person having great skill or experience in a particular field


What is the
definition of phlebotomy?

To cut into a vein for the purpose of withdrawing a blood specimen


What is the
definition of venipuncture?

To cut into a vein for any purpose


Communication skills
consist of :

Speaking in a pleasant tone, making eye contact, being patient


Who is considered the “
father” of modern medicine?

Hippocrates


What is a “
barber
-
surgeon”?

A person who would cut hair, give an enema, let blood and pull teeth

What does
OSHA stand for?

Occupational Safety and Health Administration


What does
OSHA do?

Sets standards for a safe and healthy workplace


What is the
best way for
a health care professional
to avoid
infection?

Hand washing between each patient and to wear gloves


If an
infection is airborne
, it means?

It is spread through droplets


An
infectious organism
is an organism which is?

Capable of spreading disease


What is a
susceptible host?

Someone who lacks an effective resistance to a disease


An infection would cause the release of:

White Blood Cells

What equipment is needed to clean up a blood spill?

Gloves, Bio
-
Hazard Bag, Paper Towel, and 1:10 dilution of bleach


What is the number
-
one cause of exposure to disease in health care
workers?

Needle
-
stick injuries

What is the CDC?

Center of Disease Control


What type of antiseptic is used to cleanse the skin of pathogenic
bacteria
fora

normal blood specimen?

70% Isopropyl
Alchol

What infection is more easily spread through accidental
needlestick

injury?

Hepatitis

What is PPE?

Personal Protective Equipment



How should a blood tube be opened to aliquot a sample?

The tube top should be covered and “popped” away from the phlebotomist


Where should lab coats be worn?

In the work place setting


The department responsible for analyzing a “Type/
Crossmatch
” is?

Blood Bank

Other tests in this department are?

Direct Coombs, and Indirect Coombs

The color of tube used primarily in this department is?

Plain Red (May use Lavender or Pink)


The department that analyzes an H & H, CBC, Reti,
SedRate
,
Platelet Count,
Diff,RBC
, WBC, Platelet count is?

Hematology

The color of tube for this department is?

Lavender/Purple

Anticoagulant in this tube is?

EDTA (Ethylenediaminetetraacetic Acid)

What department within a laboratory would handle a PTT/APTT
specimen?

Coagulation/Special Hematology

What is the color of tube?

Light Blue

What is the anticoagulant?

Sodium Citrate

Other tests in this department are:

PT, Fibrinogen, D
-
Dimer
, Coagulation factors

APTT must be tested within 4 hours


What department within a laboratory would handle a specimen for a
Culture and Sensitivity?

Microbiology


In what department of the hospital would you see a patient having
radioactive isotopes injected into his/her arm?

Nuclear Medicine



What kind of specimens are sent to the anatomical pathology
laboratory?

Biopsy Tissue, Cytology Specimens, Autopsy Specimens


Blood collected in a Red Tube Yields:

Serum


What are the 3 main veins that are used for venipuncture?

Basilic
, Median
Cubital
, Cephalic


The most common vein used for venipuncture is?

Median
Cubital


Whenever drawing blood some of the considerations used for
deciding which vein to draw blood from is?

Bounce, Depth, Size also does it move, is it visible, does it looked bruised and red,

Does it have a pulse and is it too hard and cord
-
like to puncture


Veins are located
in Skeletal Muscle and Collagen


Veins have
valves



What gauge needle is most commonly used for performing venipuncture?

21
-
22 Gauge (20
-
22)


What is an evacuated system?

One that has tubes that are vacuum

Is a Closed System


What is a non
-
evacuated system?

One that consist of a needle and a syringe

Use for tiny veins


Butterfly needle
is used on Pediatric Patients


Whenever drawing blood from an IV site, how much blood should you
draw in a discard tube?

10 cc/10ml

Draw below (distal) to the site of the IV


Whenever doing a
venipuncture proper ID of patient
is the single most
important step




What reaction might occur if the patient is upset or frightened?

Sympathetic blood flow could occur and the WBC and Glucose will elevate


The purpose of the tourniquet is?

To give the vein time to fill as it “DAMS” the blood between the site and tourniquet


Remove the tourniquet within how many minutes?

One to two

Why?


If left on longer it can cause
hemoconcentration


Clean a venipuncture site in?

Concentric Circle


What is the common bacteria found on the skin?

Staphylococcus
aureus


Do not use the window for doing a venipuncture, Why?

Because if the
patient”Jumps
”, and you might get stuck with the needle


The proper way to hold a vein for a venipuncture is?

With your thumb below the site and fingers out of the way