Fundamentals of Phlebotomy
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1 Fundamentals of Phlebotomy May
2 Historical Origins: Superstition Phlebotomy Today: Diagnostic tool CP
3 Potential Exposure from Needle Stick Injuries 1 in 6 - Hepatitis B 1 in 20 - Hepatitis C 1 in HIV CP
4 Tracking at Mayo Clinic Rochester Decline from 1.5 Exposures/10,000 to 0.2 Exposures/10, handed recapping blocks 1987 Disposal of evacuated holders 1988 CDC Universal Precautions 1989 CDC HIV and Hepatitis B prevention guidelines 1991 OSHA occupational exposure to bloodborne pathogens final rule CP
5 Tracking at Mayo Clinic Rochester (cont) Decline from 1.5 Exposures/10,000 to 0.2 Exposures/10, Resheathing needles and retractable lancets 1992 Biohazard container improvement initiative 1994 Clean needle stick removed from database 1995 Discontinued changing needles for blood cultures CP
6 Tracking at Mayo Clinic Rochester Frequency Rate per 10,000 punctures CP
7 2010 Blood/Body-Fluid Exposures 592 Needlestick and Blood/Body-Fluid Exposures occurred to Mayo staff during 2010 (161 hollow core punctures or needles) 7
8 Order Entry, Phlebotomy Supplies and Safety 8
9 New Device / Equipment Evaluation Device / Equipment Name Evaluation Site Date of Evaluation Rating Scale Strongly Agree (please circle)- Strongly Disagree Is the Device Safe? User Friendly? Easily Adapted to the Work Environment? Better than existing device? Comments 9
10 Research from Center for Disease Control (CDC) Research from CDC indicates that selecting safer medical devices could prevent 62-88% of sharps injuries in the hospital setting Szabo J: MLO 33(3):18, 2001 CP
11 Orders for Collection & Preparing the Accession Order Ordering the collection Physician Designated healthcare professional Preparing the order for collection The phlebotomist 11
12 Phlebotomy Safety: Hand Cleansing Soap & Water Waterless Hand Sanitizer CP
13 Safety: Latex Allergy Studies indicate that 5-17% of healthcare workers show latex sensitivity, compared to 1-6% of the general population Exposure can be reduced by switching to lower allergen products, or by using non-latex substitutes CP
14 14
15 Phlebotomy Supplies: Needles 15
16 Phlebotomy Supplies: Evacuated / Syringe / Winged Infusion 16
17 Phlebotomy Supplies: Skin Preparations 70% Isopropyl Alcohol Tincture of Iodine 17
18 Phlebotomy Supplies: Gauze and Pad & Gauze Roll 18
19 Phlebotomy Supplies: Capillary Collection Devices 19
20 Capillary Collection 20
21 Phlebotomy Supplies: Needle Gauge* * Determined by the size & condition of the vein 21
22 Considerations Prior to the Collection Thorough patient history Patient condition Time of collection Basal state Fasting Age Gender Diurnal or daily variations 22
23 Additional Considerations Age Growth Development Safety Considerations Communication 23
24 Physical Conditions of a Patient Affecting Blood Collections Stress Dehydration Strenuous exercise Pregnancy Smoking habits Weight, age and other factors 24
25 Mayo Clinic Patient Identifiers Patient must state and spell their first and last name Patient must state their date of birth 25
26 Patient Identification
27 Additional Variables to Patient Identification Language or cultural barriers Pediatric patients Unidentified patients Unconscious patients Dementia, Intubated patients and other possibilities 27
28 NOTE: It is the responsibility of the phlebotomist to perform PATIENT IDENTIFICATION with each and every patient interaction regardless of how many times in a work shift the phlebotomist may see the same patient for additional collections. 28
29 Patient Identification, Arm Anatomy, & Collection Materials 29
30 Approach & Identify the Patient Identifying yourself Observe surroundings Considerations Patient to spell first & last name Patient to give date of birth Tech code or initial all collection labels 30
31 Vein Assessment Site selection process and anatomical structure. 31
32 Arm Anatomy: Preferred Sites/Veins Cephalic Vein Median Cubital Vein Basilic Vein 32
33 Three Phlebotomy Methods Evacuated Syringe Winged Infusion (Butterfly) 33
34 Joint Commission Recommended Guideline for Age Groups Infant and toddlers: 0 to 3 years Young children: 4 to 6 years Older children: 7 to 12 years Adolescence: 13 to 20 years Young adults: 21 to 39 years Middle adults: 40 to 64 years Adults: 65+ years 34
