1. Mix tubes with anticoagulants 5-10x gently.
2. Avoid drawing from hematoma
3. Don't draw plunger back forcefully, and avoid frothing
4. Dry venipuncture site completely
5. Avoid probing, traumatic venipunctureIndwelling
Pre-analytical testing phase
It includes procedures such as laboratory handling and identification that take place prior to any laboratory testing.
It has a proper control measures to avoid subsequent issues.
It starts with the doctor's given order and ends when the laboratory testing has officially commenced.
During this phase, aside from the ability to draw blood from the patient, the phlebotomist should also possess the skill of being able to identify factors that affect the process and address the same as needed.
The laboratory test is used by the physicians to diagnose and monitor the presence of a disease.
They compare the results to a reference range or reference interval. This range shows high and low limits of result values as compared to healthy individuals.
Several factors are considered as part of the reference interval study or the interpretation of the data obtained.
TRUE
Laboratory test
is used by physicians to diagnose and monitor the presence of a disease. The physicians compare the results to a reference range or reference interval.
Reference range or Reference interval
this range shows the high and low limits of result values as compared to healthy individuals. Several factors are considered as part of the reference interval study or the interpretation of the data obtained.
Basal state
It is an ideal in establishing reference range since it represents the condition of the metabolism of the body early in the morning or after approximately 12 hours of fasting.
age
gender
and;
conditions of the body.
factors that can influence the basal state.
Age
Altitude
Dehydration
Diet
Diurnal Variation
Drug Therapy
Exercise/IM Injection
Fever
Gender
Jaundice
Intramuscular Injection
Position
Pregnancy
Smoking
Stress
Temperature and Humidity
These are the factors (physiological variable) that affects blood collection
Age
Red Blood Cells (RBC), White Blood Cells (WBC), creatinine clearance
Altitude
red blood cells (RBC)
Dehydration
Hemoconcentration, Red Blood Cells (RBC), enzymes. Iron (FE), Calcium (Ca), Sodium (NA)
Diet
Glucose, lipids, electrolytes
Diurnal Variation
(Thyroid Stimulating Hormone) TSH, cortisol, Iron (Fe)
Drug Therapy
Enzymes, hormones
Exercise/IM Injection
(Potential of Hydrogen) pH, Carbon Dioxide Partial Pressure (PCO2 ), Creatinine Kinase (CK), Lactic Acid Dehydrogenase (LDH), glucose
Fever
Hormones, cortisol
Gender
Red Blood Cells (RBC), Hemoglobin (HgB), Hematocrit (Hct)
Jaundice
Yellow color interfaces due to increased biliburin
Intramuscular Injection
Creatine Kinase (CK) and the skeletal muscle fraction of LDH
Position
Protein, Potassium (K)
Pregnancy
Red Blood Cells (RBC)
Smoking
Cholesterol, cortisol, glucose, growth hormones (GH), triglyceride, White Blood Cells (WBC)
Stress
White Blood Cells (WBC), Iron (Fe), Adrenocorticotropic Hormone (ACTH), catecholamine, cortisol
Temperature and Humidity
Hemoconcentration
Burns, Scars, &
Tattoos
Damaged Veins
Edema
Hematoma
Mastectomy
Obesity
Problem areas to avoid and troubleshooting in the Site selection
Burns, Scars, & Tattoos
A site which has burns, scars or tattoos is not recommended because veins in the area may be difficult to examine and blood circulation maybe impaired.
Burns may be too painful to touch and tattoos may also be susceptible to infection due to the dyes used that may interfere with the process.
Damaged Veins
Aside from encountering difficulty in puncturing the site when veins are damaged another problem is the possibility of getting inaccurate results.
Veins could be Sclerosed or hardened or Thrombosed or clotted.
Edema
It is also known as oedema.
It is an abnormal swelling caused by accumulation of fluid in the tissues.
The tissues become fragile, making the task of locating the veins harder.
This condition maybe due to reactions from medications, pregnancy, infections and other medical problems.
Hematoma
It is a solid swelling or mass of blood in the tissues which is caused by the leakage of blood from the vessels during venipuncture.
This is not only painful because it obstructs the blood flow it could also lead to the contamination of blood sample.
Mastectomy
a treatment or procedure for breast cancer that requires removal of the breast through surgery.
Blood drawing becomes a challenge since the lymph flow is obstructed, and there maybe swelling and infection after the surgery.
