PHLEBOTOMY: VENIPUNCTURE, ETS & COMPLICATIONS Flashcards
what are the contents in an unclotted blood
- plasma (contains fibrinogen)
- White blood cells and platelets
- Buffy coat
- Red blood cells
What are the contents of a clotted blood?
- Serum (without fibrinogen)
- Clot (blood cells in fibrin clot)
One of three different specimens may be used:
What are the 3 different specimens?
- While blood
- Serum
- Plasma
This specimen, It must be analyzed within limited time
Whole blood specimen
In whole blood:
Over time, cells will lyse (rupture) in whole blood, which will change the concentration of some analytes as ___, _____, and _____.
Potassium
Phosphate
Lactate dehydrogenase
In whole blood specimen, Some _______ will continue which will alter analytes concentration like ____ and _____.
cellular metabolic processes
glucose and lactate
Serum is the same as plasma except it
doesn’t _______ (as
fibrin).
contain clotting factors
contains all clotting factors
plasma
Serum and plasma all have the same
contents of ____, ____, and _____ except clotting
factors
electrolytes
enzymes proteins
hormones
Plasma percentage
55%
White blood cells and platelets percent
< 1%
Red blood cells percentage
45%
Clotting factors + calcium =
Thrombin
Fibrinogen + thrombin
Fibrin strands
A process by which blood is obtained from a
patients vein.
Venipuncture
It is the deoxygenated blood with a
dark red color
Venous blood
Sites for venipuncture
- Antecubital Fossa
- Veins of the wrist
- Dorsal aspect of the hand
- Veins of the ankle
Methods used in venipuncture
- Syringe
- Evacuated tube
- Butterfly method
The major site for venipuncture
Antecubital Fossa
The major site for venipuncture
Antecubital Fossa
Most common site for venipuncture
Antecubital Fossa
The vein is the best site for venipuncture because it is the largest and the best anchored vein
Median cubital
the second choic Vein
Cephalic vein
third choice vein
basilic Vein
Basilic vein should not be chosen unless no other vein is more prominent due to its closeness to the ____
brachial artery
Sites to be avoided:
BACTEIA
- Intravenous lines in both arms
- Burned or scarred areas
- Arms with hematoma
- Cast on arms
- Thrombosis Veins
- Edematous Veins
- Arms with arteriovenous shunt or fistula
Rules for Intravenous line:
- Never draw above an IV line
- Draw from other arm
- Draw from the hand of the other arm
- Draw below the IV
Indwelling lines:
●Heparin locks
- Used to administer medication
- Only nurses can access these lines
- Can collect blood: called the “line draw”
- Must clear line of heparin contamination by discarding first 5-10cc of blood
Procedures in syringe method
- Approach the patient in a friendly, calm manner. Provide for their comfort as much as possible, and gain the patient’s cooperation.
- Identify the patient correctly.
- Properly fill out appropriate requisition forms, indicating the test(s) ordered.
- Verify the patient’s condition. Fasting, dietary restrictions, medications, timing, and medical treatment are all of concern and should be noted on the lab requisition.
- Check for any allergies to antiseptics, adhesives, or latex by observing for armbands and/or by asking the patient.
- Position the patient. The patient should either sit in a chair, lie down or sit up in bed.
Hyperextend the patient’s arm. - Apply the above the selected puncture site. Do
tourniquet application at 3-4 inches. Do not
place too tightly or leave on more than 1
minute to avoid increasing risk for
hemoconcentration). Wait 2 minutes before
reapplying the tourniquet - The patient should make a fist without pumping the hand.
- Select the venipuncture site.
- Prepare the patient’s arm using an alcohol prep. Cleanse in a circular fashion, beginning at the site and working outward. Allow to air dry.
- Grasp the patient’s arm firmly using your thumb to draw the skin taut and anchor the vein. The needle should form a 15 to 30 degree angle with the surface of the arm. Swiftly insert the needle through the skin and into the lumen of the vein. Avoid trauma and excessive probing.
