Basic Phlebotomy Skills for the Health Care Professional

Transcription

1 Basic Phlebotomy Skills for the Health Care Professional Working together to make you better! Carolinas College of Health Sciences revised July 2012

2 Basic Phlebotomy Skills for the Health Care Professional FACULTY Susan B. Thomasson, MEd., MT(ASCP)SH, LMBT Director, Continuing Education Coordinator, Phlebotomy Program Carolinas College of Health Sciences Charlotte, NC

3 Basic Phlebotomy Skills for the Health Care Professional Welcome. This modue is designed for healthcare professionals who wish to enhance their skill set by learning the basics of blood collection. It is intended to be a resource with the Basic Skills workshop. NOTE: The Clinical Laboratory at Carolinas Medical Center processed and ran over 5 million tests last year. The laboratory personnel are dedicated to providing the most accurate results in a timely manner. There is a highly-skilled team of professionals working together in the lab to determine presence or absence of disease and they provide data necessary for diagnoses and treatment. THEREFORE, it is therefore very important that lab specimens be collected, labeled, and transported properly to achieve the most accurate results! You will learn how to: 1. Relate at least three categories of resources available to you regarding laboratory testing and results; 2. Describe the difference between serum and plasma ; 3. List the additives in at least 8 types of collection test tubes, and how the additives work; 4. Correlate collection test tubes and the specific laboratory tests associated with each tube type; 5. Relate the order of draw for the evacuated and syringe methods of blood collection; 6. List the information required on the lab specimens, labels, and requisitions; 7. Demonstrate proper techniques for venipuncture using the evacuated tube system and the winged infusion set 3 according to the Clinical and Laboratory Standards Institute guidelines.

4 What are my resources? Carolinas Laboratory Network Directory of Services (Manuals) Contains Critical values that will be called to the unit List of tests and appropriate tubes Availability of testing Collection Procedures: Urine, Blood, Cytology, Other special procedures Synapse: Reference> Clinical > Clinical Policies and Procedures> Carolinas Laboratory Directory of Services CMC Nursing Policy and Clinical Practice Manual- on People Connect People! Laboratory Phlebotomists/ Venipuncture technicians Call the Laboratory (Ask for a Medical Laboratory Scientist or Phlebotomist) Your preceptor/educator, peers, manager List 3 important resources available to you for laboratory specimen collection and testing: 4

5 The Right Tubes for The Right Test Always verify the type of test with orders Refer back to the manuals!!! The correct test tube or container is CRITICAL Use the right container Different tests/ different equipment on different body fluids! REVIEW: Know the difference Serum: the clear/yellow liquid portion of blood after it has clotted; clotting factors used in process; contains NO fibrinogen Plasma: the clear yellow portion of the blood remaining if an anticoagulant has been added to the blood; has clotting factors (Contains Fibrinogen); can be re-mixed = whole blood) The difference between serum and plasma is: 5

6 The Right Tubes for The Right Test TUBE COLOR ADDITIVE Common Tests Department Sterile/ blood cultures Blood bank tests SPS or ACD Blood cultures /FUO Blood bank tests Light Blue Sodium citrate Coagulation Tests PT, PTT Red/Gold/ Tiger Clot activator Gel separator Chol, Ca, Thyroid, Hep screen, Glucose, Sodium Green Heparin Chemistries Na-Hep= Genetics Dark Blue +/- Heparin or EDTA Metal testing Lead testing (Pb) Lavender EDTA CBC, WBC, RBC, Plt Blood bank Microbiology Blood bank Coagulation Hematology Chemistry Chemistry Cytogenetics Chemistry Hematology Pink EDTA Blood bank Blood Bank Gray Na Fluoride (anti-glycolytic agent) K-Oxalate (anticoagulant) Glucose testing Lactic Acid Chemistry 6

7 Most common TUBES Blood cultures are always drawn first if ordered. This helps prevent contamination from other tubes and actions. These are all SERUM tubes. The GOLD and Tiger Tops have GEL SEPARATORS and the RED tubes have CLOT ACTIVATORS LIGHT BLUE tubes have Sodium Citrate as the anticoagulant. MUST BE FILLED!! COAGULATION TESTS 7

8 TUBES GREEN tubes have HEPARIN as the anticoagulant. NOTE: Solid color tops are full draw tubes. The translucent top is a short draw tube. Purple or Lavender tubes have EDTA as the anticoagulant. Note the solid top is a regular fill tube and the translucent top is a short draw tube. PINK tubes also have EDTA Used for BLOOD BANK 8