35 Site Selection Process: Considerations Burn and/or Scars Skin Integrity Edema Hematoma Mastectomy 35
36 The Venipuncture Procedure 36
37 Evacuated Tubes Color Codes Anticoagulated Tubes Citrate light blue Heparin - green EDTA Purple, pink, or lavender Oxalate/Fluoride (antiglycolytic) - gray Serum tubes Gel Separator - gold or red/black Non- gel separator - red 37
38 CLSI (NCCLS) H3-A5 Order of Draw Culture tubes (not illustrated) Coagulation tubes Serum tubes with or without clot activator with or without gel Heparin tubes with or without gel EDTA tubes Oxalate/fluoride tubes 38
39 Mayo Clinic Order of Draw Serum Gel Separator Serum (Red) Anticoagulant Tubes Citrate Heparin EDTA Oxalate/Fluoride 39
40 Evacuated Tube Considerations Mixing* by gentle inversion Fill volumes of the of tubes * Follow manufacture's guidelines for the number of inversions 40
41 Patient and Sample Identification The consequences of an incorrectly labeled tube are the same as an incorrectly identified patient. 41
42 Tips for Phlebotomists Remain calm, professional and polite Place no blame Look at all possible sites for second collection Apply heat Consider reduced amounts Consult a more experienced phlebotomist 42
43 Specimen Transport 43
44 Specimen Processing 44
45 Hematoma forming 45
46 Conditions That Cause a Hematoma Needle placement Failure to remove the tourniquet before removing the needle Not applying adequate pressure on the site after the needle is removed 46
47 Needle Placement Conditions That Cause a Hematoma Accessing the vein too slowly Needle is too deep and has gone completely through the vein 47
48 Ways to Prevent a Hematoma Penetrate only the upper most vein wall Remove the tourniquet before removing the needle Use major veins, not superficial veins Apply gentle pressure to the site with gauze after needle removal and while bandaging 48
49 1- Hemolyzed 2- Normal 3- Icteric 4- Lipemic
50 Acute Hemolysis Elliott K, et al. Transfusion 43:297,
51 Fainting Nausea WHAT TO DO? Common Complications of Phlebotomy Safety of the patient is the first concern Immediately stop procedure Do not leave patient unattended Call for assistance if needed 51
52 The Venipuncture Process: Evacuated Method Patient Identification Tourniquet application Site selection & cleansing Phlebotomy collection Removal of the tourniquet Remove needle and apply pressure Wrap and secure site Label tubes 52
53 The Venipuncture Process: Winged Infusion with a Syringe Patient Identification Tourniquet application Site selection & cleansing Phlebotomy collection Removal of the tourniquet Remove needle and apply pressure Wrap and secure site Dispense blood Label tubes 53
54 The Venipuncture Process: Syringe Method Patient Identification Tourniquet application Site selection & cleansing Phlebotomy collection Removal of the tourniquet Remove needle and apply pressure Wrap and secure site Dispense blood Label tubes 54
55 The Venipuncture Process: Winged Infusion /Evacuated Method Patient Identification Tourniquet application Site selection & cleansing Phlebotomy collection Removal of the tourniquet Remove needle and apply pressure Wrap and secure site Label tubes 55
56 References Accuracy in Patient and Sample Identification. GP33-P. (2009). CLSI. 29(13) Dale, J. C., Hermansen, J., McConnell, Nielsen, J. (1998). Accidental needlesticks in the phlebotomy service of the department of laboratory medicine and pathology at Mayo Clinic Rochester. COMMUNIQUÉ A Mayo Medical Laboratories Publication. 23(5). Dale, J. C., Pruett, S. K., and Maker, M. D. (1998). Accidental needlesticks in the phlebotomy service of the department of laboratory medicine and pathology at Mayo clinic Rochester. Mayo Clinic Proceedings. 73(7) Procedures and Devices for the Collection of Diagnostic Blood Specimens by Skin Puncture, 5th ed. H4- A6. (2004). NCCLS. 24(21). Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens, 6th ed. H4-A6. (2008). CLSI. 28(25). Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture, 4th ed. (1991). H3-A3. NCCLS. 11(10). Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture, 5th ed. (2003). H3-A5. CSLI. 23(32). Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, 6th Ed. (2007). H3-A6. CLSI. 27(26) Szabo, J. (2001). MLO. New OSHA bloodborne pathogen standard clarifies need for employers to select safer needle devices. 33(3)
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