Phlebotomy Flashcards
The majority of error occurs during the ___ stage of testing
pre analytical
Name some examples of phlebotomy negligence
nerve injury
hemorrhage
injury due to fainting
death of a patient
What is the type of blood of choice for most routine lab tests
-venous blood
What type of blood is used in blood gases
arterial blood from the artery
What type of blood is collected from fingers
capillary blood- capillaries, arterioles and venules, interstitial and intracellular fluid
How can you make more blood come from a finger stick
by warming up the area, makes arterial blood increase
What is the difference between serum and plasma
plasma- contains fibrinogen, the clear, yellow portion of anticoagulated blood
serum- yellow portion of clotted blood, serum is separated from the blood clot
Label the picture on Ch1 slide 31
A-SST not centrifuged
B- SST after centrifugation
C-centrifuged without additive or gel
What is lipemia
milky appearance, increased lipids
What are the main pre analytical variables that the patient can interfere with that will affect their test results
fasting, exercise, stress, smoking, circadian rhythm, posture, age
Patients should avoid strenuous ____ for ___ hours before having blood collected
exercise
24 hours
How do test results change if the patient is too stressed
increase in WBCs, decrease in iron, abnormal hormone values
How long should patients refrain from smoking prior to blood draw
1 hour
How does the diurnal rhythm affect test results
body fluids change throughout the day, hormone levels change, cortisol, testosterone, estradiol, progesterone, renin, TSH, serum iron, WBCs eosinophils
How can posture affect test results
enzyme, protein, lipid, iron Ca levels change with posture, should be sitting not standing nor lying down
What is hemolysis
red plasma due to RBC rupture making them release hemoglobin content
What are icteric specimen
when the serum or plasma becomes brownish yellowish
What are some reasons a specimen would be rejected
unlabeled, QNS, wrong tube, wrong order of draw, wrong time if timed sample, light protection, clotted specimen if for coag
How long can a tourniquet stay on a patient
1 minute max
What is the standard gauge for venipuncture with straight needles?
21 or 22
What is the standard gauge for small veins and hands
23 or 25
What is the rule when you are drawing blood from a butterfly into a light blue tube
you must draw a discard tube before the light blue with a non additive tube or another blue top
When should isopropyl alcohol NOT be used, what is used in its place
chlora prep- for blood culture collections
betadine-
What information must be on a requisition?
DOB, full name, test performed, name of provider, ICD 10
What is the difference between routine and timed tests
routine- scheduled often
timed- must be collected at specific time
Inpatients always have _______, you cannot draw from them if they dont have it!
wristband
The tourniquet should go ___ inches above the _____
3-4 inches, antecubital fossa- elbow pit
How can the patient help you find a vein, what can you do?
make a tight fist, no pumping
feel for vein with non dominant hand
feel more important than sight
veins do not have a pulse!
What sites on the hands should you NEVER draw from
palm side of the wrist, lateral wrist above the thumb
What procedures affect where you can draw blood from? What other sites should you avoid
mastectomy, arms with IVs, no fistulas or shunts, no hematomas or edemas, no injuries or burns
What sites in what order can you draw blood from
antecubital fossa, check both arms, check both hands
What veins can you draw from
median cubital vein
median cephalic vein
What vein on the arm can you NEVER draw from
cephalic vein- on the side of your pinky
What structure provides support and anchors the median cubital vein
bicipital aponeurosis
What side of the arm is the median cephalic vein on
the thumb side
Why is the basilic vein a no no
close to major artery and nerve, tends to roll, more painful
What veins should you draw from in hands
central veins
What is the site selection order of preference for blood draw
median cubital, cephalic, accessory cephalic, basilic, dorsal hand,
When should you push the tube into the adaptor
after inserting the needle into the vein
What position should the needle be in
bevel up
What angle should you use for a straight needle
15-30 degree angle
What should you do right after drawing a patients blood
label the tubes in their presence, reconfirm name and DOB
What is the last step to drawing blood
bandage the patient, discard trash and dismiss patient
What is the max amount of times a single person can try to stick a patients vein
2 times
What can you try if you can’t find a vein
tap the area gently, hang the arm down, warm compress, fist, tighter tourniquet
What must you do between patients as a phleb
sanitize hands and change gloves
How many times should you invert the tubes with additives or anticoagulants
5 to 8 times
What is the name of the substance that separates blood serum or plasma in gold top tubes
polymer gel
What additives are in gold or tiger top tubes? What department do they go to
silica, gel separator SST
chemistry
Do gold and tiger top tubes contain serum or plasma?