9 TUBES DARK BLUE can have EDTA, Heparin or No anticoagulant. For METAL TESTING Trace element free! GRAY Sodium Fluoride is Antiglycolytic inhibitor (preserves glucose) Potassium Oxalate is anticoagulant. 9

10 Order of the Draw: The Evacuated (and Syringe) Systems Sterile Tubes (Blood Cultures--bottles) Drawn first to help prevent contamination with skin microorganisms and ensure accuracy. Light Blue MUST BE EXACTLY FILLED (9 parts blood to 1 part anticoagulant) The amount is critical to the PT, PTT, Fibrinogen, and Factor Assay level values Regular 3.0 cc blue tube: draws 2.7 cc blood to the 0.3 cc anticoagulant in the tube [MUST maintain 9:1 ratio blood to anticoagulant] Invert gently IMMEDIATELY to mix the anticoagulant with the blood (6 to 8 times) Red or SST ( Gold gel tube) Invert gently to mix (6-8 times); the plastic tube has clot activator Green Invert gently to mix anticoagulant (6-8 times) Lavender Invert gently to mix anticoagulant (6-8 times) Gray Invert gently to mix anticoagulant (6-8 times) MIXING IS CRITICAL! Hint: For correct order of draw: Stop, Light s Red, Green Light, Go! 10

11 Order of the Draw: The Evacuated and Syringe Systems Directions: Use colors to fill the syringe in the correct order of draw Sterile Tubes (Blood Cultures) Light Blue (Last in; first out) (Remember the exact amount!) Red or SST (serum separator tube) Green Lavender Gray Remember to gently invert immediately the tubes with anticoagulants! This prevents clots from forming and causing inaccurate patient results. 11

12 Order of the Draw Preview this video clip about the Order of Draw. P5pcmqPuSDo 12

13 Order of Draw for Finger Sticks & Heel Sticks According to CLSI (Clinical and Laboratory Standards Institute), collect finger stick and heel stick specimens as follows: Anticoagulated specimens first followed by non-anticoagulated specimens. 1. Lavender (EDTA) bullets are first, to insure accurate platelet counts 2. Green (Heparin) 3. Serum (amber bullet with yellow top) Note: For BILIRUBINS** **If collected in the RED top bullets, protect bilirubin from overexposure to light by inserting into the amber sleeve **Bilirubins may be collected in a GREEN bullet IF it is protected from light from collection time to lab delivery. (cover with foil or other opaque cover to prevent exposure to light.) 13

14 Right Information: Labels All specimens must be labeled at the patient bedside after the blood is in the tubes before you leave the patient Use at least 2 patient identifiers and compare with patient ID band Patient must have ID band on before collecting blood All test tubes must be labeled with Patient s history number Patient s last name; first name Date and Time of Collection Collector s initials or Tech code Inpatient tubes must have arm band unique identifiers 2 nd identifier Follow department protocol for using preprinted barcode stickers 14

15 Right Information: Labels Blood Bank Specimens must be Hand-labeled!!! No stickers; no addressographs Paper requisition required Include all of the information listed above, plus the unique identifying number Mislabeled or unlabeled specimens will be discarded and new specimens must be collected! Requisition (or pre-printed sticker) must accompany specimens to the lab Requisitions /LABELS MUST INCLUDE history number, patient's last name, first name; location; ordering MD/ID number; test to be performed; date and time collected 15

16 Right Patient ALWAYS Verify that you have the correct patient.with the right test!!! Collect only one patient s set of specimens at a time. Label tubes after the blood is in the tubes and before you leave the patient!!!! Notes: 16

17 Right Technique Your patient's results depend on you! Review procedure techniques for Blood Cultures. (Aseptic technique is critical!) Venipuncture: Clean with 70% isopropyl alcohol For Blood cultures: Clean skin with 70 % Isopropyl alcohol on infants less than 2 months; Chloroprep on infants and children older than 2 months. Don t use alcohol if drawing an alcohol (ethanol) level Avoid traumatic sticks..can result in Hemolysis (breaking up of RBCs = faulty test results) Protect bilirubins, beta-carotene, and folate levels from long exposure to light by wrapping in foil or other cover before taking to the lab 17

18 Right Technique Main veins Median Cubital Cephalic Basilic Alternate sites: Back of hand Lower arm Foot or ankle ONLY with physician order 18