In addition, tourniquet cannot be applied because it can cause injury. It should also be noted that it could also change the blood composition.
Obesity
A condition of an individual that is grossly overweight.
Patients that are obese have veins are deep and they are harder to locate.
A solution is to use a longer tourniquet or try locating the cephalic or cubital vein.
Arterial
Line
Arteriovenous Shunt or Fistula
Blood Sampling Device
Heparin or Saline Lock
Intravenous (IV) Sites
Central Vascular Access Devices (CVADs)
Vascular Access Sites and Devices
Arterial Line
To obtain samples for arterial blood gas and laboratory studies, critically ill patients require arterial lines where a thin catheter is inserted into an artery.
This also used to monitor blood pressure continuously.
Neither tourniquet nor venipuncture are allowed in the arm with an arterial line.
Arteriovenous Shunt or Fistula
It is a passageway created thru surgery which is usually in the arms with the intention of connecting the artery and a vein directly.
This maybe created for hemodialysis treatment or pathological process such as erosion of arterial aneurysm.
Blood Sampling Device
A blood sampling device is used to avoid the use of needle sticks, reduce infections, and reduce wastage from line draws.
The device collects blood from the arterial or central venous catheter where it is connected.
Heparin or Saline Lock
It is commonly called a "hep-lock."
It is an intravenous (IV) catheter attached to a stopcock or cap with diaphragm.
The basic function is to provide access for administering medicine or drawing blood from the patient.
This is threaded in the peripheral vein which is in the lower arm above the wrist for up to 48 hours.
It is usually flushed with heparin or saline (to prevent clogging) and capped for future use.
Intravenous (IV) Sites
An IV line is a thin plastic tube or catheter inserted into a vein in the forearm to inject a volume of fluids into the bloodstream.
The phlebotomist should avoid collecting blood from the arm with IV because the blood collected could be contaminated with IV fluid.
If blood collection is necessary, collection site should be below the IV.
Take note that collection of blood from known previously IV sites should be avoided for 24 to 48 hours.
Central Vascular Access Devices (CVADs)
CVADs is also known as indwelling lines which is a tubing inserted to the main vein or artery used for blood collection, monitoring the patient's pressures and administering medications and fluids.
Central Venous catheter lines
Implanted port
Peripherally inserted central catheter (PICC)
3 types of Central Vascular Access Devices (CVADs)
Central Venous Catheter
It is also known as a central line inserted into the large vein (subclavian) and advanced into superior vena cava.
Implanted Port
It is a surgically implanted disk-shaped chamber attached into the indwelling line.
This is usually placed on the upper chest just below the collarbone.
Peripherally Inserted Central Catheter (PICC)
It is a flexible tube inserted into the veins of extremities and the central veins.
Allergies to Equipment and Supplies
Excessive Bleeding
Fainting
Nausea and Vomiting
Pain
Petechiae
Seizures/Convulsion
7 Complications associated with Blood Collection
Allergies to Equipment and Supplies
When the patient has adhesive allergy, a gauze should be placed over the site and should be removed after fifteen minutes.
The alternative is to ask the patient to apply pressure for five minutes.
For Antiseptic allergy, simply use a different antiseptic.
And for latex allergy, look for a sign to indicate the allergy and use a non-latex alternative for gloves, tourniquet and bandages.
Excessive Bleeding
When a patient is on aspirin or anticoagulant, the bleeding may take a longer time.
The pressure should be applied to the site until the bleeding stops.
The attention of the authorized personnel should be called when the bleeding continues after five minutes.
Fainting
It is a temporary loss of consciousness which is caused by the insufficient flow of blood to the brain.
If the patient is prone to fainting during venipuncture, they are asked to lie down during the procedure.
Nausea and Vomiting
When the patient feels nauseous and has the tendency to vomit, the phlebotomist has to discontinue the procedure until the patient feels better or until the feeling subsides.
An emesis basin or wastebasket should be provided, and a cold damp washcloth should be applied in the forehead.
Pain
The patient should be warned before the needle insertion, and the phlebotomist should avoid redirection of the needle.
If the patient complains of extreme pain or numbness, remove the needle and apply ice to the site because this could indicate nerve involvement.
The phlebotomist needs to document the incident if the condition persists.
