Phlebotomy
For
Health Care Workers
Phlebotomy
Phlebos is Greek for “Vein”
Tome means to “cut”
Phlebotomy means to cut a vein
Phlebotomy is a term used to describe the specialized technique of blood
collection by a venipuncture
“Veni” is a prefix which means vein
Puncture refers to the penetration of the vein for any
reason, including the administration of IV’s and other
medications. (Venipuncture)
Phlebotomy is an invasive procedure that invades the body
through cutting or puncture, and is performed by
professionals known as a:
Phlebotomists
History of Phlebotomy
First documented in Egypt around 1000 BC
Removing blood from the veins dates back as far as 1400 BC
Leeches: Were used in 1800s
Venesection: Vein was pierced with a sharp object to drain blood
Cupping: Produced a vacuum effect by pulling blood to the
capillaries under a heated glass cup
Phlebotomy profession emerged as a result of technology and
expansion of lab function in the late 1980s and 1900s
Bloodletting as a profession is believed to have originated with
Barber Surgeons in the 12th Century , in Italy.
The Barber Surgeon carried a red and white staff or cane crowned
with a ball as a symbol of his skills in bloodletting and his role in the
health care of the day.
The red stripe of his staff or cane stood for the blood of the patient
The white stripe was for the bandages of the procedure
The ball on the top was for the cup which was used to catch the
blood flow
The Barber Surgeon could perform surgeries, administer enemas, let
blood, pull teeth, and even cut hair.
A blue and white staff signified patriotism
Following developments in the history of
phlebotomy in chronological order
• Hippocrates’ theory on the relationship between excess body fluids
and disease
• Appearance of the barber pole symbol
• Collection of blood for diagnostic testing
• Development of structured phlebotomy training programs
• Certification of phlebotomists
Two behaviors that represent negative body
language:
• Shuffling into the room
• Avoiding eye contact
Demonstrate good telephone communication skills
• By making sure the call is not an emergency before
placing them on hold
• Providing instructions to a patient
• Explain you are going to transfer their call
Why is the appearance and personal hygiene
of the phlebotomists important to the patient?
Patients feel that the quality of care they receive is
reflected by the appearance and cleanliness of the
caregiver
Five barriers to effective verbal communication and
means to overcome each:
• Hearing Impairment: Speak slowly and look directly at the person
• Emotions: Use a calm tone of voice and demonstrate confidence &
concern
• Age: Use age-appropriate phrases and words
• Educational Level: Use terminology appropriate to the educational
level
• Language Proficiency: Attempt to locate a translator; use basic
words and sign language
Clinical and Laboratory Standards Institute (CLSI)
Established the techniques and principals for
the phlebotomy profession.
Primary role of the phlebotomist is: To obtain blood
specimens and transport specimens for diagnostic testing.
Representative of the laboratory to the patient and the
health care staff of the institution. Requires a
professional, courteous, and understanding manner in all
contacts with the patient.
Two methods for collecting blood is:
1. Venipuncture
2. Microtechnique (dermal/capillary puncture)
Sometimes arterial blood is collected by phlebotomists.
Functions of a phlebotomist
1. To obtain venous blood specimens for
diagnostic testing
2. To remove blood from donors for blood
transfusions
3. Collect and properly package urine
specimens
4. Accept incoming specimens
5. Route specimen to the proper
departments to be tested and analyzed
Phlebotomist is a valuable member of the
health care team
Responsible for:
1.Collection
2.Processing
3.Transportation of specimens
Duties of the phlebotomist
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Demonstrate professional attire, attitude
and communications
Know facility’s policies and procedures
Properly identify patients
Collect both venous and capillary blood
specimens
Select the appropriate and accurate
specimen container for the specified
tests
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Cont’d
Properly label, handle, and transport
specimens following department policies
Sort specimens received and process
specimens for delivery to laboratory
departments
Perform computer operations and/or
update log sheets where required
Perform point-of-care testing
Perform quality control checks
Observe all safety regulations
Phlebotomy Programs
• Require high school diploma or GED
• Offered in hospitals, technical and
private schools and community
colleges
• Clinical training is from 120/200 hours
• Courses vary from a few weeks to
months
Phlebotomy Organizations
ASCP: American Society of Clinical Pathologist
PBT (ASCP)
ASPT: American Society of Phlebotomy Technicians
CPT (ASPT)
AMT: American Medical Technologist
RPT (AMT)
NPA: National Phlebotomy Association
CPT (NPA)
Entering the Room
Should greet the patient and identify themselves and the
procedures that will take place. Put the patient at ease.
