Edited For Class Phlebotomy

CHAPTER - 17
PHLEBOTOMY
2004 Elsevier, Inc. All rights reserved.
Slide 0
Introduction to Phlebotomy
Purpose of phlebotomy: collect blood for laboratory analysis Types of blood collections:
Arterial puncture (performed in a hospital setting;

not by medical assistants) Venipuncture Skin puncture
Slide 1
Venipuncture
Puncturing of a vein for the removal of a venous blood sample Performed when a large blood specimen is needed Methods
Vacuum tube: use of evacuated tube (glass or

plastic tube containing a vacuum)

Fastest Most convenient Most often used
Butterfly and syringe: for difficult draws (e.g.,

small veins)
Slide 2
General Guidelines for Venipuncture

Patient preparation for venipuncture Provide patient with advance prep, if required Patient prep listed in reference sources (e.g., lab directory) Ask patient if he/she prep properly before performing (i.e. if need to be fasting, verify before drawing blood)
Just before inserting needle, tell patient he/she will

feel a small stick Avoids startling patient, which could cause patient to move
Slide 3
Patient Position of Venipuncture

Depends on vein being used Most common VP site: antecubital space
Patient should be seated in chair Arm extended in downward position to form

straight line from shoulder to wrist with palm facing up Arm should be well supported on armrest by rolled towel or by patient placing fist of the other hand under elbow
If patient state that he/she faints during VP, draw with pt.
lying and arm extended off of table
Slide 4
Patient Position of Venipuncture
Never have patient on stool or standing
Fainting could occur; patient may be injured

Venous reflux: blood flows from evacuated tube back into patients vein
Can cause patient to have adverse reaction to a tube

additive (particularly EDTA-Lavender tube) To prevent:, keep keeping patients arm in a downward position
Slide 5
Application of the Tourniquet

Purpose: makes patients veins stand out so they are easier to palpate Causes venous blood to slow down and pool in veins in front of tourniquet When applying:, important to obtain correct tension
Should slow (not stop!!) venous flow without

affecting arterial flow Too tight: obstructs arterial and venous flow and may give inaccurate test results Too loose: veins wont stand out enough to be palpated Should fit snugly and not pinch skin
Slide 6
Guidelines for Applying the Tourniquet

Do not apply over sores or burned skin Place 3 to 4 inches above bend in elbow Ask patient to clinch fist: pushes blood from lower
arm into veins for easier palpation Never leave on for more than 1 min

Uncomfortable for patient Causes venous blood to stagnate and can alter results
Slide 7
Guidelines for Applying the Tourniquet
Remove tourniquet when good blood flow is

established (Note: it is best to remove tourniquet just before removing needle) Always remove the tourniquet before removing the needle
If needle removed first: blood is forced out of puncture site into surrounding skin causing a hematoma
Slide 8
Types of Tourniquets
Rubber tourniquet: flat, soft band of rubber
Advantage: easily removed with one hand
Velcro-closure tourniquet

Band of rubber with Velcro attached at ends Easier to apply; more comfortable for patient Disadvantage: more difficult to remove; may not fit around arm of obese patients
Slide 9
Site Selection for Venipuncture

Best site usually located in antecubital space Antecubital space: surface of arm in front of elbow
Veins have wide lumen, easily accessible, close to

surface of skin Skin is less sensitive; less pain for patient
Do not use small spidery veins on surface of skin
Slide 10
Veins to use:
Median cubital: best vein; located in middle of

antecubital space Basilic and cephalic: located on either side, when median cubital cannot be used
Disadvantage: may roll; firm pressure should be applied below vein to stabilize it
Slide 11
Brachial artery is located in antecubital space
Artery pulsates, is more elastic, and has a thicker

wall If punctured patient feels more pain and blood is bright red and comes out pulsing
If occurs: remove tourniquet and needle, apply pressure with gauze pad for 4 to 5 min
Slide 12
Antecubital veins
Slide 13
Guidelines for Site Selection

Examine antecubital veins in both arms
Ask patient which vein which arm is usually used for VP. Apply tourniquet Ask patient to clench fist
Ensure that veins stand out as much as possible

