Department of Pathology Point-of-Care Testing. Procedure Name: Phlebotomy Procedure # POC 1023

Transcription

1 Procedure Name: Phlebotomy Procedure # POC 1023 Date Adopted: 10/19/01 By: Ann Bengzon, R.N. Revised: 2/21/05 Reviewed by: Date: 2/21/05 PURPOSE: Collection of blood samples appropriate for age of patient providing for proper technique, labeling, and transportation of specimen to Main Laboratory for analysis. Methods conserve blood loss alleviating anemia, reserve veins for parenteral therapy and allow for frequent accurate monitoring of acid base and respiratory status. 1. POLICY: A. Written order, standing order, or protocol for blood work must be present for samples to be drawn. B. Patient MUST have an identification band with correct, complete, and legible information before any blood samples can be drawn. If the patient can not be given a unit number, a typenex number will be assigned and a unit number will be given when available. C. All labels must: 1. Be clearly and completely imprinted with the patient s name and unit number. Information may be hand printed in ink if printed labels are not available. 2. Tests are to be requested in computer or if not available a down-time form must accompany specimen(s). 3. Date, time, phlebotomist initials, clock number must be written on specimen(s). 4. Blood Bank specimens must have the complete signature of the phlebotomist, clock number, date and time specimen was collected. 5. Blood will be drawn by certified operators using correct policies and procedures of Sinai Hospital. D. PATIENT IDENTIFICATION: Compare the spelling of the name of the patient and the patient ID number on the label with the number and name on the ID band. If the patient is lucid, ask the patient to spell their legal first and last name, and give any titles (i.e., Sr. Jr., III, etc). If there is no ID band, if information on the ID band is inaccurate,

2 incomplete or misspelled, the nickname is present or if there is any discrepancy between the labels and the ID band the specimen MAY NOT be obtained until the problem is resolved. If drawing a Blood Bank specimen, also compare the requisition slip with the ID band and the labels. E. Blood sample(s) MUST be labeled after the draw, and before leaving the patient s bedside. 2. ORDER OF BLOOD SAMPLING: ( Should be used for multiply specimens) A. Vacutainer Tubes: 1. Blood Culture 2. Light Blue Top Tube (Citrate Tubes / PT/APTT) 3. SST Tube (Gel no additive) 4. Dark Green Top Tube (Lithium Heparin 5. Light Green Top Tube (Na Heparin with Gel) 6. Pink Top Tube (Blood Bank) 7. Lavender Top Tube ( EDTA) 8. Dark Blue Top Tube (Heavy Metals) 9. Gray Top Tube (Toxicology) 10. Specimens for Bedside Testing B. Microtainer Tubes: 1. Lavender 2. Mint Green (Lithium Heparin with Gel Gold (with Gel) 3. Gold (clot activator with Gel) 4. Red (no additive) 4. PHLEBOTOMY A. HEELSTICK Skin puncture blood collection used to obtain serum blood samples on infants to avoid venipuncture. 1. Equipment: a. Gloves b. Microlancet c. Capillary tube or microtainer d. Alcohol preps

3 e. 2X2 gauze sponge f. Request labels g. Seal-Ease h. Warm Pack i. Band-Aid PKU: a. Filter paper b. PKU slip 2. Procedure: a. Physician or practitioner writes orders. b. Request tests in computer. Prepare patient labels. See Specimen Labeling Procedure. c. Assemble equipment at bedside, including labels. Identify patient according to policy. d. Wash hands. e. Don gloves. f. Position patient properly. g. Select puncture site to minimize the risk of excessive scar formation and infection. Draw an imaginary line from the middle of great toe posteriorly to the heel, or laterally to a line drawn posteriorly between the 4 th and 5 th toes to the heel. (See figure 1). Lateral heel site of choice because it prevents damage to the posterior tibia nerve in the fat pad of heel, which in late years could impeded walking. h. DO NOT PUNCTURE: 1. through previous site 2. deeper than 2.4 mm. 3. on the posterior curvature of the heel 4. cold or cyanotic areas 5. bruised or swollen areas 6. Never use Bard-Parker Surgical Blade i. Hold heel with moderately firm grip. Use the forefinger at the arch of the foot and the thumb well below the puncture site at the ankle. Cleanse site with 70% isopropyl alcohol in a circular motion from insertion site outward. j. Wipe off excessive alcohol with 2X2-gauze sponge. (Alcohol is irritating to site and may produce hemolysis, or false lab. values). k. Puncture lateral aspect of heel. Punctures should be made on the posterior curvature of heel.

