Phlebotomy
In the Emergency
Department
OBJECTIVES
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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
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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
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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
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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
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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?