19 Right Technique Dermal puncture/ finger sticks/ heel sticks: Follow same cleansing procedure as with venipuncture. For most tests, Wipe off the first drop of blood with a clean gauze pad. This helps prevent contamination with tissue fluid, other debris and alcohol. Collect specimen according to protocol. Heel sticks are recommended for infants younger than one year. (Stick only the medial or lateral plantar surface. NEVER over the heel (calcaneous bone) as it may cause osteomyelitis (bone infection). Finger sticks: use 2 one of the middle two fingers. According to Clinical and Laboratory Standards Institute, bandages are not recommended for any child under 2 years of age due to choking hazard. These tests must be performed by VENIPUNCTURE---not dermal puncture due to the larger amount of blood needed for the analysis. Erythrocyte sedimentation rate Coagulation studies (PT, PTT, Factor Assays) Blood cultures 19

20 Right Technique ** **See attached check list for venipuncture and dermal puncture procedure and collection of blood cultures. Sites to avoid: Above an IV (IV fluid will dilute blood = erroneous results) Side of Mastectomy (chance of lymphedema and infection) Burns/ Scars/ Tattoos/ Hematomas (increased chance of infection/ pain) Underside of wrist (too close to nerves and tendons and arteries) Central Line draws: Phlebotomists will not be collecting blood by Central Lines. For nursing staff and other healthcare professionals, you need to know which tubes to put the blood in (correct order). Follow order of draw for syringe method for putting blood into the test tubes. 20

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24 Getting the Results 1st: Look in the Cerner System to see if specimen has been received by the lab 2nd: Look up the results in Cerner; Check for print-out 3rd: Call lab only if reasonable time has passed Remember: Critical Values will be called to the Unit/ Health Care Provider NOTE: Turn around time (TAT) In-house STAT specimens = 1 hour In-house ROUTINE specimens = 2 hours Definition: Turn around time = Time the specimen is received in the lab until the time the results are complete. 24

25 Venipuncture Competency Checklist Name Date Rating: S=Satisfactory N=Needs Practice U=Unsatisfactory Procedure Step Rating Comments 1. Prepare paperwork/ review test requisition 2. Introduce yourself / identify the patient 3. Explain procedure and verify diet restrictions 4. Wash hands and put on gloves 5. Assemble equipment and supplies 6. Reassure patient and position patient 7. Apply tourniquet 8. Select venipuncture site 9. Release tourniquet 10. Cleanse puncture site and allow to air dry 11. Select proper equipment and tubes 12. Reapply tourniquet 13. Anchor vein 14. Insert needle into vein 15. Fill tubes following proper order of draw 16. Release tourniquet within one minute of application 17. Remove tubes from holder and mix by gentle inversion 18. Place gauze, withdraw needle, and apply pressure to site 19. Close safety devise and dispose of needle in sharps container 20. Label tubes and follow specimen handling instructions 21. Check patient s arm and apply bandage *bandages not recommended for infants less than 2 years old. 22. Properly dispose of used materials and gather equipment 23. Thank patient 24. Remove gloves and clean hands (wash or foam) 25. Complete paperwork and take specimens to lab 25

26 Finger/ Heel Stick Competency Checklist Name Date Rating: S=Satisfactory N=Needs Practice U=Unsatisfactory Procedure Step Rating Comments 1. Prepare paperwork/ review test requisition 2. Introduce yourself / identify the patient 3. Explain procedure and verify diet restrictions as necessary 4. Wash/clean hands and put on gloves 5. Assemble equipment and supplies 6. Reassure patient and position patient 7. Select dermal puncture site (middle or ring finger most appropriate; or on the heel-plantar surface, on the sides; avoid the calcaneous on the posterior curve of the heel) 8. Warm the site by gentle holding, warm compress, or heel warmer 9. Cleanse puncture site and allow to air dry 10. Select proper equipment and collection containers 11. Using the appropriate puncture device, make a puncture no more than 2.0 mm deep on the side of the finger tip or heel 12. With dry gauze, wipe away the first drop of blood making sure the area is completely dry 13. Apply moderate pressure approximately 1 cm behind the puncture site to obtain a drop of blood 14. Release pressure immediately to allow recirculation of blood 15. Repeat Steps 12 and 13 while collecting blood 16. Fill microtainer following proper order of draw 17. Mix Lavender and green bullets by gentle inversion 18. Place gauze over site and apply pressure to site until bleeding has stopped 19. Dispose of puncture device in sharps container 20. Label tubes and follow specimen handling instructions 21. Check puncture site and apply bandage* *bandages not recommended for children less than 2 years old. 22. Properly dispose of used materials and gather 23. equipment 24. Thank patient 25. Remove gloves and clean hands (wash or foam) 26. Complete paperwork and take specimens to lab 26

