phle ch9

how must you greet an unconscious pt?

the same way you greet awake, assume they can hear - “might feel a little poke”

if pt. is asleep…

awaken them gently, tell them your turning on the light, give them time to become orrientated

pt. identification for young, cognitively impaired, or unconscious

pt.’s:

ask pt. nurse, relative, friend - document name of verifier, compare to req form and ID band

ideal time to collect blood?

basal state

basal state

early in morning, best baseline, when pt. refrained from strenuous exercise and has been fasting for 12 hrs

reference values

normal values

determined from normal, representative sample of basal state

diet

phleb’s responsibility - '“ have you been fasting?”

*for glucose and lipid tests

posture

no standing while drawing blood
*Changes in high-molecular-weight compounds between supine and erect position

*lab results in elderly pt. most affected by posture

*ask to sit while grabbing equipment to allow blood to stabilize

how does pregnancy change blood

increased plasma volume, lowers normal reference ranges

diurnal variation

normal fluctuations of blood levels at different times of day based on 24 hr cycle

*cortisol, other hormones, iron - must be collected at specifed times

medications

“are you on any medications or supplements?”

“are you on any blood thinners?”

*be aware of any procedures being performed at the time you’re collecting a specimen & note this on requisition form - if doing an H&H, note if there was a transfusion

if you have to come back to draw blood?

chart: nurse name informed, time, reason why cant, when you will come back

syncope

fainting, vasovagal reaction - insufficient blood flow to brain

notice: cold, clammy, pale skin or hyperventilation

remove torniquet and needle

push fluids

vasovagal reaction

BP drops, heart rate drops, blood vessels in legs dilate, blood pools in feet, push fluids
*Part of the involuntary nervous system that regulates heart rate & BP malfunctions in response to a trigger that causes a vasovagal reaction.

petechiae

small, nonraised red hemorrhagic spots

(may have prolonged bleeding after venipuncture)

pt. refusal

Patient’s right

Documentation: “pt refused draw at time, date, intials

inform why doctors would want it - only once

*You may be guilty of assault if the pt. perceives that his/her refusal is being ignored.

Psychiatric patients

only bring in necessary equipment

*pt may become agitated, will come back at diff time

Skin conditions or open sores

place tourniquet over pt.’s gown or cover the area with gauze or dry cloth before application - elderly pt.

Hemoconcentration

Prolonged tourniquet time

*temporary increase in the concentration of red blood cells and other components in the blood, caused by a decrease in plasma volume (plasma passes to tissues)

*hemolysis, affects lab values

vein enhancement

massage, wrist up

gravity

heat

*dont pump

physician approved veins?

leg and foot veins - high risk of infections, necrosis, clots

*never do underside of wrists - nerve damage

hematoma

draw below

blood pools under skin, bruise

stop if u see one forming

mastectomy pt

removal of lymph nodes, if add tourniquet - cause lumphedema (accumulation of lymph)

use other arm

*Drawing blood from the arm on the side of a mastectomy with a patient’s permission may have legal ramifications

IVs

select vein in opposite arm, or go below if have to

heparin and saline locks

*discard 5mL - no coag tests at all

*turn off IV 2 minutes before - Alert nurse that specimen has been collected &

infusion may be restarted

*Document location of venipuncture & that it was drawn below an infusion site.

fistula

no coband, check before you torniquet

permanent surgical fusion of artery and vein

*arteriovenous AV fistula - fusing of radial artery and cephalic vein most common

*arteriovenous graft - using looped artificial tubing

do not draw from this arm

*prolonged bleeding, risk of infection

cannula

Temporary external connection of artery to vein

• Only specially trained personnel

what antiseptic to use for blood alcohol levels

iodine - check fot allergy

use soap and water

what antisepctic to use for blood cultures

chloraprep

pulling plunger speed

• faster than the rate of blood flow may cause the walls of the vein to collapse & can cause hemolysis.

• slowly can cause the blood begin to clot before collection is completed.

what is straight needle

needle on syringle into annecubital area

discard tube

use burner tube when doing l. blue top using syringe draw since 0.5 mL of air in tubing

Technical Complications - Failure to obtain blood

Needle position

• Bevel against vein wall

• Needle too deep or too shallow

• Collapsed vein

• Needle beside the vein

• Faulty evacuated tube

Nerve Injury

Median cubital nerve

“Nicking” the nerve (blind - fishing - probing) NEVER

High-risk sites: underside of wrist and brachial vein

Legal ramifications

Iatrogenic Anemia

Blood loss caused by treatment

• High volume removed by venipuncture

Infants or elderly

Anticoagulant Reflux

Backflow from tube to vein

Adverse patient reactions

Avoiding reflux always keep pt.’s arm & tube in a downward position, which allows the collection tubes to fill from the bottom up.

Compartment syndrome

Accumulation of blood into the tissues pressing

on nerves; it can cause permanent nerve injury

what is requisition form

formal request for goods, services, or personnel

what to do if glucose pt hasnt been fasting?

call doctor and ask

what to do if pt is on blood thinners

document, coban, extra pressure

edema

excess tissue fluid

venous cathater

dialysis, plastic tube in neck - dont touch

what to do with the syringe first

prime it first, pull back to stop the vaccum within the tubing

failure to anchor?

infliltrate vein (go thro) - cna collapse vein, vein moves

how to move blood from syringe to tubes

use transfer device, never put needle into the tube

what to do if second puncture fails

document it, get another phleb, tell nurse

what happened if pt feels tingling, numbness, burnign?

needle hit nerve

what will happen if sample hemolysed

destroy rbc, when spun: sample will not be clear

alcohol, shaking, small needle

how to prevent infection after removing needle

ask pt. to keep bandage on for 15minutes

aseptic technique

gloves, alcohol

time sensitive samples

cortisol: high in morning - alert and beats back sleep inertia

TSH; 2-4 am high, 4-8am low

iron: in morning, after fasting - 12 hrs

whats potassium important for

heart health

can cause heart attack

if hit artery…

hold pressure longer - 10 minutes

document!