4 l. After puncture, wipe off first drop of blood with 2X2 gauze. The first drop is discarded because it is diluted with tissue fluid. m. Be sure to maintain the heel in a horizontal position. Do not allow the tube to touch (scrape) the skin. n. Collect blood into sample tube by holding tube below level of puncture and allow blood to flow freely into tube. Avoid squeezing (or milking) the heel to fill tube, as this introduces serum, tissue fluid and possible venous blood and renders the sample inaccurate. o. Keep the puncture site clean of residual or dried blood by wiping the site off with gauze pad after every couple of drops. p. Fill tube(s) to require amount. q. Once required amount is obtained, cap & shake tube gently to ensure adequate mixing of the reagents. r. Longer than 2 minutes of collection time will frequently result in poor specimen collection and increase incidence of micro clotting. s. After collection is completed, slightly elevate the infant s foot and apply pressure with 2X2-gauze sponge to site for 1-2 minutes and apply Band-Aid. Pressure should stop bleeding. t. Seal or cap collection tube. Label specimen according to Specimen Labeling Policy and Procedure, prior to leaving the patient. u. Discard lancet in needle container. v. Send bagged specimens to laboratory according to Pneumatic Tube Policy and OHSA standards. w. Document on appropriate flow sheet or in Progress Notes. PKU: a. Follow steps a through m in general procedure. b. Fill capillary tube with blood. c. Without touching filter paper, allow blood to drop and fill 5 collection circles on filter paper collection card. The blood must saturate through to the back of the filter paper. The printed circle on both sides of the paper will look completely red with blood. Circle must be completely filled without disturbing the surface of the filter paper. d. Label PKU card. e. Allow blood spots to air-dry completely at room temperature. f. Place filter paper in PKU rack when finished and sign off in PKU logbook. B. PERIPHERAL To provide blood sampling appropriate for age, with a butterfly/ or standard venipuncture needle. Usage of lower volume vacutainer tubes or syringes will be utilized to conserve blood loss.

5 1. EQUIPMENT: a. Tourniquet b. Gloves c. Vacutainer Barrel d. Needle (butterfly or standard venipuncture needle) e. 2X2 alcohol swabs f. Paper tape or Band-Aid g. 2X2 gauze pads h. Appropriate blood tubes i. Zip lock bag j. Label(s) 2. PROCEDURE a. Verify order for blood work. b. Request test(s) in computer. Print labels. c. Identify patient according to policy. d. Wash hands. e. Don gloves. f. Apply tourniquet. g. Select venipuncture site by palpating for a vein. h. Select needle size/type for age of patient and size of vein. i. Release tourniquet. Assemble equipment at bedside including labels. j. Clean potential site with alcohol swabs in 3 concentric circles from the center outward. Allow to air dry. k. Reapply tourniquet. l. Grasp vacutainer needle/ butterfly in dominant hand with bevel side up. m. Hold patient s arm securely with non-dominate hand. Pull skin taut 1-2 inches below the puncture site with your thumb to keep the skin from rolling. n. With the needle on a degree angle, insert needle. Blood should appear in tubing if using a butterfly. o. Stabilize the vacutainer system with non-dominate hand, place first specimen tube in vacutainer holder and gently and firmly engage tube into interior needle. p. Stabilize needle holder so that needle is not inadvertently removed from vein. q. Allow tubes to fill. They will stop automatically. r. If multiple tubes are to be drawn, remove the first tube as soon as the flow stops, and repeat until all specimens have been obtained. Blood tubes with additives should be

6 inverted slowly and gently five (5) times. If only a blue top tube (PT/APTT) is to be drawn, a discard tube must be drawn first. s. After the last specimen has been obtained, remove the tube. t. Release the tourniquet. u. Place gauze over insertion site. v. Withdraw needle. Do not apply pressure until needle is out of the vein. w. Apply pressure dressing, and secure with tape/band-aid. x. Discard needle in appropriate container. Do not recap or break needles. y. Label all tubes prior to leaving patient s bedside. Place tubes in zip lock bag. z. Remove gloves, and wash hand. Send specimen to laboratory. 5. CROSS REFERENCE: ASCP (American Society of Clinical Pathologist) Blood Collection: Routine Veinipuncture, 1989, Deanna Klosinski, M.S., MT, Claudia Miller, M.A,M.T. Virginia Narlock, MS,M.T.