University of Miami Fundamentals of Phlebotomy Power Point Presentation I need to make the attached document into a power point presentation (all inlcude)

University of Miami Fundamentals of Phlebotomy Power Point Presentation I need to make the attached document into a power point presentation (all inlcude) Medtexx Medical Corporation
Fundamentals
Of
Phlebotomy
Second Edition
PHLEBOTOMY
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PHLEBOTOMY
Table of Contents
Phlebotomy: The Historical Perspective
4
History
Devices Used for Drawing Blood
Universal Precautions & Biosafety Techniques
Infection Prevention
4
5
7
8
Human Anatomy & Physiology
10
Skin Layers
General Structure: Arteries and Veins
10
14
The Tourniquet
20
Assembling the Equipment
22
Blood Collection: Routine Venipuncture & Specimen Handling
24
Venipuncture Procedure
Order Form/Requisition Form
Labeling the Sample
Equipment
Order of Draw
Venipuncture Site Selection
Performance of a Venipuncture
Troubleshooting
Performance of a Fingerstick
Blood Collection on Infants
Additional Considerations
Safety & Infection Control
24
25
27
27
28
31
31
33
39
40
41
42
Possible Complications from Phlebotomy
43
Problems Obtaining a Specimen
Patient Complications
43
43
Blood: Samples & Collection
45
Types of Blood Samples
Collection Tubes
Special Procedures
Crossmatches
Blood Culture
45
45
53
53
54
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PHLEBOTOMY
Oral Glucose Tolerance Test (GTT)
General Collection Requirements
Special Collection Techniques
Collecting a Blood Sample Using a Butterfly Needle Syringe
Drawing Blood Using a Lancet for Microdraw or Infant Heel Stick
Measured Bleeding Time
55
56
59
60
62
63
Arterial Puncture
65
Glossary
69
Resources
96
Appendix A: Order of Draw for Multiple Tubes
i
Appendix B: Sample Requisition Form
ii
Appendix C: Hepatitis Overview
iii
Appendix D: Proper Glove Removal
xi
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PHLEBOTOMY
PHLEBOTOMY: THE HISTORICAL PERSPECTIVE
Objective
This lecture will concentrate on the historical perspective of phlebotomy, and show that
man’s initial fascination with his blood and body fluids has had a direct influence on the
study of Biomedical Science today.
Meaning of ‘Phlebotomy’
The term ‘Phlebotomy’ suggests the taking of Blood only. This subject is not only
concerned with “blood letting”, but rather the whole range of skills and knowledge
necessary for the collection of viable specimens for later analysis in a laboratory.
History
‘Phlebotomy’ comes from the Greek word phlebos, meaning veins, and tome, meaning
incision.
Historical evidence suggests the possibility of blood letting for therapeutic reasons may
have begun in Egypt around 1400B.C. Tomb paintings from this time show the
application of a leech to a patient.
Hypocrites (460-377 B.C.), also known as the father of modern science, was responsible
for early medical theory, which believed illness was caused by an “imbalance” in the
body. The removal of this “excess” was thought to restore this balance.
The practice of bloodletting seemed logical when this foundation of all medical treatment
was based on the four body humors: blood, phlegm, yellow bile, and black bile. Health
was thought to be restored by plugging, starving, vomiting, or blood letting.
The art of blood letting was flourishing well before Hypocrites in the fifth century B.C.
By the Middle Ages, both surgeons and barbers were specializing in this bloody practice.
Barbers advertised with a red (for blood) and white (for tourniquet) striped pole. The pole
itself represented the stick squeezed by the patient to dilate the veins.
The practice reached unbelievable heights in the 18th and early 19th centuries. The first
U.S. president, George Washington, died from a throat infection in 1799 after being
drained of nine pints of blood within 24 hours. The draining of 16-30 ounces (1-4 pints)
of blood was typical. Blood was often caught in a shallow bowl. When the patient
became faint, the “treatment” was stopped. Bleeding was often encouraged over large
areas of the body by multiple incisions. By the end of the 19th century (1875-1900),
phlebotomy was declared quackery.