Do they have any extra instructions
serum, let clot for 30 minutes
What additives do red top tubes have? anticoagulants? Does it have any additional instructions?
no additive, clot for 60 minutes, no gel barrier
What tubes do not have any additives
red and white tops
What additives or anticoagulants do lavender top tubes have?
EDTA-irreversibly binds Ca
prevents clotting
What additives or anticoagulants do pink top tubes have?
EDTA
What additives or anticoagulants do light blue top tubes have? Does it have any extra instructions?
sodium citrate- reversibly binds Ca
must be fully filled
invert less 4-5 times, don’t overmix it
What ratio of blood to anticoagulant do you need for a light blue top tube
9:1
What additives or anticoagulants do light green/ mint top tubes have
lithium heparin- anticoagulant inhibits thrombin
What additives or anticoagulants do dark green top tubes have
sodium heparin- inhibits thrombin
What additives or anticoagulants do gray top tubes have
sodium fluoride- inhibits glycolysis
potassium oxalate- binds Ca to prevent clotting
What kind of tests are performed on gray top tubes
glucose, blood alcohol, lactic acids
What additives or anticoagulants do orange top tubes have
thrombin- converts fibrinogen into fibrin causes rapid clotting
What tests are performed on orange top tubes
STAT serum testing like troponin, rapid serum tube is another name
What additives or anticoagulants do royal blue tops have
chemically free of trace metals, might have EDTA or sodium heparin
What tests are performed on royal blue top tubes
copper, zinc, cobalt, lead, aluminum
What additives or anticoagulants are in tan top tubes
EDTA, lead testing
What additives or anticoagulants do yellow top tubes have
ACD- acid citrate dextrose, binds Ca and preserves RBCs
SPS- binds calcium and complement
What tests are performed on yellow top tubes
BB and immunology testing if ACD
blood cultures if SPS
What additive do black top tubes have
buffered sodium citrate
Erythrocyte sedimentation rate
State the order of draw
- blood culture (steriles), aerobic then anaerobic
- light blue- coag
- red/gold/ tiger- serum tubes
- Greens- heparin tubes
- lavender/ pink/ royal blue/ tan- EDTA tubes
- Grey- glycolytic inhibitor
What could happen to a coag test if the order of draw is wrong
could become contaminated with anticoagulants
What could happen if the grey top tube is collected in the wrong order of draw?
potassium in the grey top could interfere with chem tests
What can happen if an EDTA tube is collected in the wrong order of draw
EDTA can bind to many metals and to Ca, causes problems with almost everyone
What lab results can you expect if a lavender top is collected before a chem test
falsely elevated potassium
falsely decreased Ca
What tube is responsible for more carryover problems than any other tube
EDTA tubes
What can happen to lab results if Gray is drawn before lavender
distorted WBCs on differentials
What lab results can be expected it a serum tube is drawn before a blue top
the clot activator in the serum tube will falsely shorten a coag test
What lab results can be expected if you draw a EDTA tube before a heparin or light blue top
falsely increase PT and PTT
True or false: if you accidentally draw from the wrong tube you can pour blood into the correct tube
False- we will find out
What could occur if you draw from an arm that has an edema, explain what that means
Edema, fluid in arm, super swollen
specimen will have excess tissue fluid
What could occur if you draw blood from a hematoma
you could be collecting old blood or cause hemolysis in your sample
What if a patient has an IV? can you draw from that arm
IV has to be turned off for at least 2 minutes
discard 5mL of blood
record that blood was drawn from arm with IV
What if you need to draw blood from a patient that has just had a transfusion
you have to wait 1 hour post transfusion
will still have elevated levels for up to 24 hrs of certain tests
What is a VAD
vascular access devices
Can you collect blood from a VAD?`
only a nurse can, all fluids have to be turned off, 5mL of blood has to be discarded
must discard 6 times the dead space of the line for coag tests
What is a CVC
central venous catheter,
Can you draw blood from a VAD?