Palpate for median cubital vein first; celphalic is

second choice (does not roll as much as basilic)
(
Slide 14

Use inspection and palpation to palpate vein
Vein does not have to be seen in order to be a good selection Vein feels like an elastic tube (gives under pressure)
Place one or two fingertips over vein Press lightly, then release pressure Do not use thumb to palpate (not as sensitive) Good vein feels round, firm, elastic, and engorged
Thoroughly assess vein

Slide 15
Do not leave tourniquet on for more than 1 min
Causes patient discomfort and hemoconcentration
Hints to make veins more prominent:
Remove tourniquet and have patient dangle arm over side of chair 1to 2 min Tap vein site sharply a few times with index and second fingers ( Do not do the arm slap thing!!!) Gently massage the arm from wrist to elbow Apply warm, moist washcloth for 5 min
Slide 16
Alternative Venipuncture Sites

Alternative sites:
Inner forearm Wrist area above thumb Back of hand

Are smaller and have thinner walls Use veins in hands as a last resort
Have a tendency to roll Are more difficult to stick Abundant supply of nerves in hand; uncomfortable for
patient Thin walls make them susceptible to collapsing, bruising
Slide 17
Alternative Venipuncture Sites
Slide 18
Types of Blood Specimens

Clotted blood: obtained from tube with no anticoagulant Serum: obtained from clotted blood: allow specimen to stand and then centrifuge it
Separates into serum and cells

Whole blood: use tube containing an anticoagulant to prevent clotting
Tube must be gently inverted 8 to 10 times
Slide 19
Plasma: obtained from whole blood that has been centrifuged
Separates into:

Top layer: plasma Middle layer: buffy coat (WBCs and platelets) Bottom layer: RBCs
Slide 20
Slide 21
OSHA Safety Precautions (Just in case you forgot!!!)

Wear gloves Wear face shields (or masks and eye protection)
whenever splashes, spray, splatter, or droplets of blood may be generated Perform all procedures involving blood in a manner so as to minimize splashing, spraying, splattering, and generating droplets of blood Bandage cuts before gloving Wash hands after removing gloves If hands or other skin surface come in contact with blood: wash with soap and water ASAP
Slide 22
OSHA Safety Precautions

If mucous membranes come in contact with blood: flush
with water ASAP Do not break, bend, or shear contaminated venipuncture needles Do not recap contaminated venipuncture needle Immediately after use place needle (and holder) in biohazard sharps container Place blood specimens in containers that prevent leakage during collection, handling, processing, storage, transport, or shipping If exposed to blood:, report incident immediately to your physician/employer
Slide 23
Vacuum Tube Method of Venipuncture

Frequently used to collect venous blood specimens Consists of:
Collection needle Plastic needle holder Evacuated tube

Commercially available system: Vacutainer
Slide 24
Vacuum Tube Method of Venipuncture

(Contd)
Slide 25
Needle
Available in 20 to 22 gauge
21 gauge most commonly used

Two lengths: 1 inch or 1 inches
Slide 26
Needle
Slide 27
Plastic Holder
Consists of plastic cylinder with two openings
Small opening: used to secure needle Large opening: holds evacuated tube
Flange: extension on large opening
Assists in insertion and removal of tubes Prevents holder from rolling when placed on a flat
surface
Slide 28
Safety-Engineered Venipuncture Devices

OSHA stipulates requirements to reduce needlestick and other sharps injuries Employers must evaluate and implement safer medical devices
Includes safety-engineered VP devices
Have a built-in safety feature to reduce risk of needlestick injury
Slide 29
Safety-Engineered Venipuncture Devices
Slide 30
Evacuated Tubes
Glass tube with rubber stopper Contains vacuum that creates suction
Pulls blood specimen into tube
Slide 31
Evacuated Tubes
Color-coded for easy identification of additive
Red: does not contain an anticoagulant
Used to obtain clotted blood or serum
Lavender: EDTA (anticoagulant)
Used to obtain whole blood or plasma (e.g., CBC) Used to obtain whole blood or plasma
Light blue: sodium citrate (anticoagulant)
Slide 32
Evacuated Tubes
Green: heparin (anticoagulant)
For blood gas determinations and pH assays

