Phlebotomy: Venipuncture And Capillary Puncture

Front 1

Introduction

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The task of collecting blood samples from patients for diagnostic testing is know as phlebotomy

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Phlebotomy

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is the process of collecting blood for diagnostic purposes or bloodletting as a therapeutic measure.

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Phlebotomist

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is a person trained to obtain blood specimens by venipuncture and capillary puncture techniques

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MA role in phlebotomy

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The M.A performing venipuncture will have direct contact with the PT and perform task that are critical to the PT's diagnosis and care. during the direct contact with the PT. IT can be positive or negative depending on the skill with which the M.A performs the venipuncture.

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Circulatory System

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is the system in which the blood is transported. Which contains the heart, arteries, veins, and capillaries.

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Function of Blood

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is to carry oxygen to the body tissues and to remove the waste product, carbon dioxide. The blood also carries nutrients to all the parts of the body and moves the waste products to the lungs, kidneys, liver and skin for elimination.

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Oxygenated

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arterial blood, which contains a high level of oxygen, leaves the heart and carries the oxygen to the tissues by releasing the oxygen through the cells walls of the capillaries. At the same time carbon dioxide is being absorbed.

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Body

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contains aproximately 6 liters of blood 45% of which is formed elements.

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Arteries

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1.Carry blood from the heart, carry oxygenated blood(except pulmonary artery)
2.Normally bright red in color
3.Elastic walls that expand with surge of blood
4.No valves
5.Can feel a pulse

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Veins

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1.Carry blood to the heart, carry deoxygenated blood(except pulmonary vein)
2.Normally dark in color
3.Thin walls/less elastic
4.Valves
5.No pulse

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Plasma

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the liquid portion of uncoagulated blood

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Serum vs Plasma

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the main difference between serum and plasma is that plasma contains fibrinogen and serum does not.

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Anticoagulant

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chemical in blood tube that prevents the cloting of blood by removing the calcium from the blood or by stopping the formation of thrombin. Is used to produce plasma specimen

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Buffy Coat

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layer of WBC and platelets that form at the interface between the plasma and RBC in a tube of blood containing an anticoagulant

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Venipuncture

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is the most commonly used method for blood collection

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Prefered site for venipuncture

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is the antecubital, which is located anterior to the elbow on the inside of the arm. Medial cubital vein is the vein that is used the majority of the time. When this vein is not available, any of the other veins that can be felt may be used. These veins include the basilic, cephalic, and median veins.The veins of the feet are an alternative when the arms are not available. An M.D permission is needed before drawing blood from the veins of the leg and feet.

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Superficial Veins of the arm

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Basilic*
Cephalic*
Median Cubical*
Median*

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Arteries of the arm

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Brachial Artery
Radial Artery(wrist)
Ulnar Artery(wrist)

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Methods of Venipuncture

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require the invasive procedure of puncturing into a vein to obtain a blood sample

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Common sizes for venipuncture

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20,21, and 22 gauges and about 1 or 1.5 inches in lenght. 16 gauge needles are often used for blood banking procedures. The larger the number the smalled the gauge.

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Vaccum Tubes

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INDICATION FOR USE:
Routine collection
Multiple tubes are needed
Whenever possible
ADVANTAGES:
Fast
Relatively Safe
Best specimen quality
Large collection amount possible
DISADVANTAGES:
May not work with:
small veins
fragile veins
diffucult veins
small children
hand or feet draws

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Butterfly Assembly

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INDICATIONS FOR USE:
Small or fragile veins
Difficult draws
Small children or older adult patients
ADVANTAGES:
Least likely to collapse vein
Less painful to PT
Can attach syringe
Can attach tube adapter
Least likely to pass through small veins
Good specimen quality
DISADVANTAGES:
Syringe not as safe since tube transfer is necessary
Specimen may be hemolyzed
Not good for large amounts of blood

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Syringe

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INDICATION FOR USE:
Children
Infants
Older adult PT
Oncology PT
Severly burned PT
Obese Pt
Inaccessible veins
Extremely fragile veins
Home testing by PT
Procedure requires
Capillary Specimen
ADVANTAGES:
Easy to perform
Requires small amount of specimen
DISADVANTAGES:
Not good for dehydrated PT
Not good for PT with poor circultation
Cannot collect for:
Blood cultures
Erythrocyte sedimentation rate

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Needle Gauges Used In Phlebotomy

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23g-often considered to small, can cause hemolysis of blood cells; used sometimes with butterfly system
22g-preferred for pediatric phlebotomy or very small veins of the hands or feet
21g-most common size used with vacuum tubes
20g-appropriate, but large for common phlebotomy
18g-not used for phlebotomy, but sometimes used in blood banking/donations
16g-most commonly used in blood banking/donations

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Butterfly Collection System

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a winged infusion set

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Multidraw Needle

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-------------------III++++=======
l l l
l l l
l l l
Bevel l l
Shaft l
Hub

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OSHA

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Occupational Safety and Health Administration.

requires that safety needles be made available to employees to prevent on-the-job needlestick injuries.