Approach the patient in a ______, _______.
friendly, calm manner.
Verify the patient’s condition.
What are the concerns that needed to be noted in the lab requisition?
- Fasting
- Dietary restrictions
- Medications
- Timing
- Medical Treatments
In positioning the patient, the patient should be:
Sitting in a chair, lie down or sit up in bed
Do tourniquet application at ___ inches.
3-4 inches
Do not place too tightly or leave the torniquet on more than
1 minute
placing the torniquet too tightly or leaving on more than 1 minute can increase the risk for
hemoconcentration
Wait __ minutes before reapplying the tourniquet.
2
Prepare the patient’s arm using an alcohol prep.
Cleanse in a ____ fashion, beginning at the
___ and working _____. Allow to air dry.
circular fashion; site and working outward
The needle should form a ____ angle with the surface of the arm
15 to 30 degree
Verify that any _______ have been met (fasting. If appropriate) and check for any ______.
dietary restrictions; sensitivity to latex.
Apply the tourniquet ___ inches above the site and instruct the patient to make a fist.
3 to 4
Disinfect the patient’s skin with alcohol pad starting at the point where you expect to insert the needle and moving outward in even ______
widening concentric circles
Always remove the ____ first before
withdrawing the needle
tourniquet
For evacuated tube method, remove the ____ first and then the ______
tube; adaptor with the needle
The key elements in labeling
are:
●Patient’s surname, first and middle.
●Patient’s ID number / Birthday
●Date of collection
● time of collection
●initials of the phlebotomist
must be on the label of EACH tube
The gauge of the needle is inversely proportional
related to the
size of the needle
the larger the gauge number, the ___ the needle ___ and ___
smaller the needle bore and length
needle is standard for venipuncture
21 gauge
butterfly needle is used for children, small and
difficult veins
23 gauge
Needle used for Blood donation
16 gauge
Needle length for 21-23 gauge
1 - 1.5 inches
Needle length for butterfly needle
1/2 or 3/4
Parts of a syringe
- Bevel
- Needle shaft
- Hub opening
- Tip
- Barrel
- Plunger
The second pic parts of a plunger
- Luer lock
- Seal
- Barrel
- Barrel Flange
- Plunger
- Plunger Flange
tubes are designed to fill with a predetermined volume of blood by vacuum.
Evacuated tube system
The _____ are color coded according to the additive that the tube contains
rubber stoppers
Blood should NEVER be poured from one tube to another since the tubes can have different ____ and ____
additives and coatings
The gauge number indicates the bore size: the larger the gauge number, the smaller the needle bore
Needles
use with the evacuated collection system
Holder/Adapter
Wipe off with alcohol and replace frequently
Torniquet
Contains 70% isopropyl alcoho
Alcohol swap
Used if blood culture is to be drawn
Povidone iodine
for application on the site from which
the needle is withdrawn
Gauze or dry cotton balls
needles should never be broken, bent or
recapped. Must be placed in a proper disposal unit immediately after use
Needle disposal unit
can be made of latex, rubber, vinyl, etc, worn to protect the patient and phlebotomist
Gloves
Parts of an ETS method
- Needle
- Tube advancement mark
- Rubber sleeve
- Holder
- Tube
The multi sample needle has a _____ sheath
Retractable
Approach the patient in a _________.
Provide for their comfort as much as possible, and gain the patient’s cooperation.
friendly, calm manner.
Identify the patient ______.
Correctly
Properly fill out appropriate requisition forms, indicating the _____.
test(s) ordered
Verify the patient’s condition. ____, ____, ____, _____, and _______ are all of concern and should be noted on the lab requisition.
Fasting, dietary restrictions, medications, timing, and medical treatment
Check for any allergies to _____, _____, or _____ by observing for armbands and/or by asking the patient.
antiseptics, adhesives, latex
Remove the needle from the patient’s arm using a _____ motion.
swift backward
Instruct the patient to apply pressure for ___ minutes.
