Phlebotomy In the Emergency Department OBJECTIVES • • • • • • Identify and verify patient Assemble supplies Select site Perform venipuncture Label specimens Document Patient Identification • At bedside, read ID bracelet • CHI’s TWO pt. Identifiers are full name and DOB • If no band, get one before the draw. • Do not draw unless proper ID! Bedside Identification • Identification of the patient is critical! • At least TWO patient identifiers MUST BE USED. • Compare the stickers from the chart to the patients armband, and ask their name and birthday. • Do not draw specimens from any patient who does not have proper ID. • If question remains, contact the nurse. Report any discrepancy. Special Circumstances • Unconscious • Non English patient: speaking or deaf: • If ID bracelet not available, get • Obtain an one. interpreter from the foreign • Use Doe,Jane or telephone Trauma,Joe language line or 1,2,3 etc. TV. Special Circumstances • Latex allergy: • Must draw with Latex free products • These include: blue tourniquet, blue latex free gloves, and paper tape. • Ensure a green allergy band is on stating the word “latex”. Approaching the patient • Identify yourself! • No chewing gum,food, or • Explain what thermometer you are about to should be in pts do. mouth at the • Tell the pt that time of they will feel venipuncture. discomfort, but • Consider the pts not that it will age and culture. not hurt. Semiconscious states • Special care must be taken when drawing unconscious, semiconscious, or sleeping patients. • Try first to gently wake the pt. • Anticipate unexpected movements or jerks of the arm. • Request assistance if needed. • A gauze pad should be readily available and tourniquet quickly released in the event of dislodgement. Information regarding the test being drawn must be given according to policy. General information only may be provided, detailed info related to the test will be given by the nurse or MD. Do not try to give a detailed explanation of testing and possible implications of results. Do not draw blood against the pts wishes! Notify the nurse or MD who will explain the reasons for the tests. Document reason for delay. Assemble Equipment • Gloves • Vacutainer or butterfly • Tourniquet, Chlorascrub, betadyne, tape, gauze • Blood Collection tubes • Blood transfer device • Labels Vein Selection • Apply tourniquet 3-4 inches above intended puncture site. Release after 1 minute. • Have patient make a fist, no pumping. • Select vein only. If an artery is accidentally punctured, apply firm, direct pressure for 5 min. • Do not select an arm with a pink arm band (restricted limb). Vein Selection • Veins should feel like spongy, elastic tubes. • If it has a pulse, it is an artery, do not use. • Thrombosed veins feel cordlike and rigid. They should not be used. • Palpate and trace the path of the vein several times with the index finger. • Feet may be used by physician order only. Special Techniques • • • • • Arm massage Tapping vein with fingers Apply warm, damp washcloth Lower extrem. over bedside Check other arm Vein Exclusions Extensive scarring Mastectomy Hematoma Fistula, vascular graft Preferred Veins Veins Arteries 1. Cephalic vein 2. Basilic vein 3. Median cubital vein 4. Median cutaneous nerve 5. Lateral cutaneous nerve Veins Arteries There are three nerves that enter the anterior compartment: 1) musculocutaneous, 2) median and 3) ulnar. The musculocutaneous nerve is the nerve that supplies the 3 muscles of this compartment but the other 2 nerves are merely passing through to perform their functions in the forearm and hand. Forearm veins Venous Layer 1. Cephalic vein 2. Basilic vein 3. Median cubital vein Aponeurotic Layer 1. Bicipital aponeurosis 2. Biceps tendon Artery-nerve Layer 1. Brachial artery 2. Median nerve Tendons of the Hand Can ya find anything? Cleansing the site • Site must be cleansed to prevent contamination of either the patient or the specimen. • Use an alcohol pad. Cleanse in a circular motion, starting from the center to the periphery. • Allow to air dry. • For blood cultures, cleanse with Chlorascrub spongesticks for 60 seconds on one side and 60 seconds on the other. Let dry. • Cleanse the rubber tops of each cx bottles w/ 2 betadyne snappy stix. Tourniquet Application A tourniquet is used to increase venous filling. This makes the veins more prominent. Wrap the tourniquet around the arm 3-4 in. above site. Tourniquet Application • Release after no more than one minute • Localized stasis or hematoma can occur = high values • Can apply over gown or gauze if pt has a skin problem Inspect Equipment 1. Visually inspect the tip of the needle 2. Move syringe plunger up and down in the barrel to test movement 3. Tap additive tubes to dislodge from walls or stopper 4. Apply gloves Ready? Vacutainer draws • Choose appropriate needle size • Thread the needle into vacutainer holder • Make sure pt arm is in downward position • Grasp arm firmly. Use thumb to draw skin taught. Thumb will be 1-2” below venipuncture site Vacutainer collection Venipuncture • With bevel lined upwards, line up the needle with the vein and puncture the vein. • Push the needle into the