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Basic Principles of

Phlebotomy
Objectives
Theory and practice of phlebotomy
How to interact professionally with patients
Occupational health hazards and appropriate
precautions
Related anatomy and physiology
Phlebotomy equipment and supplies
Phlebotomy procedures
Complications of venipuncture and how to
handle them.
What is phlebotomy
The term phlebotomy refers to the ancient
practice of bloodletting
Phlebotomy: Historical Practice

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What is phlebotomy
The term phlebotomy refers to the ancient
practice of bloodletting
Now the term phlebotomy is used for the
withdrawal of blood from a vein, artery, or
the capillary bed for lab analysis or blood
transfusion.
Modern Phlebotomy
Diagnosis and management of disease

Remove blood for transfusions

Therapeutic reasons:
Polycythemia
Hemochromatosis

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Who is a phlebotomist
Collects blood and other specimens

Prepares specimens for testing

Interacts with patients & health care


professionals
plays a vital role in any health care system
Who is a phlebotomist
Other medical professionals, including
doctors, nurses, technologists, and
medical assistants must also be trained to
collect blood specimens.
Laboratory work flow cycle
Laboratory Workflow Cycle
Laboratory Workflow Cycle
Laboratory Workflow Cycle
Professionalism
Professionalism
Confidentiality
All employees are responsible for
maintaining confidentiality of medical
information
Attitude
Tone of voice and facial expression will
determine how patients respond to you.
Always be polite, friendly, calm, and
considerate.
Appearance
Your personal appearance will also affect
the impression you make.
Comply with your facilitys dress code and
personal appearance policies.
Safety
Blood-Borne Pathogens
Infectious micro-organisms which live in
the bloodstream.
You can be exposed to bloodborne
pathogens if you are injured with a
contaminated needle.
You can also be exposed if your mucous
membranes, including eyes, mouth, or the
inside of your nose come into contact with
contaminated body fluids.
Blood-Borne Pathogens

Diagram of
Hepatitis C
Virus
Occupational Health and Safety
Administration of the federal government
has mandated bloodborne pathogen
training for all workers who are at risk of
exposure.
OSHA Training
Standard Precautions
Personal Protective Equipment
Hand Washing
Hazardous waste disposal
Needle sticks and prevention act
Standard Precautions
Standard Precautions
Standard Precautions means treating all
body fluids and substances as if they were
infectious.
Standard Precautions
Potentially infectious body fluids include:
Blood, Semen, Vaginal Secretion,
Peritoneal, pericardial and pleural fluids,
and Saliva
Sweat and tears are not generally
considered infectious.
Personal Protective Equipment
Personal Protective Equipment
lab coat
Gloves
Face masks ( certain types of isolation)
Hand Washing
Hand washing is the single most important
infection control measure.
Wash hands thoroughly before, after, and
between all patient contacts.
Be sure to turn off faucets using a paper
towel to avoid contamination.
Hand washing
Remove rings
Stand by the sink but do not touch it
Apply soap and rub hands together
Both sides of the hand, between fingers,
around knuckles, under fingernails
Rinse hands in a downward motion
Dry hands with a clean paper towel
Turn off water with another paper towel
Hand Washing
Hazardous waste disposal
All needles & other
sharps must be
disposed of in
approved sharps
disposal containers.
Other contaminated
waste must be
discarded in an
appropriate
biohazard bag or
waste receptacle.
Needlestick
Needle sticks and prevention
act
Safety Devices should always be
encouraged
Anatomy & Physiology
Anatomy & Physiology
Anatomy is the branch of science
concerned with the study of the structure
of the body.
Physiology is the branch of science
concerned with the study of the function of
the body.
Anatomy & Physiology
The cardiovascular
system consists of the
Heart, and Blood Vessels.
Its main function is
circulate oxygenated
blood from the lungs to
various organs, and
return blood depleted of
oxygen to the lungs,
where it is reoxygenated.
Blood Function:
1. Supplies nutrients to tissues:
O2, hormones, glucose

2. Removes end-products of metabolism:


CO2, urea, creatinine

3. Provides defense mechanism: WBC, antibodies

4. Prevents blood loss:


platelets, coagulation proteins
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Anatomy & Physiology
Blood Collection sites
Anatomy & Physiology
Anatomy & Physiology
Anatomy & Physiology
Anatomy & Physiology
Blood Components
Blood Components
Circulating whole blood is a mixture of:
Plasma (which contains fluid, proteins, and
lipids), and
Formed elements, consisting of red cells,
white cells, and platelets.
Blood Composition:

