Phlebs Ch. 8

Patient Reactions and Phlebotomy Complications

The best method to avoid nerve damage is to...

Avoid probing and only puncture veins that can be felt in order to...

After a venipuncture is completed, bleeding should stop after...

After two minutes, you should reassess the venipuncture site to confirm...

No patient should leave before you have...

Tubes should be labeled before the patient is allowed to...

If bleeding continues for more than two minutes after venipuncture...

You should hold pressure on the venipuncture site for 5 minutes if bleeding continues for more than...

If minor bleeding continues for more than 5 minutes after venipuncture...

You should apply Coban - an elastic gauze bandage if...

If Coban is applied to a patient, they must wait this long before being reassessed and allowed to leave...

15 minutes is the amount of time a patient must wait before being reassessed and allowed to leave if...

Coban should ideally be removed within how long due to complications with circulation...

Coban should ideally be removed within 15-30 minutes due to...

If a hematoma begins to form...

Apply firm pressure to the site for at least

Icteric means...

A yellow or orange color of plasma/serum due to excess bilirubin (jaundice)

Colors of Serum or Plasma Samples

• Normal - Yellow/Straw Colored

• Hemolyzed - Red color

• Icteric - Yellow-Orange

• Lipemic - White, Milky

Contingencies for Recovering a Failed Venipuncture

• Re-tie the tourniquet

• Use a blood pressure cuff as a tourniquet if you have no other option

• Massage the arm; NEVER slap the arm

• Lower the patient’s arm

• Warm the venipuncture site

• Reseat the tube

• Try a different tube

• Place your finger below the venipuncture site and stretch the vein slightly

• Rotate the needle ¼ to ½ turn

• Pull back or advance the needle slightly

The sample will be contaminated by IV fluid if it is drawn...

If the sample is drawn above an IV, or in less than two minutes from the IV being turned off...

If an IV cannot be shut off, the three choices are...

• Draw a microcollection if it can be used for the tests ordered

• Obtain permission to draw from the ankle or ofot

• Wait at least 30-60 minutes after the IV has been removed

  • To allow blood to circulate within the arm without contamination

When the IV is shut off, you should draw at least 2 discard tubes first, in order to...

In order to make sure all contaminants are removed, you should draw this many discard tubes after an IV is turned off

When the IV is shut off, if drawing blood cultures, you should draw how many discard tubes to remove contaminants?

6 Discard tubes should be drawn when...

When encountering a patient with a fistula, you should draw from...

The opposite arm should be drawn from if the patient has one of these...

• Can also use the hands/capillaries according to April

The median cubital vein is typically the most prominent to feel, but for bariatric patients this vein should be used first...

The cephalic vein is preferred for this type of patient because it is not as deep as the median cubital vein...

The most common reasons for nerve damage are...

Attempting venipuncture on the basilic vein or inserting the angle at a greater than 30 degree angle

If collection is stopped early due to the patient experiencing pain...

You must draw from another site, such as the other arm

Deep, probing venipunctures can result in...

Nerve damage

If the nerve was only touched, numbness usually goes away...

In a few hours to days

If a nerve is damaged, the numbness

Could be permanent

Phlebotomists have caused legal issues for health care facilities because of

Causing nerve damage

Nerve damage can only be determined by

A physician

If a patient is about to faint, they will show these symptoms

• Turning pale

• Perspiring

• Beginning to breathe shallowly

  • Followed by drooping eyelids

  • weak, rapid pulse

  • unconsciousness

If a patient faints while in a chair...

You must hold the patient in the chair to prevent them from sliding onto the floor

If the patient collapses to the floor

• Cushion the patient, lower the head and arms

• Wipe the forehead and back of the neck with a cold compress if necessary

These may have an adverse effect on the patient if used to revive them from syncopy

Ammonia inhalants

Ways to prevent Syncope

• Explain the procedure

• Ask the patient if they have a history of syncope, have them lie down if so

• Distract the pt by having a second phleb speak to them

• Have the pt look away from the needle

• Have the pt move their toes or tense their legs to distract them

• Have the pt perform these techniques during venipuncture, until the needle is withdrawn

You should keep a patient reclined for how long if they have a history of syncope

5-10 minutes - monitor as they get up

Nauseous patients should be instructed to

breathe deeply and slowly

Nauseous patients should be given

An emesis basin, wastebasket or container

A cold compress applied to the forehead

facial tissues should be ready

If a patient does vomit, they should be given

Water to rinse their mouth out

Diabetic shock is usually the result of

Too much insulin in the pt’s system

Diabetic shock can occur due to too much

Insulin in the bloodstream

Signs of diabetic shock are

• Cold sweat and pale face

• Weakness and shaking

• Sudden confusion/Instant personality change

If a patient in diabetic shock is conscious enough to swallow, what can temporarily help?

A glass of orange juice or cola

If a patient goes into convulsions

Do not try to restrain them

move objects out of the way to prevent injury

cushion them if they are on the floor

Record the time when convulsions started and ended

Call the physician or nurse for help

Stay with the patient until they are comfortable to leave

They will usually recover within a few minutes

Patients who go into convulsion will usually recover in...

A few minutes

If a person falls unconscious with no pulse or respirations, dilated eyes, and a blue or grey skin tone...

Immediate cardiopulmonary resuscitation is necessary (CPR) to avoid pt death

At the first sign of a hematoma, the phlebotomist should...