27 Basic Phlebotomy Skills for the Health Care Professional POST TEST Please circle the most appropriate answer. 1. The three main categories of resources available to you regarding laboratory testing and results are a. Administrative Policy and Procedure Manual, Yellow Safety Manual, Department Manager/Preceptor/Educator b. Green Laboratory Manual, CMC Policy and Clinical Practice Manual, Nursing and Clinical Laboratory Staff c. Nursing Administration Manual, CCHS Web-site, Pathologists 2. The primary difference between serum and plasma is a. Plasma contains fibrinogen and serum does not b. Serum contains fibrinogen and plasma does not c. Serum comes from whole anticoagulated blood 3. It is critical that the Light Blue-topped tube is filled properly in order to get accurate patient results. Why? a. There is no additive in the Light Blue tube, and so it doesn t matter b. The RBC, HGB and HCT will be more accurate. c. The reference values for coagulation studies are based on the 9 parts blood to 1 part anticoagulant ratio. 4. In order to collect an effective finger stick sample with the least amount of trauma, which fingers are the best choice? a. 1 st and 4 th ( index and pinkie ) b. 2 nd and 3 rd (middle and ring fingers) c. Any finger will work fine 5. For finger stick samples, which test would be collected first? a. Amber bullet with gel (bilirubin) b. Green bullet ( chemistries) c. Lavender ( important for platelet counts) 6. A primary cause for a specimen to be hemolyzed is a. Using a 25 gauge needle with a 12 CC syringe, pulling forcefully to obtain the specimen b. Moving the needle laterally to try to locate the vein (probing) c. Not allowing the alcohol/cleanser to dry before venipuncture d. All of the above 27

28 Basic Phlebotomy Skills for the Health Care Professional POST TEST P.2 7. EDTA is the anticoagulant in the a. Dark Blue tubes b. Lavender tubes c. Green tubes 8. A BMP (Basic Metabolic Package) is routinely collected in a a. Green tube or green bullet b. Red top tube with yellow insert (has gel separator) or brown bullet c. Gray tube or brown bullet 9. Coagulation tests (ex: PT, PTT, Fibrinogen) are collected in a a. Light Blue tube b. Gray tube c. Tiger Top 10. Blood bank specimens ( Type and Cross match, ABO) are collected in which tube? a. Light Blue b. Lavender c. Gray 11. The blood cultures, when ordered with other tests, are always collected first in the standard venipuncture procedure a. To allow time for clotting b. To prevent contamination c. Because it is easier to do the bottles first 12. In the order of draw (evacuated or syringe), blood is put into the collection tubes in this order a. Sterile (blood culture), Red, Gray, Light Blue, Green, Lavender b. Red, Gray, Green, Lavender, Sterile (blood cultures), Light Blue c. Sterile (blood culture), Light Blue, Red, Green, Lavender, Gray d. The order doesn t matter 13. All patient specimen test tubes must have this information on each tube: a. Patient name, Room #, Charge nurse initials, Doctor b. Unique identifying number, Patient name, Telephone #, Room number c. Patient name, date and time of collection, collector s initials and unique identifying numbers 28

29 Basic Phlebotomy Skills for the Health Care Professional POST TEST P Blood bank specimens must a. Have hand-written labels b. Be delivered to the lab by 0700 c. Be centrifuged before delivery to the lab 15. Requisitions (either computer-generated or manual) must contain a. Patient s name, Location, Ordering MD b. Patient History Number, Test to be ordered, Date and time of collection c. Both A and B 16. Laboratory specimens are labeled only a. In the presence of the nurse manager b. At the bedside at time of collection (after the blood is in the tubes) c. In the lab 17. In performing a proper finger stick, why is it important to wipe away the first drop of blood for most tests? a. Keep the finger dry b. Prevent platelet contamination c. Prevent the specimen from being contaminated with tissue fluid 18. A heel stick is never performed at the posterior curvature of the heel. Why? a. To prevent damage to the calcaneous (and risk puncturing the bone) b. Not enough blood will flow from this site to get accurate results c. It hurts too much 19. Heel sticks are performed on infants a. Up to one year old b. Up to two years old c. Only up to 6 weeks 20. Tests that cannot be performed by heel stick or finger stick include a. Ammonia, bilirubin, hemoglobin b. Erythrocyte sedimentation rate, coagulation studies, blood cultures c. ABO, PKU, BMP 29

30 Post Test Key 1. B 11. B 2. A 12. C 3. C 13. C 4. B 14. A 5. C 15. C 6. D 16. B 7. B 17. C 8. B 18. A 9. A 19. A 10. B 20. B Recommendation: The student will make an 80% or above to be considered successful on this module. (Can miss 4 = 80.00) Each question = 5 points miss 1 question = 95.0 miss 2 questions = 90.0 miss 3 questions = 85.0 miss 4 questions = miss more than 4 questions:= please study and retake the test. 30