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PHLEBOTOMY
Devices Used for Drawing Blood
A variety of devices were used to draw blood,
•
•
Lancet – The lancet was first used before 5th century B.C. the practitioner
manually perforated the vein. Many shallow cuts were sometimes made.
Spring-Loaded Lancet – Came into use during the early 18th century. The device
was cocked and a “trigger” fired the spring-driven blade into the vein.
•
The Fleam – Used during the 18th century. Many varieties existed. Sometimes a
wooden “fleam stick” was used to hit the back of the blade and drive it into the
vein.
•
Scarificator – The scarificator, a series of twelve blades, was also in vogue during
the 18th century. The device was cocked and the trigger released spring-driven
rotary blades that caused many shallow cuts. The scarificator seems more
merciful than other bloodletting instruments. Blood was caught in shallow bowls.
•
Flint Cup – During the 17th to 19th centuries, blood was also captured in small
flint cups. Heated air inside the cup created a vacuum causing blood to flow into
the cup, a handy technique for drawing blood form a localized area. This practice
was called ‘cupping’.
•
Leeches – (Hirudo medicinalis); Leeches were “enticed” by “leeches” to attach
themselves to the skin. The area was chosen and a drop of milk or blood was the
bait. Once the leech was engorged, it was allowed to drop off. In the early 1800’s,
the little animal became quite scarce, and leech farms were having difficulty
keeping up with the demand. Therefore, they became quite expensive.
With this fascination came the need to “see” the components of the body fluids.
“Antony van Leeuwenhoek (1632-1723)” was an unlikely scientist. A tradesman of Delft,
Holland, he came from a family of tradesmen, had no fortune, received no higher
education or university degrees, and knew no languages other than his native Dutch. This
would have been enough to exclude him from the scientific community of his time
completely. Yet with skill, diligence, an endless curiosity, and an open mind free of the
scientific dogma of his day, Leeuwenhoek succeeded in making some of the most
important discoveries in the history of biology. It was he who discovered bacteria, freeliving and parasitic microscopic protists, sperm cells, blood cells, microscopic nematodes
and rotifers, and much more. His researches, which were widely circulated, opened up an
entire world of microscopic life to the awareness of scientists.
Leeuwenhoek is known to have made over 500 “microscopes,” of which fewer than ten
have survived to the present day. In basic design, probably all of Leeuwenhoek’s
instruments — certainly all the ones that are known — were simply powerful magnifying
glasses, not compound microscopes of the type used today. A drawing of one of
Leeuwenhoek’s “microscopes” is shown at the left. Compared to modern microscopes, it
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PHLEBOTOMY
is an extremely simple device, using only one lens, mounted in a tiny hole in the brass
plate that makes up the body of the instrument. The specimen was mounted on the sharp
point that sticks up in front of the lens, and its position and focus could be adjusted by
turning the two screws. The entire instrument was only 3-4 inches long, and had to be
held up close to the eye; it required good lighting and great patience to use.
It is open to debate when blood first began to be examined for diagnostic purposes. It is
known that other body fluids have been examined since medieval times.
The invention of the microscope in the 17th century, coupled with advances in
physiologic chemistry and cellular physiology on the 19th century, paved the way for the
examination of blood as a diagnostic tool.
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PHLEBOTOMY
UNIVERSAL PRECAUTIONS AND BIOSAFETY TECHNIQUES
1. Assume ALL human blood, plasma, serum, body fluids (semen, saliva, tears,
cerebrospinal and amniotic fluid, milk and cervical secretions) and tissues to be
contaminated with Human Immunodeficiency Virus (HIV) and/or Hepatitis
Viruses (e.g., HBV). Handle them with appropriate care!
