Phlebotomy OF patient ,some basic knowledge,its an important topic for all Lab specialist

2. Phlebotomy

3. Objectives
• Theory and practice of phlebotomy
• How to interact professionally with patients
• Occupational health hazards and appropriate
precautions
• Related anatomy and physiology
• Phlebotomy equipment and supplies
• Phlebotomy procedures
• Complications of venipuncture and how to handle
them.

4. Theory and Practice of Phlebotomy

5. What is phlebotomy
• The term phlebotomy refers to the ancient
practice of bloodletting
• Now the term phlebotomy is used for the
withdrawal of blood from a vein, artery, or the
capillary bed for lab analysis or blood
transfusion.

6. Who is a phlebotomist
• Collects blood and other specimens
• Prepares specimens for testing
• Interacts with patients & health care
professionals
• plays a vital role in any health care system

7. Who is a phlebotomist
• Other medical professionals, including
doctors, nurses, technologists, and medical
assistants must also be trained to collect
blood specimens.

8. Laboratory or Blood Bank work flow
cycle

9. Laboratory Workflow Cycle

10. Laboratory Workflow Cycle

11. Laboratory Workflow Cycle

12. Professionalism

13. Professionalism

14. Confidentiality
• All employees are responsible for maintaining
confidentiality of medical information

15. Attitude
• Tone of voice and facial expression will
determine how patients respond to you.
• Always be polite, friendly, calm, and
considerate.

16. Appearance
• Your personal appearance will also affect the
impression you make. Professional dress.
• Comply with your facility’s dress code and
personal appearance policies.

17. Safety
micro-organisms
bloodborne pathogens
contaminated body fluids.

18. Blood-Borne Pathogens
• Infectious micro-organisms which live in the
bloodstream.
• You can be exposed to bloodborne pathogens
if you are injured with a contaminated needle.
• You can also be exposed if your mucous
membranes, including eyes, mouth, or the
inside of your nose come into contact with
contaminated body fluids.

19. • Advance countries :
Occupational Health and Safety Administration
of the federal government has mandated
bloodborne pathogen training for all workers
who are at risk of exposure.

20. Training
• Standard Precautions
• Personal Protective Equipment
• Hand Washing
• Hazardous waste disposal
• Needle sticks and prevention act

21. Standard Precautions

22. Standard Precautions
• Standard Precautions means treating all body
fluids and substances as if they were
infectious.

23. Standard Precautions
• Potentially infectious body fluids include:
Blood, Semen, Vaginal Secretion, fluids, and
Saliva
• Sweat and tears are not generally considered
infectious.

24. Personal Protective Equipment

25. Personal Protective Equipment
• lab coat
• Gloves
• Spectacles
• Face masks ( certain types of isolation)

26. Hand Washing
• Hand washing is the single most important
infection control measure.
• Wash hands thoroughly before, after, and
between all patient contacts.
• using a paper towel to avoid contamination.

27. Hand washing
• Remove rings
• Stand by the sink but do not touch it
• Apply soap and rub hands together
• Both sides of the hand, between fingers,
under fingernails
• Rinse hands in a downward motion
• Dry hands with a clean paper towel
• Turn off water with another paper towel

28. Hand Washing

29. Hazardous waste disposal
• All needles & other
sharps must be
disposed of in approved
sharps disposal
containers.
• Other contaminated
waste must be
discarded in an
appropriate biohazard
bag.

30. Needlestick

31. Needle sticks and prevention act
• Safety Devices should always be encouraged

32. Anatomy & Physiology

33. Anatomy & Physiology
• Anatomy is the branch of science concerned
with the study of the structure of the body.
• Physiology is the branch of science concerned
with the study of the function of the body.

34. Anatomy & Physiology
• The cardiovascular system
consists of the Heart, and
Blood Vessels.
• Its main function is circulate
oxygenated blood from the
lungs to various organs, and
return blood depleted of
oxygen to the lungs, where
it is reoxygenated.

35. Anatomy & Physiology

36. Blood Collection sites

37. Anatomy & Physiology

38. Anatomy & Physiology

39. Blood Components
• Circulating whole blood is a mixture of:
• Plasma (which contains fluid, proteins, and
lipids), and
• Formed elements, consisting of red cells,
white cells, and platelets.