Formed elements (~45%) Fluid component (~55%)


RBC Water (~92%)
WBC Protein (~7%)
Platelets etc
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Blood cells
Whole Blood
Blood without anticoagulant:
Spontaneous clotting occurs
and is irreversible

Fibrinogen fibrin strands

Fibrin strands entrap cells

Centrifuge serum

Serum lacks fibrinogen


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Coagulation Reaction:
Clotting factors + calcium thrombin

Fibrinogen + thrombin fibrin strands

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Coagulation:
In vivo
Blood is fluid
Clot is formed to
protect injured vessel

In vitro
Spontaneous reaction
Triggered by glass or poor drawing technique

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Blood Clot
When a blood sample
is left standing without
anticoagulant, it forms
a coagulum or blood
clot.
The clot contains
coagulation proteins,
platelets, and
entrapped red and
white blood cells.
Serum
Serum contains all
the same substances
as plasma, except for
the coagulation
proteins, which are
left behind in the
blood clot.
Blood with anticoagulant:
Clotting is prevented and
irreversible

Mix: completely invert 8-10x

Whole blood

Centrifuge plasma

Plasma contains fibrinogen 61


Plasma
Anti-coagulants:
Remove calcium
Neutralize thrombin

Whole blood
Plasma
Serum

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Plasma
Appearance
Normal: clear and yellow

Abnormal:
Hemolyzed = pink to red (ruptured RBC)
Icteric = dark orange-yellow (bilirubin)
Lipemic = cloudy (fat, triglycerides)

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Appearance

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Equipment
Valid Test Results Require:
Trained personnel
Causes of pre-analytical error
Invalid test results
Quality control
Quality assurance
Sophisticated
instruments

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Safety Practices:
For infection to spread:
1. Infectious substance: HBV, HCV, HIV
2. Mode of transmission
3. Susceptible host

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Modes of Transmission:
Parenteral: any route other than the
digestive tract
Intramuscular Non-intact skin: chapped
Intravenous hands, cuts, cuticles
Subcutaneous Percutaneous: needles, sharps
Mucosal Permucosal: mouth, nose, eyes

Ingestion

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Safety Practices:
Infection Control: stop the spread of infection

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Safety: Infection Control
Hand washing
Primary means of preventing spread of
infection (especially nosocomial)
Minimum 15 seconds, soap, friction
Wash hands before and after each blood draw
PPE
Lab coat
Gloves
Mask
Standard precautions at all times 72
Safety: Engineering Controls
PPE
Sharps containers
Safer medical devices

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Safer Medical Devices:

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Equipment:
1. PPE: gloves, lab coat, mask

2. Cleaning agent
Alcohol pads: routine
Povidone iodine: blood culture collection and
blood gases
Soap and water: alcohol testing, allergies

3. Cotton balls, gauze


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Equipment: gloves

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Equipment: coat

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Equipment:
4. Bandage, tape (use caution with children)

5. Sharps container:
Discard needles,
lancets
Biohazard marking
Puncture resistant

NEVER recap, bend


break needles
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Equipment:
6. Tourniquets:
Slows venous blood flow down
Causes veins to become more prominent
NEVER leave on for >1 minute
AVOID rigorous fist clenching or hand
pumping (potassium, lactic acid, LD)
Latex allergy

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Tying on the Tourniquet:

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Equipment:
7. Needles
NEVER reuse a needle
NEVER use if shield is broken
NEVER recap, cut, bend or break

Drop immediately into sharps container after


venipuncture

Size of needle is indicated by gauge:


Larger gauge number indicates smaller needle diameter
21, 23 gauge needles routinely used for phlebotomy
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Needles:

Used with syringe system Used with vacutainer system82


Multi-sample Needle:

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Butterfly Needle:

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Butterfly Needle:
Most often used with
syringe

Expensive, thus not used


for routine draws

Used for small, fragile


veins

Increased risk of needle


stick injury
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Equipment:
8. Tube holder/
vacutainer adapter

