Phlebotomy, Blood Circulation, and Lab Safety: Key Concepts for Healthcare Students

Purposes for phlebotomy

-Diagnostic purposes

-Monitor drug lvl

-Store sample for donation/transfusion

-Remove excess amt of blood

-Medical research

Duties of phlebotomy

-Collect blood and non-blood specimen

-Process and handle blood

-Patient interview and education

-Perform CLIA waived testing

-Perform QC

-Data entry

-Obtain vitals

-Patients identify

-Adhere to OSHA and HIPPA standards

-Follow all lab safety rules, policies or guide

ID PI

-Full first and last with mid initial

-DOB

-MRN if in patient

-Cannot draw without ID band and if info is incorrect

-PI has a right to stop at any point during the procedure

HIPPA

Health insurance portability and accountability act

PHI

- Protected health info

- Cannot disclose anything to family

HIPPA and PHI

-Lab tests

-Medical orders

-Medical diagnosis

-Medical procedure

-Medications

-Test results

-Appointment time/place

-Patient demographics

PI BOR

-Right to know what procedure is being performed and q/a

-Right to confidentiality regarding procedure

-Right to who can receive their health-related info

-Right to refuse treatment

-Right to know what tests are being performed

-Right to obtain a copy of medical records

circulatory sys

Deliver O2, nutrients 2, nutrients, hormones, and enzymes to cells

pulmonary circulation

heart to lungs to heart (oxygenated)

systemic circulation

heart to body (deoxygenated)

veins

carry blood to the heart

arteries

transport blood away from the heart

BP cuff

sphygmomanometer

fistula

vein and artery fused

graft

joining an artery and a vein

% types of blood vessels

Arteries: main branches (carry blood away from the heart)

Arterioles: small branches (control blood flow from capillaries)

Veins: main branches (collect blood from capillaries)

Venules: small branches (return blood to heart)

Capillaries: tiny exchanging vessels (exchange O2, nutrients, and waste)

whole blood

blood that circulates the body

coagulation

process of blood clotting

plasma

liquid portion of anti coagulated blood

serum

liquid portion of coagulated blood (no clot factor)

anticoagulant

prevents clotting

what does a blood sample yield if it has clotted

serum

if a blood sample has not clotted due to an anticoagulant, what will it yield?

plasma

blood pH

-Alkalinity scale is from 0-14 (normal range is 7.3- 7.45)

-When range is below: acidosis, DKA (diabetic keto acidosis)

-When above: alkalosis

RBC

-Erythrocytes, thrombocytes: platelets

- Too few: anemia, can result from excessive blood or developed due to an underlying disease that can affect RBC production

- Too many: polycythemia vera, thickened blood, can lead to multi organ failure

hemAchromatosis

absorb too much iron; diet, transfusions, genetics

WBC

- Leukocytes: protect body from infection and give immunity; monocytes, lymphocytes, neutrophils, eosinophils, basophils

- When levels elevate the body is fighting infection

- Too few: leukemia, result from infection or side effect of chemo

- Too many: leukocytosis, inflammation/infection, persistent leukemia

Homeostasis

equilibrium/balance

antecubital fossa

- 15-30 degree angle

- Median cubital: #1 preferred choice, most anchored

- Cephalic: easier to palpate in obese PI (thumb side)

- Basilic: close to brachial artery (pinky side)

Hand vein

- Alot of nerves

- 2-3 angle, up to 10

- Alternate sites: neck, groin, foot

antigens

substance that triggers an immune response leads to production of antibodies

antibodies

proteins substance that helps defend the body

agglutination

when blood types are incompatible (death)

what should you do if there is an IV in a PI

have a nurse take one out if there are two, and ask the nurse to pause it (wait 3-5 min to draw)

autologous

self blood donated for yourself

skin diagnostic test

culture of skin tissue, biopsy of skin, fungal scraping

NS diagnostic test

CSF sampling, glucose, protein, serotonin, acetylcholine receptor antibodies

Muscular diagnostic test

lactic acid, cold agglutination, anti-nuclear antibody, creatine kinase, autoimmune

urinary diagnostic test

- Urinalysis, urine cultures and sensitivity (C&S), 24-hour urine collection, blood kidney function panel, BUN, albumin test, electrolyte panel, kidney or bladder biopsy, urine cytology