2. Gain knowledge – Be prepared:
• Personnel should understand their risk categorization (per Depts. of Labor and
Health and Human Services) before initiating work: Category I: Personnel
routinely handle blood, body fluids and issues. Category II: Personnel
occasionally handle or work around such materials. Category III: Personnel
never work with or around such materials.
• Be familiar with the CDC/NIH Manual “Biosafety in Microbiological and
Biomedical
• Laboratories’ view biosafety videos and are familiar with the company’s
Biosafety Manuals. Ask your supervisor to explain any procedures or
concepts not clear to you before beginning work.
• Category I and II personnel should get the new, safe and effective Hepatitis B
vaccination.
3. Remember: The most susceptible route of laboratory infection for HIV and HBV
is by accidental needle sticks, contamination of the mucous membranes, or
through broken, abraded or irritated skin. Use appropriate caution and maximum
protection to prevent such contact.
4. Avoid spilling, splashing or open aerosolization of human blood or body fluids.
Wear latex gloves, protective lab garments and face and eye shields when
handling human materials.
5. Understand the principles of good microbiological practice before working with
biohazardous materials. Examples include use of aseptic technique, proper
decontamination procedures, emergency biohazard spill management and proper
use of biosafety equipment. Develop proficiency before beginning work.
6. Use Biosafety Level-2 work practices, containment and laboratories when
handling human materials where droplet and aerosol production are likely. Avoid
aerosol-generating activities in handling human materials. When such procedures
are necessary, use biosafety cabinets or other containment and personal protective
equipment.
7. When culturing or manipulating known HIV or HBV, use Biosafety Level-3 (BL3) procedures. Any procedure which requires concentration of HIV or HBV or
other human viruses from human materials should be handled under BL-3
containment and handling conditions. Use appropriate biosafety level conditions
(BL-2 or BL-3) when handling non-human primates and other animals inoculated
with human pathogenic materials.
8. Dispose of human and animal biohazardous waste or materials contaminated with
them in accordance with CDC/NIH biosafety and institutional guidelines.
9. Decontaminate laboratory protective garments, gloves and protective equipment
to render them non-infectious.
10. Clean all work areas and equipment used in handling human biohazardous
materials with proven disinfectant (e.g., 1:10 dilution of Clorox) when concluding
work to protect personnel from accidental infection.
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PHLEBOTOMY
11. Assume that human serological and biological reagents (e.g., antibody, antigen or
antisera) used in the laboratory are contaminated with HIV or other viruses and
handle them accordingly.
12. Understand your institution’s medical surveillance program and be familiar with
the appropriate standard operating procedures for accidental exposure to human
materials. Specific measures must be followed as per CDC/NIH Guidelines in the
Universal Precautions. The specimens involved must be identified and tested for
HIV and HBV and the procedures followed.
13. Report every accident to your supervisor and Occupational Medical Service
personnel.
14. Responsibility for instituting, training and monitoring of biosafety practices in
laboratories handling human materials, HIV or HBV rests with the Laboratory
Director or the designated Principal Investigator (PI). These individuals must
categorize positions; provide facilities, biosafety equipment, biosafety
procedures and training to employees accepting such work assignments to permit
the safe conduct of the work. These responsible individuals must ascertain the
proficiency of the employee in performing the assigned task before permitting the
work to begin.
15. Laboratory personnel have a clear responsibility to fully understand and
consistently adhere to the biosafety practices detailed in the Biosafety and
General Safety Manuals as well as to the biosafety guidelines detailed here and
by the CDC and NIH. Responsibility for conscious or thoughtless non-compliance
with or violation of these guidelines falls on the laboratory worker.
Note: Hand Washing Technique for Skin Exposure to Blood or body Fluids
1.
2.
3.
4.
Wash with a good liquid antimicrobial detergent soap.
Rinse well with water.
Apply solution of 50% isopropyl or ethyl alcohol.
Wash again with the liquid soap and rinse well.