40. Whole Blood

41. Plasma

42. Plasma

43. Blood cells

44. Blood Clot
• When a blood sample is
left standing without
anticoagulant, it forms
a coagulum or blood
clot.
• The clot contains
coagulation proteins,
platelets, and
entrapped red and
white blood cells.

45. Serum
• Serum contains all the
same substances as
plasma, except for the
coagulation proteins,
which are left behind in
the blood clot.

46. Equipment

47. Trays
• Trays should be sanitized
daily using appropriate
disinfectant
• Kept Organized and well-
stocked.

48. Blood Collection tubes
• glass or plastic tube
with a rubber stopper.
• It has a vacuum so that
blood will flow into the
tube.
• anticoagulants and/or
other chemical
additives.

49. Blood collection tubes
• Rubber stoppers of
blood collection tubes
are color coded.
• Each type of stopper
indicates a different
additive or a different
tube type.

50. LAVENDER
• EDTA to prevent
clotting
• hematology studies.
• Should be completely
filled
• Must be inverted after
filling

51. LIGHT BLUE
• sodium citrate.
• coagulation (clotting)
studies.
• must be completely
filled
• must be inverted
immediately after filling

52. GREEN
• sodium or lithium
heparin
• for tests requiring
whole blood or plasma
such as ammonia

53. RED
• No additives
• Blood bank tests,
toxicology, serology
• Must not be inverted
after filing

54. GRAY
• Inhibitor for glycolysis +
anticoagulant
• Sodium Fluride
+potassium oxalate.
• glucose levels.

55. YELLOW
• Acid citrate dextrose
• Inactivates
complements
• DNA studies, paternity
testing

56. ROYAL BLUE
• heparin or Na EDTA
anticoagulants
• Tube is designed to contain
no contaminating metals
• Trace element and
toxicology studies

57. Blood Culture Bottles
• Different blood culture
bottles are used for
aerobic, anaerobic, and
pediatric collections.

58. Blood collection tubes: Safety
• The rubber stopper is
positioned inside the
plastic shield

59. Sizes
• Adult:3 - 10 ml
• Pediatric 2 - 4 ml.
• Tubes for fingersticks or
heelsticks ½ or less

60. Expiration Dates

61. Holders
• A plastic holder must be
used with the
evacuated tube system.

62. Syringes

63. Syringes with built-in safety devices

64. Needles

65. Needles
• Different sizes.
• size =gauge.
• The larger the needle, the smaller the gauge
number.
• 21 or 22 gauge needle is mostly used.

66. Needle Components

67. Single Draw Needle
• Single draw needles are
of the type that fit on a
syringe, and can be
used only to fill the
syringe to which they
are connected.

68. Multiple Draw Needle
• Used with vacuum
collection tubes.
• They have a retractable
sheath over the portion
of the needle that
penetrates the blood
tube.

69. Needles with built-in safety devices
An internal blunt needle
that is activated with
forward pressure on the
final blood tube prior to
withdrawal of the
needle from the vein.

70. Butterfly Needle
• Winged infusion set
• Difficult venipunctures
including pediatric
draws
• with a syringe or a
holder and vacuum
collection tube system.
• 21, 23, or 25 gauge.

71. Butterflies with built-in safety features
• number-one cause of needlestick injuries, so
proper use of their safety devices is critical.

72. Butterflies with built-in safety features

73. Lancets
• Lancets are used for
difficult venipunctures,
including pediatric
draws.

74. Tourniquets
• Vein easier to SEE, FEEL,
and PUNCTURE

75. Sterilization

76. Bandaging Material

77. Gloves
• Gloves must be worn
for all procedures
requiring vascular
access.
• Non-powdered latex
gloves are most
commonly used;

78. Sharp Disposal Container

79. Collecting Blood

80. Greeting
• Always greet patient in a professional, friendly
manner.
• A good initial impression will earn the patients
trust, and make it easier and more pleasant to
draw a good specimen.
• Knock on the patient’s door before entering.
• Identify yourself by name and department.
• Explain the reason for your presence.

81. • The more relaxed and trusting your patient,
the greater chance of a successful atraumatic
venipuncture.
Technical Tip

82. • Good verbal, listening, and nonverbal skills are
very important for patient reassurance
Technical Tip

83. Patient Identification
• Make sure the name, medical record number,
and date of birth on your order/requisition
match those on the patient’s armband.
• Verify the patient’s identity by politely asking
them to state their full name.

