Книга_3777_Библиотеки_им_академика_М_И_Перельмана

CHAPTER 5 Collection by Routine Venipuncture

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I

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A

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Figure 5-4 Venipuncture with the butter y needle system. (A) Attach butter y system to syringe. (B) Apply

tourniquet with patient’s hand closed. (C) Prep selected site with alcohol. (D) Insert needle at approximately 5–10 degree angle. (E) Slowly pull blood into syringe. (F) When the appropriate amount of blood has  lled the syringe, remove tourniquet withdraw needle and apply pressure to site. (G) Immediately activate safety feature on needle. (H) Dispose of needle into sharps container. (I) Check to ensure bleeding has stopped. Apply bandage.

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PART 2 Blood and Urine Collection

21. Attach a blood transfer device.

22. Transfer blood into appropriate collection tubes using correct

order of draw. The order of draw for a syringe is the same as for the evacuated system. Do not remove the stopper from the collection tube and manually  ll the tube. Removing the stopper may allow for under lling or over lling the tube. In addition, there is a greater risk to exposure of blood should there be a spill. Do not leave the needle on the syringe and puncture the stopper. This increases the risk of an accidental needlestick to the phlebotomist.

23. Allow vacuum to draw blood into tube. Do not forcefully depress

the syringe plunger.

24. Gently invert tubes 4-5 times to mix anticoagulant with blood.

25. Discard needle and transfer device into sharps container.

26. Label tubes with appropriate information, and bag for transport.

27. Bandage patient.

28. Discard gloves.

29. Clean up area.

30. Thank patient.

31. Wash hands.

Please refer to Figure 5-4.

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SUMMARY

Careful blood collection techniques are critical for the phlebotomist. Organizing the workload, preparing the patient for the venipuncture in a pleasant manner, assembling the equipment ef ciently, and performing a smooth, successful venipuncture are crucial aspects of the phlebotomist’s work. Taking care not to injure the patient should also be foremost in the phlebotomist’s mind, as well as ensuring personal safety during the blood draw. Experience will provide the phlebotomist with a smooth, ef cient technique, both for communicating well with the patient and for performing a successful venipuncture.

REVIEW ACTIVITIES

1. Absolute identi cation of the patient is mandatory to __________

______________________________________________________.

2. ASAP orders have priority over

orders.

CHAPTER 5 Collection by Routine Venipuncture

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3. The hospital phlebotomist should awaken a patient before

collecting a blood sample because

.

4. The phlebotomist should not draw specimens above an intravenous

site because

.

5. A blood sample should not be collected from the arm on the side

of a mastectomy because

.

6. Specimens should not be collected from a hematoma area

because

.

7. The evacuated collection system should not be used on a small,

fragile vein because

.

8. Blood cultures should always be drawn  rst when drawing

multiple tubes because

.

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9. Blood bank specimens should be drawn in

tubes rather than in gel-separator tubes.

10. When performing a venipuncture, the most frequently used

veins in the forearm are the

11. A good, healthy vein feels

patient’s arm for longer than

and the .

to the touch.

minute.

DISCUSSION QUESTIONS

1. You need to collect a CBC, protime, amylase, and BUN on a

patient. After assessing the patient’s veins, you determine that the best vein is on the right hand. What are the steps involved in collecting the blood specimen from this patient?

2. You enter the inpatient room of Mr. Smith. You  nd that he has

no armband. However, you know Mr your high school science teacher. You are going to collect a CBC and B12. He has an IV in his right hand. What are the steps involved in collecting the blood specimen from Mr. Smith?

. Smith, because he was

-stopper

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“The differences in venous

and skin-puncture blood

should not restrict the use

of skin-puncture blood.”

—National Committee

for Clinical Laboratory

Standards (1986)

Collection by Skin Puncture

After studying this unit, it is the responsibility of the learner to be able to:

1. List several situations in which the preferred method of blood collection

is skin puncture.

2. Explain several situations in which skin puncture is not the preferred

method of blood collection.

3. Describe the appropriate site selection criteria for heelsticks and

 ngersticks.

4. State the steps in performing a  ngerstick.

5. Demonstrate the appropriate steps in performing a  ngerstick.

6. State the steps to performing a heelstick.

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capillary action the process by which blood

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automatically  ows into a thin tube during a capillary blood collection procedure

cyanotic displaying blueness of the skin, as from

imperfectly oxygenated blood

interstitial  uid  uid between the tissues

lateral referring to the side

osteomyelitis an in ammatory disease of the

bone, resulting from infection

plantar relating to the sole of the foot

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S

PART 2 Blood and Urine Collection

kin puncture, or capillary puncture, is a procedure in which

the skin is punctured with a lancet to obtain a capillary blood

sample for laboratory testing. While laboratory tests are most

often performed on venous blood, there are situations in which

venipuncture is not appropriate.

CHOOSING THE SKIN PUNCTURE

In several situations, the skin puncture may be preferable to the venipuncture. These situations may arise when:

The patient is an infant, and a good vein is not found.• The patient is a small child, and either a proper vein is not found •

or the child will not cooperate with the venipuncture. Tests are ordered that require only a few drops of blood.

•

The patient is very apprehensive about a venipuncture and insists • on a skin puncture (parents can also request this procedure for their child).

Repeated venipunctures are not successful.• The patient has severe burns.• The patient has thrombotic tendencies.• The patient’s veins must be reserved for therapeutic purposes such •

as intravenous lines. The patient has fragile super cial veins.•

A skin puncture is not appropriate when:

The patient is severely dehydrated. • The patient is in shock.• The patient has chronic poor circulation.• The patient is extremely cold.• More blood than can be obtained by a skin puncture is needed for •

testing.