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Additives

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are used to improve the quality of the specimen.

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VENIPUNCTURE TUBES

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VENIPUNCTURE TUBES

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Red: Clotting Tubes
(Nonadditive tubes)

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Additive: None or glass particles
Department for Testing:
Serum determinations
Type and cross match-blood bank
Drug levels-chemistry
RPR, Titers, HIV testing-serology/immunology

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Red/Gray: Tiger Tops"SST"
(separator tubes for serum or plasma)

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ADDITIVE:
Glass particles or Thixotropic gel
DEPARTMENT FOR TESTING:
Serum determinations:BMP's, panals(lipids, thyroid, etc), FSH, PSA
Helibacter pylori, etc- chemistry

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Green/Gray: Plasma separator tubes "PST"
(separator tubes for serum or plasma)

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ADDITIVE:
Heparin with gel separator
DEPARTMENT FOR TESTING:
Plasma determinations-chemistry
Coagulation studies-coagulation

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Light Blue: Anticoagulant
(additive tubes)

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ADDITIVE:
Sodium Citrate
DEPARTMENT FOR TESTING:
Coagulation studies-all go to coagulation department
Fibrinogen, platelet aggregation, prothrombin time(PT)
Partial Thromboplastin Time(PTT)

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Green: Anticoagulant
(additive tubes)

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ADDITIVE:
Sodium heparin
Ammonium heparin
Lithium heparin
DEPARTMENT FOR TESTING:
Electrolytes-chemistry
Coagulation studies, platelet counts
STAT chemistry panals

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Lavander: Anticoagulant
(additive tubes)

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ADDITIVE:
Ethylenediaminetetraacetic acid(EDTA)
DEPARTMENT FOR TESTING:
Whole blood specimen
CBC,WBC, differentials, sedimentation rates, hemoglobins, glycohemoglobins, hematocrits

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Gray: Anticoagulant
(additive tubes)

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ADDITIVE:
Sodium fluoride or potassium oxalate
DEPARTMENT FOR TESTING:
Blood glucose levels
Blood alcohol levels(ETOH)

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Yellow
(special tube)

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ADDITIVE:
Sodium
Polyanetholesulfonate(SPS)
Acid dextrose citrate(ACD)
DEPARTMENT FOR TESTING:
Blood Cultures
DNA or paternity testing
Viral loads(cell morphology)

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Royal Blue
(special tube)

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ADDITIVE:
Trace-element free
May contain heparin in some tubes-check label
DEPARTMENT FOR TESTING:
Toxicology studies

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Standard Order of Draw

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1.Blood culture tubes or vials:yellow top or culture bottles
2.Sodium Citrate:Light blue tops
3.Serum Tubes:Red tops and Red/Grey tops(SST)
4.Heparin Tube:Green top
5.EDTA tubes:Lavander top
6.Glycolitic inhibiter:Gray top

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BMP

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basic metabolic rate

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CBC

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complete blood count

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ETOH

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ethyl alcohol

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FSH

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follicle stimulating hormone

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HIV

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human immunodeficiency virus

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PSA

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prostate specific antigen

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RPR

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rapid plasma reagin

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SST

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strains specific typing

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Thrombin

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a type of clot activator that is used fr STAT testing.

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Tourniquet

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is a soft, pliable, rubber or elastic strip approx 1in wide by 15-18 inches long.
Cannot be on longer than 1 minute.

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PT and Specimen Identification

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The PT first and last name middle initial, any assigned identification number, the date time, and the initials of thew person collecting the specimen must be written on the tube immediatly after drawing the PT blood

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Positioning the Patient

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before blood draw discuss with the PT any previous problems with the blood being taken.

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Patient with no problems

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a.pt must be in a seated position or reclining position before any attempt is made to draw blood
b.do not allow the pt to sit on a tall stool or stand while drawing blood. There is always the possibility that the PT will syncope(faint) and be injured
c.the sitting position requires a chair with adequate arm supports that are adjustable for the best venipuncture position

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Patient who wil Syncope(faint)

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a.pt who indicated that they fainted in the past when having blood drawn should be instructed to lie down
b. reclining position is the ideal position from which to draw a blood sample from the PT
c. a pillow may be required to help support the PT's arm by keeping it straight for easier venous access

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Hematoma

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an accumalation of blood around the venipuncture site. blood will be forced out of the needle hole and into the surronding tissue

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Hemoconcentration

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a tourniquet that is left on too long

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Needle Position

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the needle should be inserted at a 15-30 degrees angle to the surface of the skin.