84. Patient Identification
• Properly identifying patients and specimens is
probably the single most critical part of your
job.
• The consequences of misidentifying a
specimen can be life threatening.

85. Patient Identification
• Never rely on the patient name on the door or
above the bed. Patients are frequently moved
from room to room.

86. • A hospitalized patient must always be
correctly identified by an ID band that is
attached to the patient.
Technical Tip

87. Standard Precautions
Wash hands

88. Apply gloves

89. • Patients are often reassured that proper
safety measures are being followed when
gloves are put on in their presence.
Technical Tip

90. Position the Patient
• Comfortable position
• Turn the arm so that the wrist and palm face
upward, and the antecubital area is accessible

91. • When supporting the patient’s arm, do not
hyperextend the elbow. This may make vein
palpation difficult.
Technical Tip

92. Applying the tourniquet
• Tie the tourniquet just above the elbow.
• The tourniquet should be applied a maximum
of 1 – 2 minutes.

93. Applying the tourniquet

94. Applying the tourniquet

95. • After applying the
tourniquet, you may ask
the patient to make a
fist to further distend
the arm veins.

96. • Patients often think they are helping by
pumping their fists
• This is an acceptable practice when donating
blood, but not in sample collection as this can
lead to hemoconcentration
Technical Tip

97. Choose a site
• The median cubital vein
• If not accessible: Cephalic vein, or the Basilic
vein.
• If not accessible: veins on the back of the
hand.
• Use a much smaller needle for these hand
veins.

99. • Using the nondominant hand routinely for
palpation may be helpful when additional
palpation is required immediately before
performing the puncture.
• Often, a patient has veins that are more
prominent in the dominant arm.
Technical Tip

101. Never
• Scarred, abraded, or inflamed skin
• Arms containing IV catheters
• Oedematous arms
• Occluded Veins
• Shunts
draw from these areas

102. Cleansing the site
• Isopropyl alcohol swab
• Outward expanding spiral starting with the
actual venipuncture site.
• Allow the alcohol to dry:-
1-disinfect the site
2-prevent a burning sensation

103. Cleansing the site

104. • Patients are quick to complain about a painful
venipuncture. The stinging sensation caused
by undry alcohol is a frequent, yet easily
avoided, cause of complaints.
Technical Tip

105. Attach needle to holder

106. Place tube into holder

107. Hold vein in place

108. Insert needle
the needle bevel up

109. Push tube into holder
• Gently push the tube
onto the needle holder
so that the catheter
inside the needle holder
penetrates the tube.
• Blood flow should be
visible at this point.

111. • Allow tubes to fill until the vacuum is
exhausted to ensure the correct blood to
anticoagulant ratio.
Technical Tip

112. Blood won’t flow
If you do not see blood flow, the tip of the
needle:
1.May not yet be within the vein.
2.May have already passed through the vein.
3.May have missed the vein entirely.
4.May be pushed up against the inside wall of
the vein.

113. TROUBLESHOOTING

114. Incomplete collection or no blood is
obtained:
• Change the position of the needle. Move it
forward (it may not be in the lumen)

115. Incomplete collection or no blood is
obtained:
• or move it backward (it may have penetrated
too far).

116. Incomplete collection or no blood is
obtained:
• Adjust the angle (the bevel may be against the
vein wall).

117. Incomplete collection or no blood is
obtained:
• Loosen the tourniquet. It may be obstructing
blood flow.
• Try another tube. There may be no vacuum in
the one being used.
• Re-anchor the vein. Veins sometimes roll
away from the point of the needle and
puncture site.

118. Other Problems
• A hematoma forms under the skin adjacent to
the puncture site - release the tourniquet
immediately and withdraw the needle. Apply
firm pressure.

119. Other Problems
• The blood is bright red (arterial) rather than
venous. Apply firm pressure for more than 5
minutes

120. Multiple Tube Collection
If you are drawing more
than one tube:
• Keep a firm grip in the
needle holder while
pressing down on the
patients arm.
• Use your other arm to
interchange tubes.