5 minutes
inhibits the use of glucose by blood
cells.
Antiglycolytic
Examples of antiglycolytic
sodium fluoride and lithium iodoactetate
prevents blood from clotting
Anticoagulant
remove calcium by forming insoluble salts
EDTA
Citrate
Oxalate
prevents the conversion of prothrombin to thrombin
heparin
If calcium is removed or thrombin is not formed, ______ does not occur
coagulation
inert material that undergoes a temporary change in viscosity during the centrifugation process
Separator Gel
serve as a separation barrier between the liquid (serum and plasma) and
cells
Separator Gel
helps initiate or enhance the clotting mechanism
Clot activator
Clot activators include ___ or ___ particles that provide increased surface area for platelet activation and clotting factors such as thrombin.
glass or silica
What are the 5 anticoagulants
- Oxalate
- Citrate
- EDTA
- Fluorine
- Heparin
combines with calcium to form an insoluble salt
oxalate
combines with calcium in a non ionized form
Citrate
it combines with calcium in a process called chelation
Ethylenediamine Tetraacitic Acid (EDTA)
forms weakly dissociated calcium components
Fluorine
forms weakly dissociated calcium components
Fluorine
prevents the formation of fibrin
Heparin
– No additive
– Glass surface activates clotting sequence
– Do not mix
– SERUM: use for TDM (therapeutic drug monitoring)
Glass Red Top Tube
-Contain additive to activate clotting sequence
– Contain inert gel =» SST (serum separator tube)
– Do invert to mix additive and initiate clotting sequence
– SERUM
Plastic Red Top Tube
•Contain clot
activator and gel
(SST)
• Invert to mix and
initiate clotting
sequence
• SERUM
Gold or Mottled-red-gray top tube
•Anticoagulant = sodium citrate
• Binds calcium
• Must be full
Blood: anticoagulant ratio critical
• Must be on ice if not analyzed within 30 minutes
• Coagulation studies
Blue-top tube
•Anticoagulant = heparin
– Three formulations:
Lithium heparin
Ammonium heparin
Sodium heparin
• Inhibits thrombin formation
• Must be full and on ice if need pH, ionized Ca
Green Top Tube
3 formulations of heparin
- Lithium Heparin
- Ammonium Heparin
- Sodium Heparin
• Anticoagulant = EDTA
• Binds calcium
• Hematology studies: CBC
PLASMA
Whole blood
Purple-top tube
•Anticoagulant = potassium oxalate
– Binds calcium
– PLASMA, Whole blood
• Antiglycolytic agent = sodium fluoride
– Maintains plasma glucose levels
• Limited use: glucose, lactate, ethanol testing
Gray Top Tube
Anticoagulant:
• ACD = acid citrate dextrose
– Paternity testing
– DNA testing
• SPS = sodium polyanethol sulfonate
– Used for special blood culture studies
– Inhibits certain antibiotics
• Both bind calcium
• PLASMA, Whole blood
Yellow-top tube
ORDER OF DRAW MICROCONTAINER
- Blood gases
- Slides and smears
- EDTA tubes
- Other additive microcontainer
- Serum microcontainer
failure to mix or inadequate mixing of samples collected into an additive tube
clotted
usually caused by a procedural error
- Hemolysis
examples of procedural error that causes hemolysis
using too small needle or too large needle, pulling back to hard on the plunger of a syringe used for collecting the sample
. The red cells clump together making the sample unsuitable for testing.
clotted
red cells rupture resulting in hemoglobin being released into the serum/plasma
hemolysis
The serum or plasma will appear red instead of straw colored.
hemolysis
certain additive tubes must be filled completely. Incorrect blood to additive ratio will adversely affect the laboratory test results
- Insufficient sample (QNS)
certain tests must be collected and placed on ice, protected from light, or be kept warm after collection.
improper storage
mortal sin of medical technologists
improper label
most common encountered in obtaining a blood specimen.