Abort the venipuncture and apply heavy pressure to the site until bleeding has stopped

If the needle punctures both the top and bottom wall of the vein...

A hematoma is likely to occur

The venipuncture site must be observed for hematoma formation for

5-10 seconds

If a hematoma or bruising occurs, remind the patient not to...

Carry a purse or objects with that arm

Petechiae are...

Small red dots indicating small amounts of bleeding under the skin

These are often the result of low platelet counts or other coagulation problems, and indicate that the patient may bleed excessively after the procedure

Petechiae

Before a site is cleansed for blood cultures, the phlebotomist should ask the patient if they are allergic to...

Iodine

The four factors causing anemia are

• Decreased erythrocytes

• Deficiency in hemoglobin production

• Deficiency of hemoglobin

• Abnormal hemoglobin

A patient with anemia will exhibit these symptoms

• Lack of energy/fatigue

• pale skin

• SOB

A hereditary condition where erythrocytes are destroyed faster than they are produced

Hemolytic anemia

A hereditary disease in which hemoglobin production is suppressed

Thalassemia

Anemia caused by drawing extensive quantities of blood from a pt; Most concern for premature infants

Iatrogenic anemia

Iron-deficiency anemia causes...

Lower than normal erythrocyte production

When the venipuncture has been unsuccessful, always pull the needle out...

Pull out slowly

The blood will often start coming just as...

Just as it seems the needle is ready to come out of the skin

If a tube fails to fill completely...

Try another tube before removing the needle, try reapplying the tourniquet more loosely next time,

Why is a blood pressure cuff a good alternative to a tourniquet?

More surface area and ability to regulate pressure

Instead of slapping the arm, try

Massaging the arm upward below the site

Other strategies to recover a failed venipuncture

• Warm the site with towels or infant heel warmers

• Lower the arm

• Reseat the tube

• Rotate the needle 1/4 to 1/2 turn

What might be a cause for a failed venipuncture for which the patient is at fault?

Failing to drink sufficient water, causing the blood to become more viscous

If two phlebotomists have been unsuccessful and a capillary collection is not possible...

Notify the physician, they may consider a VAD

If glucose is being tested in a patient with saline solution IV

The glucose value will be less due to dilution

• Could also be increased if they are receiving a glucose solution instead

After the IV has been shut off for 2 minutes, what other precautions should be taken?

• Select a vein other than the one with the IV

• Tie the tourniquet below the IV site

When labeling a sample drawn from an arm with an IV, you should

Record that blood was collected from the arm with the IV and what was running in the IV

Collecting a blood through an IV needle often results in...

Increased hemolysis and recollection requests

Venous Access Devices VADs

• Arterial lines

• Venous catheters

• Percutaneous Indwelling Central Catheters (PICC)

• Heparin/saline locks

Heparin or Saline is used in IVs to...

Flush the line to keep blood from clotting in it

After blood is pulled from a line...

Heparin or saline is injected until all the blood has been pushed back into the patient, keeping it clear

Samples taken from a line contain a mixture of blood and heparin or saline, you must discard...

The capacity of the line must be discarded at least twice to clear any fluids from the line

Coagulation tests should not be collected from a line that

Has been flushed with heparin or had anticoagulants infused

• If there is no alternative, the line must be flushed 6 times

If a coagulation test needs to be collected from a line that contained heparin, it should be flushed with...

Saline to remove any heparin stuck to the walls of the line

A discard sample of at least this size should be drawn after flushing a line to clear any heparin/etc

At least 5mL

A cannula is a

Type of tubing connector used on dialysis and kidney transplant pts

A fistula is an artifial shunt connection done by a surgical procedure to...

Fuse a vein and artery together

If a patient has a fistula

You should draw from the opposite arm

An ammonia test must be placed on ice and delivered to the lab within...

20 minutes of collection

A patient with an ammonia test should be drawn last so that...

The sample can be delivered to the lab immediately

Make sure you have all of your equipment before leaving the patient because...

Items sometimes get entangled in bedsheets or fall to the floor

Drawing a patient without consent from the patient or their legal caregiver can result in charges of

Assault and battery

Patients with obesity have these, which feel like veins but do not return blood

Tissue globules

Patients with obesity are often reluctant to have blood drawn because

Their veins are hard to find

If a patient takes anticoagulants/blood thinners, pressure should be held on the site for at least

5 minutes, before being observed for 5-10 seconds. If bleeding continues, hold an additional 5 minutes.

An outpatient that has continued to bleed can not be allowed to leave for at least

15 minutes, to determine if the bleeding has stopped

If a patient immediately bleeds through the gauze square,

Apply several layers of fresh gauze to the site and hold pressure until you are sure bleeding has stopped. The arm must be wrapped with a non-latex elastic bandage over several layers of gauze once bleeding has stopped. The nurse must be asked to monitor inpatients, and outpatients must be instructed to wait an additional 15-30 minutes to be certain the bleeding does not return

Why should you treat every patient on anticoagulant therapy as if they will continue bleeding, and hold for 5 minutes?

They have a tendency to develop hematomas, causing problems for the next phlebotomist

The best way to obtain blood from a vein that tends to collapse is to use a

Syringe, performing small gentle pulls one at a time, allowing the vein to refill between pulls, without allowing the blood to clot in the syringe. You should be done within 30 seconds and immediately transfer the blood to tubes.

If a 10mL tube collapses a vein, what tube should you try instead?

Three 3mL tubes, to obtain approximately the same volume.