Used to obtain whole blood or plasma (e.g., GTT) Made of refined glass and special stopper Used to detect trace elements (e.g., lead, arsenic)
Gray: potassium oxalate (anticoagulant)
Dark blue: heparin or no additive

Slide 33
Evacuated Tubes
Slide 34
Evacuated Tubes
Additive used depends on type of test performed
Do not substitute one additive for another
Leads to inaccurate results
Label of tube indicates:
Additive content Expiration date Tube capacity
Slide 35
Evacuated Tubes
(Contd)
(Contd)
Slide 36
Order of Draw for Multiple Tubes

Blood culture tubes
Drawn first to prevent contamination by other

tubes
Red-stoppered tubes-known as red plain tops
To prevent contamination of nonadditive tubes by

additive tubes
Slide 37
Order of Draw for Multiple Tubes
Coagulation tubes (light blue)
To prevent erroneous test results When needle penetrates skin: thromboplastin can
enter blood specimen affecting results If no other tube is needed: red-stoppered should be drawn first to prevent contamination by thromboplastin or draw two blue tops and discard the first
Serum separator tubes Additive tubes: in this order: green, lavender, gray
Slide 38
Evacuated Tube Guidelines

Select proper tubes
According to tests being performed Amount of specimen needed

Check tubes for cracks; will not hold vacuum Check expiration date: outdated tube may not have a vacuum and lab will not process results. Label tube with patients name, date, MA initials
Slide 39
Fill tubes until vacuum is exhausted
Tube will be almost, but not quite full Prevents rush of air from entering tube and
damaging cells Tube with additive: ensures proper ratio of additive to blood
Slide 40
Remove last tube from plastic holder before removing needle
Prevents blood from dripping out of needle

Mix tubes containing anticoagulant immediately
Invert tube gently 8 to 10 times Shaking tube causes hemolysis Inadequate mixing may cause inaccurate test
results
After VP:, top of stopper may contain residual blood
Follow OSHA BBPs Standard to avoid exposure

Slide 41
Butterfly Method of Venipuncture

Also called winged infusion method Term butterfly derived from plastic wings located between needle and tubing Use:
Adult patients with small antecubital veins Children, who typically have small antecubital
veins When antecubital veins not available and an alternative site is used (e.g., hand)
Slide 42
Gauge of needle: 21 to 23 Length of needle: to inch Needle attached to tubing Luer adapter attached to posterior needle
Plastic holder screwed into Luer adapter
Also available with a hub adapter; used to attach syringe Safety needles available
Slide 43
Slide 44
Guidelines for the Butterfly Method

Patient position
Antecubital, wrist, and forearm veins

Arm in straight line from shoulder to wrist Hand on armrest with loose fist or grasp a rolled towel Locate vein between knuckles and wrist bones
Hand veins
Tourniquet
Forearm or wrist: 3 inches above site Hand: just above wrist bone
Slide 45
Guidelines for the Butterfly Method
Compress plastic wings together
Insert with bevel up at 15-degree angle to skin Once entered:, decrease angle to 5 degrees
After needle insertion: slowly thread needle inside vein an additional inch.
Anchors needle in center of vein

To prevent venous reflux: keep tube and holder in a downward position Follow proper order of draw (same as for vacuum tube method)
Slide 46
Syringe Method of Venipuncture

Least used method
Blood specimen must be transferred from syringe

to evacuated tube
Risk of accidental needlestick
Used to obtain blood from small veins that are likely to collapse Offers more control than other methods Once vein is entered, specimen obtained by pulling back on plunger of syringe
Slide 47
Problems Encountered with Venipuncture

Failure to obtain blood May occur with:
Obese patients: often have small veins, superficial

veins, and veins buried deeper in adipose tissue Elderly patients with arteriosclerosis may have veins that are thick and hard
Are difficult to puncture
Veins that are small or thin-walled are likely to

collapse
After two unsuccessful attempts, notify physician
Slide 48
Failure to Obtain Blood

Factors that result in failure to obtain blood once needle has been inserted:
Not inserting needle far enough prevents needle from

entering the vein
Inserting too far causes needle to go through vein

Slide 49
Bevel opening becoming lodged against vein
Slide 50
Remove needle if blood not obtained: do not probe
Uncomfortable for patient May affect integrity of blood specimen