- Ecchymosis (bruise)
. It is caused by leakage of a small amount of fluid around the tissue area.
ecchymosis
second most common complication
syncope (fainting)
Before drawing blood, the collector should ask if he/she had prior episodes of fainting.
syncope
when leakage of large amount of fluid around the puncture site causes the area to swell.
hematoma
Incorrect needle placement examples
- Needle is too big for the vein
- Needle fails to puncture the site or angle is increased
- Needle that goes through or beyond the vein
- Bevel on vein upper wall does not allow blood to flow
- Bevel on vein lower wall does not allow blood to flow
- Needle is inserted too far (through and through)
- Needle partially inserted and causes blood leakage into tissue
- Collapsed
- Correct insertion technique; blood flows freely into needle
Correct needle placement:
one reason is that the vein is missed because of improper needle positioning
- Failure to draw blood
small red spots indicating the small amounts of blood have escaped into the skin epithelium
petechiae
swelling caused by an abnormal accumulation of fluid in the intracellular spaces
edema
veins may be neither readily visible nor easy to palpate
obesity
veins may be neither readily visible nor easy to palpate can use of a __________ in locating the vein.
blood pressure cuff
The cuff should not be inflated ___________ pressure and should not be left on the arm longer than 1 minute.
any higher than the patient’s diastolic
is an increased concentration of larger molecules and analytes (potassium) in the blood
hemoconcentration
primary effect is Hemoconcentration
prolonged torniquet application
The ___________ pressure causes some water and elements to leave the extracellular space.
hydrostatic
Other complications include
(BDSO SVAM)
- Burned
- Damaged
- Scarred
- Occluded veins
- Seizure and tremors
- Vomiting and choking,
- Allergies
- Mastectomy patients
rupture of red blood cells with the consequent escape of hemoglobin
hemolysis
Can cause the plasma or serum to appear pink or red.
hemolysis
ways to prevent hemolysis
- Mix tubes with anticoagulant additives gently
- Avoid drawing blood from a hematoma
- Avoid drawing the plunger of the syringe back too forcefully and avoid bubbles on the sample
- Make sure the venipuncture site is dry
- Avoid a probing, traumatic puncture
fluid may dilute the specimen, so collect from the opposite arm if possible
IV therapy
Otherwise, samples may be drawn the IV by following this procedure:
- Turn off the IV for at least 2 minutes before venipuncture (inform the nurse)
- Apply the torniquet below the IV site. Select a vein other than the one with IV.
- Perform the venipuncture. Draw 5mL of blood and discard before drawing the specimen tubes for testing.
there will be a temporary increase in glucose and lipid content in the blood.
diet
increased white blood cell counts and cortisol levels.
smoking
can lead to decrease pulmonary function and result in increased hemoglobin levels.
smoking
results in a shift of body water from the inside vessels to the interstitial spaces.
posture
- levels of certain hormones such as cortisol and adrenocorticotrophic hormones decrease in the afternoon.
diurnal rhythm
other test values, such as iron and eosinophil levels increase in the afternoon.
diurnal rhythm
muscle activity elevates creatinine, protein, creatine kinase, AST and LDH.
exercise
activates coagulation and fibrinolysis and increase platelet and white blood cells.
exercise
cause a temporary increase in white blood cells.
stress
- Prolonged application of torniquet ( >1 )
venous stasis
- Drawing above IV
- Short draw (blood to anticoagulant ratio
hemodilution
- Traumatic stick
- Too vigorous mixing
- Alcohol is still wet
- Using too small needle
- Forcing blood into syringe
hemolysis
- Inadequate mixing
- Traumatic stick
clotted sample
- Short draw
- Sodium citrate tube draw volume critical
partially filled tubes
- Using incorrect cleanser
- Alcohol still wet
- Powder from gloves
- Drawing above the IV
specimen contamination
- Exposure to light
- Pre – chilled tube
- Body temperature
specimen handling