Petechiae
This condition involves the appearance of small red or purple spots that look like rashes, which appears on the arm when tourniquet is applied.
Seizures/Convulsion
When seizures or convulsions occur, the blood draw should be discontinued immediately.
Hold pressure over the site but make sure that movement is not restricted, the mouth is free from any obstruction and the patient is protected from self-injury.
Call the attention of the first-aid personnel.
Hematoma Formation
Iatrogenic Anemia
Inadvertent Arterial Puncture
Infection
Nerve Injury
Reflux of Anticoagulant
Vein Damage
Troubleshooting Failed Venipuncture
Collapsed Veins
Tube
Vacuum
10 Procedural Error Risks and Failure to draw blood
Hematoma Formation
The phlebotomist should hold pressure on the site immediately after discontinuing the draw.
A cold compress or ice pack maybe offered to help address the swelling.
-Excessive or blind probing
-Inadvertent arterial puncture
-Size of the
vein is too small
-The needle penetration has gone all through the vein
-Needle is not completely inserted
-Tourniquet is still on when the needle was removed
-Pressure is not adequate
These are the conditions that can trigger hematoma:
Iatrogenic Anemia
This results from blood loss due to blood draw.
It is important to ensure to collect only the required specimen volume because if 10% of the blood volume is removed at once from the body, the patients could face a threat.
Inadvertent Arterial Puncture
This happens when blood is filling up the tube rapidly and there is a rapid formation of hematoma on the site.
Infection
Infection can be avoided by making sure that tapes or bandages are not opened ahead of time;
needles are not preloaded into the tube holders, insertion site of the needle is not touched after sterilization;
cap is removed just before venipuncture, and;
patients are advised to keep the bandage on the site for at least 15 minutes.
Nerve Injury
Nerve injuries happens when there is improper site selection, rapid needle insertion, excessive redirection of the needle and blind probing.
If the initial attempt is not successful, the phlebotomist should try to redirect the needle by using a slightly forward or backward movement.
The next step is to remove the needle and look for an alternative site.
Reflux of Anticoagulant
To avoid blood that has already been drawn to flow back into the vein from the collection tube, which may cause adverse reaction because of the presence of tube additives, make sure to keep the arm of the patient in a downward position and the tube just below the venipuncture site.
Vein Damage
Damaging the vein could be avoided by following the proper technique and avoiding blind probing.
Hemoconcentration
Hemolysis
Partially Filled Tubes
Specimen
Contamination
Wrong or Expired Collection Tube
5 Specimen Quality
Hemoconcentration
It is a decrease in the fluid content or plasma volume which is usually caused by tourniquet that stagnates the normal flow of blood, leading to the increase in concentration of red blood cells and other nonfilterable large molecules.
Hemolysis
It is also called Haemolysis, refers to the rupture pes of the red blood cells.
The hemoglobin is then released to the surrounding fluid.
Partially Filled Tubes
This happens when the phlebotomist pulls a tube before reaching the required volume which may lead to the incorrect blood-to-additive ratio.
Specimen Contamination
This means that the specimen is compromised due to incorrect handling, which includes allowing alcohol, powder or other materials into the sample.
Getting glove powder or perspiration into films and specimens, using the wrong antiseptic, or simply not following the proper antiseptic procedure could interfere with the results.
Wrong or Expired Collection Tube
It should not be used because the manufacturer could not warrant the quality of the seal and pressure after the expiration date declared in the tube.
Venipuncture attempts could fail due to improper seating of the tube and failure of the needle to go through the stopper.
TRUE
The phlebotomist must be aware and must take measures to ensure that the proper procedures are followed.
TRUE
The needle position is critical to the success of the venipuncture
TRUE
-Needle not inserted far enough
-Bevel partially out of skin
-Bevel partially into vein
-Bevel partially through vein
-Bevel completely through vein
-Bevel against vein wall
-Needle beside vein
-Undetermined
position
The phlebotomist should ensure that the following do not happen:
Collapsed Vein
This usually occur when conditions are less than ideal, which leads to the veins being blocked, resulting to insufficient blood flow.
This happens when there is a strong pressure in the vacuum of the tube or plunger, the tourniquet is too close to the site or it is too tight, or when the tourniquet was removed during the draw.
Tube Vacuum
To avoid failure due to loss of vacuum, the phlebotomist should make sure that the bevel is not partially out of skin and the tube itself is not damaged.