Occasionally, evacuated tube may not have a vacuum; replace with a new tube
Slide 51
Inappropriate Puncture Sites

If patient complains of pain or soreness, avoid site Do not use areas that are:
Scarred Bruised Burned Adjacent to areas of infection
Avoid an arm in a cast or affected by mastectomy
Slide 52
Scarred and Sclerosed Veins

Caused by:
Many venipunctures over years (scarred veins) Elderly patients with arteriosclerosis (sclerosed
veins)
Veins feel stiff and hard; difficult to stick Recommended: use another vein
If not possible:, insert needle with careful pressure

to avoid going through vein
Slide 53
Collapsing Veins
Most likely to collapse: small veins with thin walls More likely to occur with vacuum tube method
Sucking action of vacuum causes vein to collapse
Use butterfly or syringe method on patients with small veins
Slide 54
Premature Needle Withdrawal

Needle comes out of vein prematurely Caused by
Patient movement Improper VP technique

Blood is forced out of puncture site from pressure of tourniquet Immediate action is required to prevent hematoma:
Remove tourniquet Apply pressure with gauze until bleeding stops
Slide 55
Hematoma
Blood leaks from vein, resulting in a bruise Cause:
Needle inserted too far and goes through vein Bevel opening is partially within and partially out of
vein Applying insufficient pressure after removal of needle
First sign: sudden swelling in area around puncture site
Remove tourniquet and needle STAT Apply pressure until bleeding stops
Slide 56
Hematoma
(Contd)
Slide 57

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CHAPTER - 17

2004 Elsevier, Inc. All rights reserved.

Arterial puncture (performed in a hospital setting;

2004 Elsevier, Inc. All rights reserved.

Vacuum tube: use of evacuated tube (glass or

Fastest Most convenient Most often used

Butterfly and syringe: for difficult draws (e.g.,

General Guidelines for Venipuncture

Just before inserting needle, tell patient he/she will

2004 Elsevier, Inc. All rights reserved.

Patient Position of Venipuncture

Patient should be seated in chair Arm extended in downward position to form

2004 Elsevier, Inc. All rights reserved.

Patient Position of Venipuncture

Never have patient on stool or standing

Fainting could occur; patient may be injured

Can cause patient to have adverse reaction to a tube

2004 Elsevier, Inc. All rights reserved.

Application of the Tourniquet

Should slow (not stop!!) venous flow without

Guidelines for Applying the Tourniquet

2004 Elsevier, Inc. All rights reserved.

Guidelines for Applying the Tourniquet

Remove tourniquet when good blood flow is

2004 Elsevier, Inc. All rights reserved.

Advantage: easily removed with one hand

2004 Elsevier, Inc. All rights reserved.

Site Selection for Venipuncture

Veins have wide lumen, easily accessible, close to

Do not use small spidery veins on surface of skin

2004 Elsevier, Inc. All rights reserved.

Site Selection for Venipuncture

Median cubital: best vein; located in middle of

2004 Elsevier, Inc. All rights reserved.

Site Selection for Venipuncture

Brachial artery is located in antecubital space

Artery pulsates, is more elastic, and has a thicker

2004 Elsevier, Inc. All rights reserved.

2004 Elsevier, Inc. All rights reserved.

Guidelines for Site Selection

Ensure that veins stand out as much as possible

Palpate for median cubital vein first; celphalic is

2004 Elsevier, Inc. All rights reserved.

Guidelines for Site Selection

Thoroughly assess vein

2004 Elsevier, Inc. All rights reserved.

Guidelines for Site Selection

Do not leave tourniquet on for more than 1 min

Causes patient discomfort and hemoconcentration

Hints to make veins more prominent:

2004 Elsevier, Inc. All rights reserved.

Alternative Venipuncture Sites

Inner forearm Wrist area above thumb Back of hand

2004 Elsevier, Inc. All rights reserved.

Alternative Venipuncture Sites

2004 Elsevier, Inc. All rights reserved.

Types of Blood Specimens

Separates into serum and cells

Tube must be gently inverted 8 to 10 times

2004 Elsevier, Inc. All rights reserved.

Types of Blood Specimens

Plasma: obtained from whole blood that has been centrifuged