the vein. Venipuncture • Grasp the flange of the needle holder and push tube forward. • Tube will start to fill with blood. • It will stop when the correct blood level is reached. • Do not change position of tube until withdrawn from needle. • Keep constant slight forward pressure. • Be careful not to move needle from vein Venipuncture • Mix immediately after drawing each tube by gently rotating 5-10 times. • DO NOT SHAKE! • Insert next tube into holder. • Observe CHI order of draw. • Do NOT draw above a running IV. Order of Draw 1. Blood cultures 2. Red-tox screen 3. Blue-coags 4. Yellow-chemistry 5. Green-cardiac 6. Lavender-CBC 7. Grey Troubleshooting • • • • Change position of the needle Try another tube Loosen the tourniquet Do not probe. NO FISHING! Venipuncture • CHI policy – Do not attempt a venipuncture more than twice. • Notify the nurse. • Notify the lab to come over and draw. • Other alternatives: • Safety Lok Butterfly draw • Fingerstick • Lower extrem. access. (Order only) Needle Withdrawal • • • • • • Release tourniquet Ensure pt hand is open Place gauze pad Remove the needle Engage safety device Hold pressure 2-3 min. Observe for excess bleeding. Pt. not to bend arm. Hemolysis in Blood Collection Don’t do it. What is Hemolysis • Rupture or breakage of the red blood cell’s (RBC’s) membrane, causing the release of the hemoglobin and other internal components into the surrounding fluid. • Visually detected by showing a pink to red tinge in serum or plasma. • Common occurrence seen in serum samples and may compromise the laboratory’s test parameters. Hemolysis Cause and Effect • Hemolysis is caused by many variables including – Traumatic Venipuncture – Improper Handling and Processing of blood tubes – Adverse conditions when transporting blood specimens Specimen Collection Technique • Vein Size and Trauma – Puncturing small or fragile veins and probing or “fishing” for the vein can lead to hemolysis – If a vein is traumatized during puncture, the tube collected may be hemolyzed – Avoid puncturing sites that have a hematoma. Hematomas are caused by blood leaking under the surface of the skin around the vein. If this “old blood” gets into your sample it will cause hemolysis Specimen Collection Technique • Needle Size – Using large bore needles can cause hemolysis by allowing a large amount of blood to suddenly enter the tube with great force – Using needles that are too small causes hemolysis by forcing blood to travel through a small opening under great force due to the vacuum suction from the blood tubes. Alcohol Preparation – Allow alcohol to dry completely prior to venipuncture. The needle can transfer wet alcohol from the skin into the blood sample and cause hemolysis Specimen Collection Technique • Under filled Tubes – Fill all tube to full capacity to ensure proper blood-to-additive ratio. Certain tubes contain additives and in high concentration due to insufficient blood sample these additives will cause hemolysis. Specimen Collection Technique • Loose Connections – Ensure that all components are tightened. Loose connection introduce air into the system and cause frothing in the specimen which will cause hemolysis. Specimen Collection Technique • Extended tourniquet time – A prolonged tourniquet time may lead to blood pooling at the venipuncture site, a condition called hemoconcentration. Hemoconcentration can cause hemolysis – Ideally, the tourniquet should be in place no longer than one minute to prevent hemoconcentration Specimen Collection Technique • Peripheral Catheter Collections – Studies show that specimens drawn through an IV catheter are 3 times more likely to hemolyze than blood drawn through a straight venipuncture. Specimen Handling Techniques • Do Not draw above and IV. • Mix the tubes through gentle tube inversion. DO NOT shake the tubes after collection. Why is Hemolysis so Important? • Hemolysis can significantly elevate some results while significantly decreasing others. Seriously Noticeably Slightly Affected Affected Affected Potassium (K) Iron (Fe) Phosphorus LDH ALT Total AST Protein T4 Troponin, Mg Ca HGB, Platelet Post-care • Release tourniquet • Open pt’s hand • Place gauze pad • Remove needle • Bandage the arm • Dispose in sharps container Labeling Specimens At the Bedside Specimen Labeling • The patient and patients blood sample MUST BE POSITIVELY IDENTIFIED AT THE BEDSIDE. • Use TWO patient identifiers – name and birth date. • Position label over stickered area long-ways. • Chill if required (gray) lactic acid or (green) ammonia. Documentation • Location • Number of attempts • Name and title • Time to lab • Any patient comments • Example: • Blood drawn left AC 1st attempt. Pt stated “You are awesome!” Blood to lab at this time. B. Safe, EDT. Blood Culture Collection • Adult- 2 sets at different sites • One green and one lavender • Green only if not enough blood • 8-10 cc per bottle • Pedi-one set • Yellow 1-4 cc Type and Screen • • • • BB# band must contain 6 things: BB#, Pt name, Pt birthday, Date… Phlebotomists initials and time. ID band and Orange Band must match. • Label tube with BB# small sticker • Send rest of labels to lab QUESTIONS?