Threaded
Flanges

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Equipment:
9. Syringe

10. Black
water proof
pen

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Syringe Safety Device:

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Workstation
Mobile phlebotomy
workstation
Workstation

phlebotomy
drawing
station
Workstation

Portable infant
phlebotomy
station
Trays

Phlebotomy collection tray


Trays
Trays should be
sanitized daily using
appropriate disinfectant

Kept Organized and


well-stocked.
Blood Collection tubes
glass or plastic tube
with a rubber stopper.
It has a vacuum so
that blood will flow
into the tube.
anticoagulants and/or
other chemical
additives.
Blood collection tubes
Used with
Vacutainer and
Syringe systems

Rubber stoppers of blood


collection tubes are color
coded.

Each type of stopper


indicates a different additive
or a different tube type.
Tubes containing
no anti-coagulant

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Red-top tube:
Glass
No additive
Glass surface activates clotting sequence
Do not mix
SERUM: use for TDM (therapeutic drug monitoring)

Plastic
Contain additive to activate clotting sequence
Contain inert gel SST (serum separating tube)
Do invert to mix additive and initiate clotting sequence
SERUM
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RED
No additives
Blood bank tests,
toxicology, serology
Must not be inverted
after filing
Gold or Mottled-red-gray top tube:
Contain clot activator
and gel (SST)

Invert to mix and


initiate clotting
sequence

SERUM

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Tubes containing
anti-coagulant

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Blue-top tube:
Anticoagulant = sodium citrate
PLASMA
Binds calcium Whole blood

Must be full
Blood:anticoagulant ratio critical

Must be on ice if not analyzed within 30 minutes

Coagulation studies
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LIGHT BLUE
sodium citrate.
coagulation (clotting)
studies.
must be completely
filled
must be inverted
immediately after
filling
Green-top tube:
Anticoagulant = heparin
Three formulations: Lithium heparin
Ammonium heparin PLASMA
Sodium heparin Whole
blood
Inhibits thrombin formation

Must be full and on ice if need pH, ionized Ca

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Green-top tube:

Most chemistry tests, STAT lab (PST)


Decreases time needed for blood to clot,
Makes turnaround time better

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GREEN
sodium or lithium
heparin
for tests requiring
whole blood or
plasma such as
ammonia
Purple-top tube:

Anticoagulant = EDTA
PLASMA
Binds calcium Whole blood

Hematology studies: CBC

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LAVENDER
EDTA to prevent
clotting
hematology studies.
Should be completely
filled
Must be inverted after
filling
Grey-top tube:
Anticoagulant = potassium oxalate
Binds calcium
PLASMA, Whole blood

Antiglycolytic agent = sodium fluoride


Maintains plasma glucose levels

Limited use: glucose, lactic acid

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GRAY
Inhibitor for glycolysis
+ anticoagulant
Sodium Fluride
+potassium oxalate.
glucose levels.
Fibrin-split Products tube
Light blue top tube with 2 yellow bands on the
label

Contains soya bean thrombin which causes


the blood to clot immediately

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Yellow-top tube:
ACD = acid citrate dextrose
Paternity testing
DNA

SPS = sodium polyanethol sulfonate


Used for special blood culture studies
Inhibits certain antibiotics

Both bind calcium

PLASMA, Whole blood


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YELLOW
Acid citrate dextrose
Inactivates
complements
DNA studies,
paternity testing
Royal blue-top tube:
Trace metal-free

Iron, copper, zinc

Label color indicates contents:


Red: no additive = serum
Purple: EDTA = whole blood or plasma
Green: heparin = whole blood or plasma

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ROYAL BLUE
heparin or Na EDTA
anticoagulants
Tube is designed to
contain no contaminating
metals
Trace element and
toxicology studies
Blood Culture Bottles
Different blood culture
bottles are used for
aerobic, anaerobic,
and pediatric
collections.
Blood collection tubes: Safety
The rubber stopper is
positioned inside the
plastic shield
Blood collection tubes: Safety
The rubber
stopper is
positioned inside
the plastic shield
Sizes
Adult:3 - 10 ml
Pediatric 2 - 4 ml.
Tubes for fingersticks
or heelsticks or
less
Type and Amount of Specimen:
Dependent upon
Test
Whole blood: EDTA or heparin?
Plasma: EDTA or heparin?
Serum: trace free? Separator gel interference?