121. Order of draw

123. Removing the Needle
• Gently release the tourniquet before the last
tube of blood is filled
• Remove the last tube from the needle
• Withdraw the needle in a single quick
movement

124. Apply Pressure
• Quickly place clean gauze over the site, and
apply pressure.
• You may ask the patient to continue applying
pressure until bleeding stops.

125. Apply Adhesive bandage

126. • The practice of quickly applying tape over the
gauze without checking the puncture site
frequently produces a hematoma
Technical Tip

127. Needle disposal
• Remove the needle from the holder if
appropriate, and properly discard it in an
approved sharps disposal container.
• Discard all waste and gloves in the
appropriate biohazardous waste container.
• Wash hands.

129. Specimen Labeling
• Label specimens at the bedside according to
your institution’s standard procedures, or
apply preprinted labels.
• Proper labeling is the single most critical task
you are asked to perform.

130. Proper labeling generally includes:
• Patient’s first and last name
• Hospital identification number
• Date & time
• Phlebotomist initials
• Your institution may provide bar coded
computer generated labels that contain this
information.

131. Summary Of Venipuncture Technique
1. requisition form.
2. Greet the patient.
3. Identify the patient.
4. Reassure the patient and explain the procedure.
5. Prepare the patient.
6. Select equipment and supplies.
7. Wash hands and apply gloves.
8. Apply the tourniquet.
9. Select the venipuncture site.
10.Release the tourniquet.
11.Cleanse the site.
12.Assemble equipment.

132. Summary Of Venipuncture Technique
13.Reapply the tourniquet.
14.Confirm the venipuncture site.
15.Examine the needle.
16.Anchor the vein.
17.Insert the needle.
18.Push the evacuated tube completely into adapter.
19.Gently invert the specimens, as they are collected.
20.Remove the last tube from the adapter.
21.Release the tourniquet.
22.Place sterile gauze over the needle.
23.Remove the needle, and apply pressure.
24.Activate needle safety device.

133. Summary Of Venipuncture Technique
25.Dispose of the needle.
26.Label the tubes.
27.Examine the patient’s arm.
28.Bandage the patient’s arm.
29.Dispose of used supplies.
30.Remove and dispose of gloves.
31.Wash hands.
32.Complete any required paperwork.
33.Thank the patient.
34.Deliver specimens to appropriate locations.

134. Syringe Specimen Collection
• Small or delicate veins
that might be collapsed
by the vacuum of the
evacuated tube system.
• May also be used to
collect blood culture
specimens.

135. Finger stick-Specimen collection
• A safety Lancet, which
controls the depth of
incision
• Finger-sticks should not
be performed on
children under one year
of age.

136. Finger stick
• If possible, use the fourth
(ring) finger or the middle
finger.
• Many patients prefer that
you use fingers on their
nondominant hand.
• Choose a puncture site near
the right or left edge of the
finger tip.
• Clean the site as you would
for routine venipuncture.

137. Finger stick
• Select a safety lancet
appropriate for the size of
the patient’s finger.
• You may warm the finger
prior to puncture to
increase blood flow.
• Make the puncture
perpendicular, rather than
parallel, to the finger print.

138. Finger stick
• Wipe away the first
drop of blood using
gauze to remove tissue
fluid contamination.

139. Finger stick
• Collect blood into an
appropriate tube.
• Label specimens
appropriately.
• Make sure bleeding has
stopped. Apply an
adhesive bandage if
necessary.
• Discard sharps
appropriately.

141. Heel stick
• Veins of small children
and infants are too
small for venipuncture;
• Butterfly needles may
be used to collect
venous blood in older
children.

142. Heel stick neonatal blood collection
• These devices are
designed to control the
depth of incision, since
going too deep into an
infant’s heel could
injure the heel bone,
and cause osteomyelitis
(bone infection).

143. Heel stick
• Firmly grasp the infants
foot.
• Do not use a tourniquet.
• The heel may be warmed
with a cloth to help increase
blood flow.
• Wipe the collection site
with an alcohol prep pad,
and allow the alcohol to
dry.
• Wipe the site with sterile
cotton or gauze, to be sure
all the alcohol has been
removed.

144. Heel stick
• Puncture the left or
right side (outskirt) of
the heel, not the
bottom of the foot.
• Wipe away the first
drop of blood since it
may contain excess
tissue fluid or alcohol
which could alter test
results.