Effective communication is essential. Both verbal and nonverbal.
Inpatient
Proper identification of the patient is mandatory. Ask for full
name, and check armband. Hospital identification number is the
primary means for identifying the patient.
Outpatient (OPD)
Use the requisition as a reference. Birthday and social security
Number is a source of information about the patient and a
method of communication between the phlebotomist and the
laboratory staff. Today OPD patients also are given an armband.
Post Venipuncture
Thank the patient after the procedure and excuse yourself
courteously, leaving the patient with a positive impression of
you and the laboratory you represent. (Clean up work areas)
Equipment and Supplies for Venipuncture
• Collection Tray with Test Tube Racks
• Evacuated Tubes
• Needles
• Holders
• Tourniquets
• Safety Disposal Unit (biohazard with symbol)
• Alcohol Wipes (70 % isopropyl alcohol)
• 2” X 2” Gauze Sponges
• Bandages
• Ammonia
• Gloves
• Requisition Forms
Common Errors
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Identification of patient
Not labeling the tubes
Wrong name of the patient on tubes
Improper selection of tubes
Improper site cleansing
Improper specimen collection
Not properly mixing the tubes
Improper transportation of specimens
Problem Patients
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Fainting
Refusal
Nausea or Vomiting
Convulsions
Excessive Bleeding
Cessation of Breathing
Unconsciousness
Obesity
Tremors
Disruptive Behavior
Deaf or Hearing Impaired
Communication Barriers
Special Precautions
Special Instructions at the Bedside
Blind or visually Impaired
Hematoma
Laboratory Departments
• Hematology
• Coagulation
• Urinalysis
• Immunohematology/Blood Bank
• Immunology/Serology
• Chemistry
1. Toxicology
2. Biochemistry
• Microbiology
1. Bacteriology
2. Virology
3. Parasitology
4. Mycology
5. Rickettsiology
• OPD/Collection & Transportation
Hematology Department
Tube: Lavender/purple
Anticoagulant: K3 Ethylenediaminetetraacetic Acid (EDTA)
Invert: 8 Times
This anticoagulant binds calcium
Tests:
CBC= Complete Blood Count
WBC= White Blood Cell
RBC=Red Blood Cell
Plt=Platelet Count
HGB=Hemoglobin
HCT=Hematocrit
Diff=Differential Cell Count (Identify 100 WBCs, RBC Morphology, Platelet estimation)
Red Cell Indicies=MCV, MCH, MCHC
RDW= Red Cell Distribution Width
MPV=Mean Platelet Volume
Other Test performed in this department are:
Reti= Reticulocyte
Sed Rate, or ESR= Erythrocyte Sedimentation Rate
Coagulation Department
Tube: Light Blue
Anticoagulant: Sodium Citrate
Invert: 8 Times
Anticoagulant binds calcium
Tests:
PT =(Prothrombin Time)
PTT= (Partial Prothrombin Time)
APTT= (Activated Partial thromboplastin Time)
D-Dimer
Fibrinogen
TT=(Thrombin Time)
Coagulation Factors
FDP= (Fibrin Degradation Products)
FSP=(Fibrin Split Products)
Blood Bank/Immunohematology
Tube: Plain Red (Glass) other tube: Pink/Lavender
Anticoagulant: None
EDTA
Invert: None
Tests:
• Type & RH
• Crossmatch (x-match)
• Antibody Screen (ABS)
• Direct Coombs (DAT)
• Antibody Identification Panel
• RhoGam
• Cold Agglutins
Blood Unit Components:
Packed Cells, Platelets, Fresh Frozen Plasma, Cryoprecipitate
Urinalysis Department
Collection Containers:
(urine)Plastic; Paper; or Metal
(stool) Plasic
(sperm) Plastic tube
Tests:
Urinalysis
• Physical (color, appearance, volume, odor)
• Chemical (Sp.Gr., pH, Protein, Glucose, Ketones, Blood, Bilirubin, Urobilinogen,
Nitrite, Leukocyte esterase WBC)
• Microscopic (WBCs, RBCs, Epithelial Cells, Casts, Crystals, Bacteria, etc.)