Amount of sample needed to perform test

Multiple labs needing the same specimen at the


same time
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Expiration Dates
Expiration Dates
Syringes
Syringes with built-in safety devices
Needle Components
Needles
Different sizes.
size =gauge.
The larger the needle, the smaller the
gauge number.
21 or 22 gauge needle is mostly used.
Holders
A plastic holder must
be used with the
evacuated tube
system.
Holders
Needle holders with built-in protection
devices
Needles
Single Draw Needle
Single draw needles
are of the type that fit
on a syringe, and can
be used only to fill the
syringe to which they
are connected.
Multiple Draw Needle
Used with vacuum
collection tubes.
They have a
retractable sheath
over the portion of the
needle that
penetrates the blood
tube.
Needles with built-in safety
devices
An internal blunt needle
that is activated with
forward pressure on
the final blood tube
prior to withdrawal of
the needle from the
vein.
Butterfly Needle
Winged infusion set
Difficult venipunctures
including pediatric
draws
with a syringe or a
holder and vacuum
collection tube
system.
21, 23, or 25 gauge.
Butterflies with built-in safety features

number-one cause of needlestick


injuries, so proper use of their safety
devices is critical.
Butterflies with built-in safety features
Lancets
Lancets are used for
difficult
venipunctures,
including pediatric
draws.
Tourniquets
Vein easier to SEE,
FEEL, and
PUNCTURE
Sterilization
Bandaging Material
Gloves
Gloves must be worn
for all procedures
requiring vascular
access.
Non-powdered latex
gloves are most
commonly used;
Sharp Disposal Container
Marking Pen
Labeling Blood Collection Tubes:
Black indelible marker (water proof)
Never pencil
Legal document
Print legibly
Required information: 5 items
Patient name
Identification number
Date of draw (mm,dd,yyyy)
Time of draw (military time)
Phlebotomist signature: first initial, last name
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Vacutainer or Syringe?
Vacutainer
Most often used
Most economical
Quick
Least risk of accidental needle stick
Syringe
More control
Reposition easily
Will see flash of blood in syringe hub when
vein successfully entered
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The Patient:
Approach
Communication
Empathy
Handling special situations
Patient identification
Arm band
Legal document
Prepare patient for blood draw
Latex allergy?
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Selecting the Site:
Antecubital area most
often accessed
Hand or wrist
Remember: 2 arms
Use tip of index finger
on non-dominant
hand to palpate area
to feel for the vein

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Collection Site Problems:
Veins that lack
resiliency

Extensive
scarring

Hematomas

Edematous
area

Side of mastectomy 148


Collection Site Problems:
Intravenous line
NEVER draw above
an IV

Draw from other arm

Draw from hand


on other arm

Draw below the IV


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Draw Below IV site:

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Collection Site Problems:
Indwelling lines:
Hickman catheters
Heparin locks
Used to administer medication
Only nurse may access these lines
Can obtain blood: called a line draw
Must clear line of heparin contamination
by discarding first 5-10 cc of blood
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Hickman Catheter:

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Inserting the Needle:
Anchor the vein
Grasp arm with your
non-dominant hand
Use thumb to pull skin
taut

Smoothly and
confidently insert the
needle bevel up
15-30 degree angle

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No Needle Movement!
You must anchor the blood-drawing equipment
on the patients arm to minimize chance of injury

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Fill Tubes:
Use correct order of draw:
Blood cultures
Red top
Blue (baby blue)
Green
Purple
Grey

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Be careful not to:
Push needle further into vein when
engaging evacuated tube
Pull needle out of vein when disengaging
tube
Pull needle out of vein as you pull back on
the plunger
Pull up or press down when needle in vein
Forget to mix additive tubes 8-10 times
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Withdraw Needle:
First release tourniquet
Disengage tube
Place cotton directly over needle, without
pressing down
Withdraw needle in swift, smooth motion
Immediately apply pressure to wound
Do not bend arm

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Label Tubes Immediately:
In sight of patient

Patient name
Identification
number
Date of draw
Time of draw
(military time)
Your initials

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Recheck Draw Site:

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Failure to Obtain Blood:
Check tube position and vacuum
Always have back up tubes near by

Needle position

Collapsed vein

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Needle Position:

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You should try again
Look at alternate site
Other arm
Hand
Use clean needle
Use fresh syringe if
contaminated

Only try twice

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Poor Collection Techniques:
Venous stasis
Prolonged application of tourniquet (>1 min)
Hemodilution
Drawing above IV
Short draw (blood to anticoagulant ratio)
Hemolysis
Traumatic stick
Too vigorous mixing
Alcohol still wet
Using too small of needle
Forcing blood into syringe 165
Poor Collection Techniques:
Clotted sample
Inadequate mixing
Traumatic stick
Partially filled tubes
Short draw
Sodium citrate tube draw volume critical
Using wrong anticoagulant

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Poor Collection Techniques:
Specimen contamination
Using incorrect cleanser
Alcohol still wet
Powder from gloves
Drawing above IV
Specimen handling
Exposure to light
Pre-chilled tube
Body temperature
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Venipuncture Procedure
Remain calm

Organize yourself

Organize your equipment:


STICK TO ELEVEN

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Equipment: Stick to Eleven
Gloves Needle
Lab coat Syringe or vacutainer
Alcohol wipe holder
Cotton ball Collection tubes with
Bandage/tape backup tubes
Sharps container Water-proof marker
Tourniquet

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Venipuncture Procedure:
Wash hands
Put on gloves
Identify patient
Latex allergy?
Position arm
Apply tourniquet

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Venipuncture Procedure:
Locate vein
Release
tourniquet
Cleanse site in
outward rotation
Allow to air dry

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Venipuncture Procedure:
Reapply tourniquet
Do not contaminate
site
Anchor vein
Insert needle
Fill tubes
Quick mix additive
tubes
Release tourniquet
Withdraw needle
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Venipuncture Procedure:
Engage safety device
Dispose of needle
immediately
Apply pressure to
puncture site
Label tubes
Recheck puncture
site
Thank patient
Remove gloves,
wash hands 174
Accidental Needle Stick:
Remain calm
Cleanse wound with alcohol
Wash wound thoroughly
Notify supervisor, instructor
Follow site protocol
Page OUCH hotline: 1-402-888-OUCH
1-402-888-6824
Complete incident report
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Syringe draw

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Syringe Safety
Transfer Device

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Mark your spot

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Hand Vein Draw

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Skin Puncture:
Method of choice for infants, children
under 1 year
Adults
Scarred
Fragile veins
Hardened veins
Home glucose monitoring (POCT)
Patients with IV

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Capillary Blood
Mixture of arterial, venous, capillary blood
and fluid from surrounding tissues

Fluid from surrounding tissues may


interfere and/or contaminate the specimen

Warming skin puncture site increases


arterial blood flow to the area

Reference ranges often differ from venous


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Skin Puncture Equipment:
1. PPE

2. Cleaning agent
Alcohol pads: routine
Soap and water: alcohol testing, allergies
DO NOT use providone iodine

3. Cotton balls, gauze


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Skin Puncture Equipment:
4. Bandage/tape

5. Sharps container

6. Warming device
Commercial warmer
Warm wet washcloth

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Skin Puncture Equipment:
7. Lancet
Always use
standardized
equipment

NEVER use a
surgical blade

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Skin Puncture Equipment:
8. Micro-specimen
containers
Capillary tubes
Microtainers
Capillary blood gas
tubes
Micropipet diluting
system

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Skin Puncture Equipment:
9. Glass slides:
used to prepare
blood smears

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Skin Puncture Procedure:
1. Wash hands
2. Approaching the patient
3. Patient identification
4. Latex allergy?
5. Bedside manner
6. Site selection
7. Cleanse site: DO NOT use providone- idodine
8. Perform puncture: Wipe away first drop of blood
9. Label the specimen 187
Skin Puncture Site Selection:

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Skin Puncture Procedure:
Hold finger between your index finger and thumb

Puncture the finger using a quick, smooth motion

Wipe away the first drop of blood

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Skin Puncture Procedure:
Collect sample
DO NOT touch collecting device to skin surface
DO NOT scrape collecting device across skin surface
DO NOT scoop blood into collecting device

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Skin Puncture Procedure:
Order of draw is critical: platelets accumulate at
puncture site causing clot formation
Blood smear
EDTA
Heparin
Serum

Apply pressure to puncture site

Label specimen in sight of patient (indelible marker)


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