145. Heel stick
• Collect the blood into
the appropriate tube.
• Do not: Squeeze the
infant’s foot too tightly
and wipe with alcohol
during the collection.

146. Heel stick
• After collection is
completed, apply
pressure to the
puncture site with a
sterile gauze pad until
bleeding has stopped.
• Do not apply an
adhesive bandage to an
infant’s foot since it
may injure its delicate
skin.

147. Heel stick

148. Heel stick

149. Heel stick

150. Heel stick

151. Butterfly
• Butterfly needles
(winged infusion set)
• are available in smaller
gauges, and are used to
draw venous blood
from children, and
adults with difficult
veins.

152. Butterfly
• Butterfly needles come
attached to a small tube
which may be
connected to:
• An evacuated tube
holder, or A syringe.

153. Butterfly

154. Special situations

155. Patients refusing blood work
• If someone hesitates to let you collect a blood
specimen, explain to them that their blood
test results are important to their care.
• Patients have a right to refuse blood tests
• If the patient still refuses, report and
document patient refusal

156. Fainting
• Rarely, patients will faint during venipuncture.
• It is therefore important that patients are
properly seated or lying in such a way during
venipuncture so that if they do faint, they
won’t hurt themselves.
• self-limited

157. Fainting; what to do?
• Gently remove the tourniquet and needle from the
patients arm, apply gauze and pressure to the skin
puncture site.
• Call for help.
• If the patient is seated, place his head between his
knees.
• A cold compress on the back of the neck may help to
revive the patient more quickly.

159. Unsatisfactory Specimens
• They can cause misleading laboratory results
• Must be rejected by the laboratory.
• The patient must then undergo another
venipuncture to get a better specimen.
• It costs time & money to redraw the specimen.
• The credibility of the laboratory is reduced if too
many unsatisfactory specimens are drawn.

160. Causes of Unsatisfactory Specimens

161. Hemolysis

162. Hemolysis
• Hemolysis means the breakup of fragile red
blood cells within the specimen, and the
release of their hemoglobin and other
substances, into the plasma.
• A hemolyzed specimen can be recognized
after it is centrifuged by the red color of the
plasma.

163. Causes of Hemolysis
• Using a too small needle for a relatively bigger
vein
• Pulling a syringe plunger too rapidly
• Expelling blood vigorously into a tube,
• Shaking a tube of blood too hard.

164. Hemolysis

165. Hemolysis

166. Hemolysis
• Hemolysis can cause falsely increased
potassium, magnesium, iron, and ammonia
levels, and other aberrant lab results.

167. Clots

168. Clots
• Blood clots when the coagulation factors
within the plasma are activated.
• Blood starts to clot almost immediately after it
is drawn unless it is exposed to an
anticoagulant.
• Clots within the blood specimen, even if not
visible to the naked eye, will yield inaccurate
results.

169. Causes of Clots
• Inadequate mixing of blood and anticoagulant
• Delay in expelling blood within a syringe into a
collection tube

170. Insufficient volume

171. Insufficient volume
• short draws will result in an incorrect ratio of
blood to anticoagulant, and yield incorrect
test results.
• Short draws can be caused by:
• A vein collapsing during phlebotomy.
• The needle coming out of the vein before the
collection tube is full.
• Loss of collection tube vacuum before the
tube is full.

172. Labeling Errorrs
• Labeling errors are the most common cause of
incorrect laboratory results.
• If detected, the incorrectly labeled specimen
will be rejected.
• If undetected, it will produce incorrect results
which might adversely affect your patient’s
care.

173. Causes
• Failure to follow proper patient identification
procedure.
• Failure to label the specimen completely and
immediately after collection.

174. Ten Commandments
I. Thou shalt protect thyself from injury
II. Thou shalt identify thy patients
III. Thou shalt stretch the skin at the puncture site
IV. Thou shalt puncture the skin at about a 15 degree angle
V. Thou shalt glorify the median vein
VI. Thou shalt invert tubes containing anticoagulants immediately
after collection
VII. Thou shalt attempt to collect specimens only from an acceptable
site
VIII. Thou shalt label specimens at the bedside
IX. Thou shalt know when to quit
X.Thou shalt treat patient's like they are family