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CHAPTER 6 Collection by Skin Puncture

This

Not this

B

Ring

Great

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COMPOSITION OF SKIN PUNCTURE BLOOD

Skin puncture blood is different in composition from venous blood. Blood obtained by skin puncture is a combination of blood from capillaries, arterioles, and venules. It more closely resembles arterial blood than venous blood. Skin puncture blood may be used for laboratory testing so long as the technique is taken into consideration when interpreting the results of blood tests and when a small sample of blood is suf cient for the tests.

As the skin is punctured, tissue is damaged and

interstitial  uid—

the  uid present between tissues—is released. The  rst drop of blood will be diluted by this and  uid will need to be wiped away.

SITE SELECTION

A skin puncture (also called a capillary puncture) may also be performed on  ngertips, heels, toes, or earlobes. However, the earlobe is not recommended as a site of choice, due to poor capillary access.

Children and Adults

Generally, the site of choice is the portion of the fingertip shown in Figure 6-1. Do not puncture the side or the tip of the  nger. The ring  nger and the middle  nger are the appropriate  ngers for puncture.

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Figure 6-1 Finger puncture site.

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PART 2 Blood and Urine Collection

The thumb,  rst  nger, and  fth  nger are not appropriate choices for skin puncture. The tissue on the  fth  nger is much thinner than on the other  ngers. The thumb and  rst  nger are usually calloused. The nondonimant hand may be a better  rst option since the  ngers may be less calloused. Patients requiring frequent  ngersticks—such as for glucose monitoring, for example—should have the puncture site rotated. The puncture should be made perpendicular to the  ngerprint. A perpendicular puncture will cause the blood to form a droplet. A parallel puncture will cause the blood to  ow down the  nger instead of forming a nice round drop.

Edematous (swollen) sites should be avoided, because a free  ow of blood is impossible. Punctures in cold, or

cyanotic, areas should also be

avoided. Blood obtained from these sites may result in falsely high hemoglobin or cell-count values.

Infants

The site of choice is the lateral (side) area of the plantar surface of the heel (“plantar” refers to the sole of the foot). The darkened areas in Figure 6-2 show the preferred areas in which to perform a heelstick. Never use the area of the heel bone as a puncture site. In addition, never puncture the area of the arch. Puncturing either of these areas may have serious consequences for the infant. Puncturing the heel bone may result in infection and disease of the bone. Puncturing the arch area may cause damage to nerves. Never perform a puncture that will go through a previous site. Never perform a skin puncture on the  nger of an infant. The tissue on an infant’s  nger is much too thin, and the procedure could damage the bone.

osteomyelitis, an in ammatory

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Figure 6-2 Heel puncture site.

CHAPTER 6 Collection by Skin Puncture

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PREPARING THE SITE

A free  ow of blood is important for accurate test results. Massaging the  nger of the adult or child and the heel of the infant until the skin is pink will stimulate circulation. Warming the skin will also increase blood  ow. A wet towel (or a packaged heating product) comfortably warmed to the touch may be applied to an adult’s or child’s  nger or to the heel of an infant. The heat source should be applied for at least 3 minutes.

COLLECTION DEVICES

A wide variety of devices are now used to collect, process, and transport blood obtained from a skin puncture. Traditionally, blood is obtained with disposable capillary pipettes that resemble plastic straws. The blood  ows into the tube through

The process of collecting skin puncture blood has been simpli ed by the introduction of different types of microcollection devices. Figure 6-3 shows two such devices. These collection devices allow for easier measuring, color coding, stoppering, centrifugation, and storage of the blood samples. Collection caps, often shaped like a scoop, are used to collect the blood.

capillary action.

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Figure 6-3 Microcollection devices.

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PART 2 Blood and Urine Collection

Lancets

A good  ow of blood is obtained with the correct use of the skin puncture device. As with the collection devices, a wide variety of skin puncture lancets are available.

Lancets are designed to control the depth of the puncture so that no damage will be done to the site. Most lancets are either blades that the phlebotomist pushes into the skin or spring-loaded devices that lie on the surface of the skin and make an automatic puncture. The spring-loaded devices have a button that, when pressed, releases the lancet into the skin. Patients may be less frightened by this device, because they cannot see the actual blade penetrate the skin.

1. Identify and greet the patient. You must always be sure that the

specimen is obtained from the correct patient.

2. Explain the procedure. The explanation should help to calm the

patient and instill con dence in your ability as a phlebotomist.

3. Assemble the equipment: gloves, lancet or puncture device,

alcohol prep pads, gauze, and collection device.

4. Select a puncture site.

5. Massage or warm the puncture site. The heel may be warmed

with a warm cloth not to exceed 42ºC (107ºF). Commercial infant heel warmers are also available.

6. Put on gloves to prevent exposure to bloodborne pathogens.

7. Cleanse the  ngertip with the alcohol prep pad to prevent

microbiological contamination of the patient and the specimen.

8. Dry the  ngertip to prevent hemolysis of the specimen from expo-

sure to alcohol, and to reduce a stinging sensation for the patient.

9. Remove cover from lancet or other device to be used.

10. Grasp patient’s  nger, placing your thumb at the base of the

 ngernail. Wrap your  ngers around the inside of the patient’s  nger. This maintains your control of the patient’s  nger while allowing you the best access to the puncture site.

11. If using a lancet, make a quick down-and-up motion with the

lancet to  rmly puncture the skin. One  rm and quick puncture is less painful than a repeated puncture because of inadequate

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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