Stool (Feces)
• WBC
• Observe for Parasites (O & P)
• Occult Blood
Spermatozoa
• Sperm count
• Motility
Types and Collection:
Random, First Morning, Timed, Midstream Clean-Catch, Catheterized
Serology/Immunology Department
Tube: SST/Gold
Plain RED
Evacuated Tubes: (SST/Gold): Gel & Clot Activator
Plain Red: None
Invert: SST/Gold mix 5 Times
Tests:
Mono
RA/RF
Lupus
ASO TITER
CRP (C-Reactive Protein)
ANA (antinuclear Antibody)
HCG (Human Chorionic Gonadotropin) Pregnancy Tests
Anti-HIV
Hepatitis B Surface Antigen (HBsAG)
Rapid Plasma Reagin (RPR)
VDRL (Venereal Disease Research Laboratory)
Chemistry Department
Tubes: Gold/SST
Red
Green/Mint Green
Gray
Lavender
Royal Blue
Clot Activator/Plain tunes:
Gold/SST: Gel & Clot Activator
Red: None
Anticoagulant tubes:
Green: Heparin (Sodium, Lithium, Ammonia)
Mint Green: Gel & Plasma Activator
Gray: Sodium Fluoride & Potassium Oxlate
Lavender: EDTA
Royal Blue: Red: None; Lavender: EDTA; Green: Heparin
Invert: 5-8 Times except for the Red which is none
Chemistry Cont’d
Tests:
Electrolytes:
Cardiac:
Sodium
Potassium
Chloride
Carbon Dioxide
CK- MB (Creatine Kinase)
SGOT/AST
LDH/LD (Lactic Dehydrase)
ALT/SGPT
Tropin
Kidney:
BUN
Creatinine
Creatinine Clearance
Liver:
SGOT/AST (Aspartate Aminotransferase)
ALT (Alanine Aminotransferase)
ALP (Alkaline Phosphatase)
Bone:
Bilirubin (Total & Direct)
Calcium
Phosphous
GGT (Gamma Glutamyl Transferase)
Amylase
Lipase
Lipids:
Vitamin B12
Cholesterol (HDL, LDL, VLDL)
Triglycerides
Lactic Acid
Folate
Ammonia
Glucose (2 Hr PC, GTT, Fasting)
Microbiology Department
Procedures in this department are:
examinations
Biochemical Reactions
Specimens are:
Blood
Urine
Feces
Sputum
Genitourinary Tract
Vaginal
Eye
Ears
Nose
Throat
Wounds (Anaerobic, aerobic)
Cultures, Stains, Microscopic
Special Handling Requirements
Chilled Specimens
Warmed Specimens
Acetone
Cold Agglutinin Test
Ammonia
Blood Gases
Catecholamine
Corticotropin
Fibrinogen
Ketones
Lactic Acid
Serum Gastrin
(Chilled specimens are cooled immediately following collection to slow down metabolic
processes that may alter some chemical values.)
Light-Sensitive Specimens
Bilirubin
Carotene
Erythrocyte Protoporphyrin
Vitamine B12
Folate
To protect from light wrap the collection containers in aluminum foil., or place in a dark
container.
Special Procedures
GTT: Glucose Tolerance Test (Diabetes Mellitus)
A multiple-timed glucose test that evaluates the metabolism of carbohydrates over
time
2 hour PC/PP:A type of glucose specimen collected 2 hours after the ingestion of
food
Fasting: Nothing to eat or drink for 8-14 hours
Forensic or Chain of Custody Specimens
Forensic specimens, which may be required for law enforcement agencies or
litigation, must follow a special protocol called chain of custody.
Chain of Custody: is a process of in-depth documentation that accounts for every
personnel contact with the specimen from time of collection through
Recording of the final results
Blood Alcohol: Must carefully follow institutional procedure when collecting these
specimens. Use a non alcohol antiseptic or soap and water for cleansing .
