Chapter 40 Phlebotomy Venipuncture and Capillary Puncture 2014

Chapter 40 Phlebotomy: Venipuncture and Capillary Puncture © 2014 Cengage©Learning. 2014 Cengage All Rights Learning. Reserved. All Rights May not Reserved. be scanned, May not copied be scanned, copied or duplicated, or or posted duplicated, to a publicly or posted accessible to a publicly website, accessible in wholewebsite, or in part. 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 © 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 © 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 see the Animations/Videos button to view the clip. © 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 © 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 © 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 © 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) © 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 (m. L) blood will yield about 1 m. L serum • Liquid part of blood is plasma • Clotting converts fibrinogen into fibrin © 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 © 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 © 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 © 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 © 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 m. L to 10 m. L; Luer-Lok tip – Needles attach to syringes © 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 © 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) © 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 © 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 © 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 © 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>> © 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 © 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 © 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 © 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 © 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 © 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 © 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>> © 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) © 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 © 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 © 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 © 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 © 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 >> © 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 © 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 © 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 © 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 © 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 © 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 © 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 © 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 © 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 © 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 © 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 © 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 >> © 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 >> © 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.