Yes
What is a PICC
peripherally inserted central catheter
Can you draw blood from a PICC?
a nurse can do it, or venipuncture can be done below it,
Can you draw blood from implanted ports?
only a nurse can
Can you draw blood from a cannula?
insertion in arm often for blood access
only by a nurse
What special action should be taken for bariatric patients
longer needles, might need to prewarm site, ask where blood draw has been successful
What special actions should be taken for pediatric patiens
smaller needles, can use local anesthetics, dermal puncture only if small volume of blood needed, infants and children cannot lose more the 5% of their blood volume in 24hrs (3% max preferred). No more than 10% can be removed over 1 month. Might need help to restrain children
What special considerations should be taken for geriatric patients
less collagen, skin is more elastic, easier to bruise, many could be on anticoagulants, beware of rolling veins, use butterfly on smaller veins
If a patient is experiencing excessive bleeding it could mean
they are on heparin or coumadin, that have low or defective platelets
What should you do if you accidentally puncture an artery
withdraw immediately, pressure for 5 or 10 minutes if on anticoagulants,
What should you do if the patient is experiencing shooting pains, tingling or numbness
you might have injured a nerve, use a cold then warm compress, document the incident,
What should you do if your patient is becoming quiet or their speech is slurred or slowed
They might faint (syncope), talk to them, remove tourniquet, withdraw needle, bandage, lower head and put a cold compress on their neck
If a patient fully falls forward and is unconcious
lower to floor and elevate feet, cold compress, no ammonia, if they don’t regain consciousness in 1 minute call 911, document incident
What to do after a patient has experienced syncope
monitor them closely for 15 minutes, make sure they look and speak normally again, do not let them stand until they are fully recovered, if fasting, give them food or drink
What is petechiae
small red spots caused by defect in platelets
What tests cannot be performed on capillary skin punctures
blood culture, coagulation tests, blood bank crossmatch
What analytes are different in capillary blood
potassium, Ca, protein, are lower
glucose is higher
True or False, microtainers have a different order of draw
True, EDTA goes first before any additives then no additives goes last
What are the limits of using warming devices
temp no more than 42C apply for 3-5 minutes
What could be the consequence of accidentally puncturing a bone
osteochondritis-painful inflammation of bone
osteomyelitis- could be fatal bone infection
What is the advisable depth for an adult finger stick
what is it for heel punctures on infants
adult- 2-3mm
infant less tan 2 mm
blood should be drawn ___ to _____ on finger sticks
perpendicular to fingerprint grooves
What part of the heel of the foot can you draw blood from
medial or lateral parts of the heel, never the middle
What is the cutoff age for heelsticks
12 months old or less
What test is a light protection test
billirubin
What does a red lid blood culture bottle mean
for mycolytic or fungal cultures
What is the maximum blood culture sets that can be draw in a day
max 3 sets
What extra step must you take before drawing a blood culture
mark the bottles 10mls above the fluid in bottle
disinfect bottle top
What arteries can be used to collect arterial blood gas
radial artery - wrist
brachial artery- arm
femoral - leg
What is important to note after ABG is drawn and sent to lab
it must be sent up on ice if it will take longer than 30 minutes to get to lab
What is an allen test
test to see if blood flow is collateral, if negative you cannot draw from radial artery
What are the common sources of error for an ABG
not delivering immediately to lab, not putting on ice
True or false: If an ABG has air bubbles, it will be accepted
False: it would get rejected
What rules must a patient follow prior to a glucose tolerance test
GTT no medications that affect glucose, fast for 8-10 hrs, 3 days of unrestricted diet and activity
When should you call a physician for a fasting glucose result?
if it is higher than 140, then you need to do a GTT
What extra steps do you have to take for a GTT test.
Give patients glucola 50g prenatal 75g non pregnant 100g pregnant they have to drink it in 5 min or less patient has to sit still, only water, if they vomit test must be rescheduled no smoking or chewing gum
What time frames do you draw blood for a 3hr GTT
draw fating, 1hr, 2hr, and 3hr
What is to be expected for a 2hr postprandial glucose test
looking to diabetes, 2 hrs after a meal, normal is less than 140
What extra procedures must be taken for chain of custody testing
document identity of everyone that handles the specimen
What is a suprapubic device and what is it for
for urine collection in babies
What is the rule for occult blood specimen?
collected 3 days after meat free diet
What temperature should O&P specimen be stored at
body temp 37C if no preservative
What part of the mouth should be used for a throat culture
tonsil area
How soon should an uncentrifuged blood sample be delivered to lab
within 45 minutes
How soon should gel separated specimen be centrifuged after collection
2 hrs
what tube tops can be centrifuged right after collection
light green tops
how soon can samples collected in thrombin be spun
5 minutes
For what reason would a chem test be rejected?
hemolysis, QNS
For what reason would a heme test be rejected
clotted for ESR if QNS
What types of specimen often need to stay warm 37C
cyro test and cold agglutinin titers
Name 4 test that need to be on ice
ammonia, lactic acid, ABG
What temp should PTT and PT/INR be kept at
room temp