Use a vacuum tube with sodium fluoride
Toxicology
Specimens evaluated for the presence of drugs
Therapeutic Drug Monitoring (TDM):
Collection and testing of blood to evaluate and manage medication therapy
effectively and safely
Important to the diagnosis and safe management of drug treatment of the client
Peak Level:
A drug level in the blood collected 15 to 30 minutes after the dosage
has been administered or when the highest serum concentration is expected
Trough Level:
A drug level in the blood collected when the lowest serum concentration
is expected, which is usually immediately before administering the next dosage
Coagulation
• Primary Hemostasis
1. Vascular Platelet Phase
2. Platelet Plug
3. Bleeding time
• Secondary Hemostasis
1. Stable fibrin clot
a. Extrinsic System
b. Intrinsic System
c. Common Pathway
2. Laboratory Assessment
a. Prothrombin Time
b. Activated Partial Thromboplastin Time
•Fibrinolysis
1. Breakdown of clot
2. Fibrin degradation Products of D-dimers
Blood
Plasma
• Formed Elements
1. Red Blood Cells (Erythrocytes)
a. Function (Transports O2 and CO2)
b. Production
c. Destruction
d. ABO Blood Type Groups
e. Rh Blood Type (positive or negative)
2. White Blood Cells (Leukocytes) Body Defense
a. Neutrophils (most numerous of WBC’s)
b. Lymphocyts
c. Monocytes
d. Eosinophils
e. Basophils
3. Platelets (Thrombocytes) Blood Clotting
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Three Major Types of Blood Vessels
Arteries: (Oxygenated Blood)
Are muscular and carry blood away from the
heart
Veins: (Deoxygenated Blood)
Have valves and carry blood to the heart
Capillaries: (Resembles more Oxygenated Blood)
Have walls only one cell thick for exchange of
substances between the blood and tissues
Flow of Blood through the heart
Vena cava
Right Atrium
Right Ventricle
Pulmonary Artery
Lung
Pulmonary Vein
Left Atrium
Left Ventricle
Aorta
Types of Needles
1. Multi-sample (evacuated method)
2. Hypodermic (syringe)
Parts of Needles
1. Hub
2. Shaft
3. Beveled Point
Size of Needles
1. 16-Gauge (Blood Donor Collection)
2. 21- Gauge (Routine Venipuncture)
3. 23-Gauge (Patient with small veins, butterfly)
Order of Draw
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Blood Cultures (Sterile) SPS/Yellow
Coagulation Tubes (Sodium Citrate) Light Blue
SST/Gold , Plain Red
Green (Heparin)/ (PST)Mint Green
Lavender (EDTA)
Gray (Sodium Fluoride, Potassium Oxalate)
Yellow (ACD)
Information that must be on a patient’s ID band
• Patient’s Name
• Patient’s ID Number
• Date of Birth
• Requesting Physician
• Tests requested
• Date and Time
Where to look for ID Band on the patient
• Wrist
• Ankle
3 Reasons for requiring a requisition
•
Authorization to perform the procedure
• Collection of appropriate equipment
• Patient location and identification
Three Major Veins
• Median Cubital (middle)
• Cephalic (outer side)
• Basilic (Inside)
Tourniquet
Length of time to leave on the arm is:
One Minute
Why use a tourniquet?
To permit arterial flow and to block
venous flow
Placement of tourniquet
3 to 4 inches above the bend of elbow
Four test results that are affected by prolonged tourniquet application are:
Proteins, Lipids, Enzymes, and Potassium
3 Reasons for vein palpation
1. Determining the direction of the vein
2. Determining the depth of the vein
3. Determining the size of the vein
Reasons to allow the alcohol to dry on the patient’s arm before venipuncture
1. Maximum bacteriostatic action
2. Preventing a stinging sensation for the patient
3. Prevention of hemolysis
Alcohol + Blood = Hemolysis
Two tests seriously affected by hemolysis are:
1. Potassium
2. LD
Hemolysis: Red Cell destruction (Pink)
Lipemic: Fats in Blood (Milky)
Jaundice: Yellow Color of plasma or serum (eyes, skin)
Reasons why blood may not be obtained
1. Collapsed vein
2. Occluded vein
3. Bevel of the needle resting on the wall of the vein
4. Defective evacuated tube
Causes of hematomas
1.
2.
3.
4.
5.
Removing the needle before removing the tourniquet
Enadequate pressure or bending the arm
Excessive probing
Needle not fully inserted through the vein
Needle inserted through the vein
Specimen Rejection
Unlabeled specimen
2. Mislabeled specimen
3. Inadequate Volume
4. Wrong Tube
5. Hemolysis
6. Clotted Anticoagulated Tube
7. Improper Transport
8. Missing Requisition Form
9. Contaminated Specimen Container
1.
What is a professional?
A person having great skill or experience in a particular field
What is the definition of phlebotomy?
