Basic Principles of Phlebotomy Part IV:

The Patient, Collection Site and Problems with Collection Sites

CLS 424 Phlebotomy

Student Lab Rotation

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The Patient:

• Approach• Communication• Empathy• Handling special situations• Patient identification

– Arm band– Legal document

• Prepare patient for blood draw– Latex allergy?

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Selecting the Site:

• Antecubital area most often accessed

• Hand or wrist• Remember: 2 arms• Use tip of index finger

on non-dominant hand to palpate area to feel for the vein

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Collection Site Problems:• Veins that lack

resiliency

• Extensive

scarring

• Hematomas

• Edematous

area

• Side of mastectomy

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Collection Site Problems:

• Intravenous line– NEVER draw above

an IV

– Draw from other arm

– Draw from hand

on other arm

– Draw below the IV

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Draw Below IV site:

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Collection Site Problems:

• Indwelling lines:– Hickman catheters– Heparin locks

• Used to administer medication

• Only nurse may access these lines

• Can obtain blood: called a ‘line draw’

• Must clear line of heparin contamination by discarding first 5-10 cc of blood

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Hickman Catheter:

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Inserting the Needle:

• Anchor the vein– Grasp arm with your

non-dominant hand– Use thumb to pull skin

taut

• Smoothly and confidently insert the needle bevel up– 15-30 degree angle

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No Needle Movement!

• You must anchor the blood-drawing equipment on the patient’s arm to minimize chance of injury

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Fill Tubes:• Use correct order of draw:

– Blood cultures– Red top– Blue (baby blue)– Green– Purple– Grey

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Be careful not to:

• Push needle further into vein when engaging evacuated tube

• Pull needle out of vein when disengaging tube

• Pull needle out of vein as you pull back on the plunger

• Pull up or press down when needle in vein

• Forget to mix additive tubes 8-10 times

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Withdraw Needle:

• First release tourniquet

• Disengage tube

• Place cotton directly over needle, without pressing down

• Withdraw needle in swift, smooth motion

• Immediately apply pressure to wound

• Do not bend arm

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Label Tubes Immediately:

• In sight of patient

• Patient name• Identification

number• Date of draw• Time of draw

(military time)• Your initials

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Recheck Draw Site:

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Failure to Obtain Blood:

• Check tube position and vacuum– Always have back up tubes near by

• Needle position

• Collapsed vein

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Needle Position:

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You should try again

• Look at alternate site– Other arm– Hand

• Use clean needle• Use fresh syringe if

contaminated

• Only try twice

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Poor Collection Techniques:• Venous stasis

– Prolonged application of tourniquet (>1 min)

• Hemodilution– Drawing above IV– Short draw (blood to anticoagulant ratio)

• Hemolysis– Traumatic stick– Too vigorous mixing– Alcohol still wet– Using too small of needle– Forcing blood into syringe

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Poor Collection Techniques:• Clotted sample

– Inadequate mixing– Traumatic stick

• Partially filled tubes– Short draw– Sodium citrate tube draw volume critical

• Using wrong anticoagulant

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Poor Collection Techniques:• Specimen contamination

– Using incorrect cleanser– Alcohol still wet– Powder from gloves– Drawing above IV

• Specimen handling– Exposure to light– Pre-chilled tube– Body temperature