QA

establish policies and guidelines defining safe practices

QC

-Steps of procedures performed as a part of a QA program

-Phlebotomists check for expired tubes and needles

CLSI (CLINICAL AND LAB STANDARD INSTITUTE)

-Develop clinical and lab practices to improve quality of medical care

-Also responsible for CE (continuing education)

PPE

personal and professional equipment

TJC

- Establishes the standard for hospitals and all other health care facilities (every 3 years)

- NPSG (national patient safety goals) part of a QCI requisition for accreditation

CLIAC (clinical lab improvement advisory committee)

Provide technical scientific advice and guidance to the CMS

CAP (College of American Pathologists)

lab inspection every 2 years

OSHA (occupational safety and health administration)

set safety standards for ALL workplaces

OSHA inspections

- Complaint inspection: employee files a complaint regarding workplace issue

- Programmed inspection: random

- Fatality or incident inspection: event of accident with 3+ employees hospitalized or fatality occurred

- Imminent danger inspection: (ex, active shooter) least common

- Referral inspection: individual, agency, or source reporting on unsafe working conditions

What are steps to take following exposure

1. wash affected area 15 min

2. report exposure

3. complete exposure report form

how long should you flush for an eye splash?

eyewash station, flush 15 min

what is the protocol for needle sticks?

wash the affected area for 10 sec, report it

injury log

confidential but kept for 40

Hepatitus B

Initial: first dose

Second: one month after first dose

Third: 6 months after first dose

needle gauges

Green: 21

Black: 22

Butterfly: 23

Baby/ turbid vein: 25

expressed consent

agree verbally/writing

informed consent

sign written consent form, that they are informed

parental consent

parent signing consent for minor

HIV consent

PI signing consent to the test being done, stating that they are aware that the test is being conducted

steps of venipuncture

1. Verify requisition/ labels

2. Introduce yourself/ verify ID/PI

3. Wash and glove/ gather equipment

4. Tourniquet, assess site; palpate

5. Cleanse area: back and forth

6. Air dry, assemble equipment

7. L hold to anchor, insert needle 15-30 angle

8. Start to collect; pop tourniquet

9. Hover gauze, take out needle

10. Hold pressure for 3-5 min

11. Invert tubes, 180 twist of wrist (8-10 times)

12. Check PI; change the gauze (bandage)

13. Thank PI or send

causes for difficult draws

- Small, deep, fragile veins

- Dehydration

- Obesity

- Anxiety or needle phobia

- Frequent blood draws

- Poor circulation

tips for difficult draws

- Warm the site (swell veins)

- Allow arm to hang to side to locate vein

- Uncross legs

- Ask about previous vein sites

conditions affecting draws

Bruises

Burned or scarred tissue

Collapsing veins

Edema

Infected areas

IV placements

Mastectomy

Rashes

Rolling veins

tattoos

PI with special needs

- Bariatric (deep vein: pick cephalic)

- Unstable (cannot draw alone)

- Geriatric (delicate, easily bruised and tear)

- Phobia (PI lie down, look away)

- Pediatric (small fragile veins, fear, decrease blood volume = limited)

- Sleeping (wake gently)

problems during procedure

Syncope: caused by a drop in heart rate and without warning, even with no history

Seizures

Allergic reactions

Petechiae

Hematoma (if occur,

Premature needle draw

Vein valve puncture (needle vibrate)

vascular steps of healing

Vasoconstriction: initial reaction to the injury is recognized

Platelet plug stage: platelets start to stick and form a temporary plug

Coagulation: stable fibrin clot formed

Fibrinolysis: breakdown of the fibrin clot

capillary collection steps

1. Position PI

2. Sanitize and glove

3. Select puncture site

4. Cleanse with alcohol

5. Squeeze finger/heel to increase blood flow

6. Use lancet

7. Wipe away first drop of blood

8. Collect blood

9. Dispose lancet

what are the tube additives?