To cut into a vein for the purpose of withdrawing a blood specimen
What is the definition of venipuncture?
To cut into a vein for any purpose
Communication skills consist of :
Speaking in a pleasant tone, making eye contact, being patient
Who is considered the “father” of modern medicine?
Hippocrates
What is a “barber-surgeon”?
A person who would cut hair, give an enema, let blood and pull teeth
What does OSHA stand for?
Occupational Safety and Health Administration
What does OSHA do?
Sets standards for a safe and healthy workplace
What is the best way for a health care professional to avoid
infection?
Hand washing between each patient and to wear gloves
If an infection is airborne, it means?
It is spread through droplets
An infectious organism is an organism which is?
Capable of spreading disease
What is a susceptible host?
Someone who lacks an effective resistance to a disease
An infection would cause the release of:
White Blood Cells
What equipment is needed to clean up a blood spill?
Gloves, Bio-Hazard Bag, Paper Towel, and 1:10 dilution of bleach
What is the number-one cause of exposure to disease in health care
workers?
Needle-stick injuries
What is the CDC?
Center of Disease Control
What type of antiseptic is used to cleanse the skin of pathogenic
bacteria fora normal blood specimen?
70% Isopropyl Alchol
What infection is more easily spread through accidental needlestick
injury?
Hepatitis
What is PPE?
Personal Protective Equipment
How should a blood tube be opened to aliquot a sample?
The tube top should be covered and “popped” away from the phlebotomist
Where should lab coats be worn?
In the work place setting
The department responsible for analyzing a “Type/Crossmatch” is?
Blood Bank
Other tests in this department are?
Direct Coombs, and Indirect Coombs
The color of tube used primarily in this department is?
Plain Red (May use Lavender or Pink)
The department that analyzes an H & H, CBC, Reti, SedRate,
Platelet Count, Diff,RBC, WBC, Platelet count is?
Hematology
The color of tube for this department is?
Lavender/Purple
Anticoagulant in this tube is?
EDTA (Ethylenediaminetetraacetic Acid)
What department within a laboratory would handle a PTT/APTT
specimen?
Coagulation/Special Hematology
What is the color of tube?
Light Blue
What is the anticoagulant?
Sodium Citrate
Other tests in this department are:
PT, Fibrinogen, D-Dimer, Coagulation factors
APTT must be tested within 4 hours
What department within a laboratory would handle a specimen for a
Culture and Sensitivity?
Microbiology
In what department of the hospital would you see a patient having
radioactive isotopes injected into his/her arm?
Nuclear Medicine
What kind of specimens are sent to the anatomical pathology
laboratory?
Biopsy Tissue, Cytology Specimens, Autopsy Specimens
Blood collected in a Red Tube Yields:
Serum
What are the 3 main veins that are used for venipuncture?
Basilic, Median Cubital, Cephalic
The most common vein used for venipuncture is?
Median Cubital
Whenever drawing blood some of the considerations used for
deciding which vein to draw blood from is?
Bounce, Depth, Size also does it move, is it visible, does it looked bruised and red,
Does it have a pulse and is it too hard and cord-like to puncture
Veins are located in Skeletal Muscle and Collagen
Veins have valves
What gauge needle is most commonly used for performing venipuncture?
21-22 Gauge (20-22)
What is an evacuated system?
One that has tubes that are vacuum
Is a Closed System
What is a non-evacuated system?
One that consist of a needle and a syringe
Use for tiny veins
Butterfly needle is used on Pediatric Patients
Whenever drawing blood from an IV site, how much blood should you
draw in a discard tube?
10 cc/10ml
Draw below (distal) to the site of the IV
Whenever doing a venipuncture proper ID of patient is the single most
important step
What reaction might occur if the patient is upset or frightened?
Sympathetic blood flow could occur and the WBC and Glucose will elevate
The purpose of the tourniquet is?
To give the vein time to fill as it “DAMS” the blood between the site and tourniquet
Remove the tourniquet within how many minutes?
One to two
Why?
If left on longer it can cause hemoconcentration
Clean a venipuncture site in?
Concentric Circle
What is the common bacteria found on the skin?
Staphylococcus aureus
Do not use the window for doing a venipuncture, Why?
Because if the patient”Jumps”, and you might get stuck with the needle
The proper way to hold a vein for a venipuncture is?
With your thumb below the site and fingers out of the way