- EDTA, heparin, Na+ citrate, bind to Ca

- Tubes without additives allow blood to clot and must be centrifuged

tube labeling

- PI full legal name, DOB, date and time of draw, tech initial

- 2 step verify before leaving the room

WNL

within normal limits

MEq/L

milliequivalent per liter

Mg/dL

miligram per deciliter

plasma

liquid portion of blood that has ANTIcoag which has prevented it from clotting

Serum

liquid portion of blood that has clotted and NO LONGER contains clotting factors

Order of draw

blood culture, light blue, red, gold (sst), green, dark green, lavender, pink gray

blood cultures (BCx or BC)

Additives: nutrient broth

DPT: microbiology

Common test: culture and sensitivity (C&S)

Inversion: 3-4

Draw the aerobic is drawn first

STAT

Detect bacteremia

light blue tube

Additive: sodium citrate

Specimen type: plasma

Dpt: Coagulation

Common test: PT/INR, PTT, aPTT, D-dimer

Inversion: 3-4 minimum

red tube

Additive: none in glass, clot activator is plastic

Specimen type: serum

Dpt: therapeutic drug monitoring (TDM)

Common use: discard tube

Inversion: 5 times if used for testing

Gold tube (sst)

Additive: silica (clot activator) and thixotropic gel

Specimen type: serum

Dpt: chemistry

Common tests: metabolic panel, lipid panel, CRP, hCG, electrolytes, hepatitis panel, hepatic function panel, renal function panel

Inversion: 5 times

Fill tube completely

ight green tube (PST)

Additives: lithium heparin w/ or w/o thixotropic gel

Specimen type: plasma

Dpt: chemistry

Common test : STAT chem tests, hCG, electrolytes

Inversion: 8 times

dark green tube

Additive: sodium heparin

Specimen type: plasma

Dpt: Chemistry

Common tests: lactic acid

Inversion: 8 times

lavender tube

Additive: K2 EDTA

Specimen type: whole blood or plasma

Dpt: hematology

Common tests: CBC, ESR, H&H, hemoglobin A1c

Inversion: 8 times

pink tube

Additive: k2 EDTA

Specimen type: whole blood

Dpt: blood bank/immunohematology

Common test: blood typing and cross matching

Inversion: 8 times

gray top

Additive: sodium fluoride and potassium oxalate

Specimen type: plasma

Dpt: Chemistry

Common tests: glucose, lactic acid, blood alcohol (ETOH)

Inversion: 8 times

royal blue with RED stripe tube

No additive

Specimen type: serum

Dpt: toxicology

Common tests: trace elements

No inversion

Test for selenium and copper

royal blue with lavender stripe tube

Additive: K2 EDTA

Specimen type: plasma

Dpt: Chemistry

Common tests: trace elements

Inversion 8 times

Test for zinc, arsenic, lead

stat

immediate (red labeled border )

medical emergency

immediate (part of triage) above stat

timed

draws over a predetermined time

routine

draws can be done within an 8 hour shift

fasting

8-12 hour (only water)

NPO

nothing by mouth incl water

PO

taken by mouth

peak lvl

highest conc (drawing)

1 hour given

- stat

trough lvl

lowest conc (drawing) 15 min b4 next dose given

- timed

TDM

therapeutic drug monitoring

diurnal

daily

what do you have to do for a lactic acid draw

no stasis (tourniquet )

QNS

quantity not sufficient

icteric serum

may have to redraw due to yellow discoloration from elevated bilirubin lvls

hemolyzed serum

may cause a redraw and su a pink or reddish