INFECTION PREVENTION
Approximately 100% of the infectious agents found in the clinical laboratory are spread
by either airborne (inhalation) or contact transmission. Proper hand washing and strict
adherence to Universal Precautions, body substance isolation and general safety will
minimize the risk of infection. Infectious disease agents are most often transmitted in one
of four methods.
1. Airborne or inhalation transmission. A susceptible individual inhales droplets
of particles of dust containing infectious agents. It is in this manner that
streptococcal sore throat, respiratory viruses, and pulmonary tuberculosis can be
contracted. Example: coughing, sneezing, centrifugation and the “popping” of
specimen container tops are responsible for droplet formation.
2. Contact Transmission. May be direct or indirect. In direct contact, the causative
agent is passed from one individual directly to another. Infections with sexually
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PHLEBOTOMY
transmitted diseases, including HIV are examples, of direct contact. Hand contact,
such as shaking hands with an infected person is also thought to be one of the
ways that respiratory virus infections are spread. It is also possible to be infected
by contact with an inanimate object (blood collection tubes etc.). Either accidental
needle sticks or by the sharing of needles by drug users are other examples. A
person may be indirectly exposed by receiving blood infected with Hepatitis C or
HIV.
3. Ingestion Transmission. Food or water containing pathogenic organisms is
ingested. Salmonelosis and Hepatitis A are examples.
4. Vector Borne. A vector or arthropod (mosquitoes, ticks etc.) are capable of
transferring pathogens and resulting in malaria and encephalitis or Lyme disease,
respectively.
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PHLEBOTOMY
HUMAN ANATOMY AND PHYSIOLOGY
Skin Layers
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PHLEBOTOMY
Major Veins
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PHLEBOTOMY
Major Arteries
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PHLEBOTOMY
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PHLEBOTOMY
General Structure: ARTERIES and VEINS
The arteries and veins are composed pf three coats of tunics and a hollow core, called a
lumen, through which the blood flows.
•
•
•
Tunica interna (intima), ENDOTHELIUM (simple squamous epithelium) and a
layer of Elastic Tissue called the internal elastic membrane.
Tunica media, thickest layer Elastic Fibers & Smooth Muscle
Tunica externa (adventitia) Elastic & Collagenous Fibers
Arteries
•
•
•
Strong, very Elastic
Adapted to carry blood under high pressure
3 layers
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PHLEBOTOMY
•
•
o Endothelium
ƒ Smooth surface
o Tunica Media
ƒ Smooth muscle, Elastic fibers
o Tunica Adventitia
Sympathetic branch of ans innervate smooth muscle in artery and arteriole
Hold about 20% total blood volume.
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PHLEBOTOMY
Veins
•
•
•
•
•
•
•
Carry deoxygenated blood to the heart
Three layers with middle layer poorly developed
o Less muscle and elastic tissue
Very distensible
Carry about 60% of total blood volume
Functions as blood reservoir
Vein in limbs have valves like flaps
Respond to falling BP by vasoconstricting
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PHLEBOTOMY
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PHLEBOTOMY
Selected Veins of the Upper Limb – Listed Alphabetically
Vein
Tributaries
Drains Into
Regions Drained
Superficial veins of
the
palm
and
anterior forearm
Median cubital v. or
basilica
Palm;
forearm
Basilic v.
Medial end of the
dorsal venous arch
of
the
hand;
superficial veins of
the
forearm;
median cubital v.
It unites with the
brachial vein(s) to
form the axillary v.
Superficial parts of
the medial side of
the
hand
and
medial side of the
forearm
Brachiocephalic v.
Formed
by
the
union
of
the
subclavian v. and
the internal jugular
v.;
tributaries;
vertebral v., thymic
v., inferior thyroid
v., internal thoracic
v., 1st posterior
intercostals v., left
superior intercostals
v. (to the left
brachiocephalic v.)
The left and right
brachiocephalic v.
unite to form the
superior vena cava.
Cephalic v.
Lateral side of the
dorsal venous arch
of
the
hand;
superficial veins of
the forearm.
Axillary vein
Superficial parts of
the lateral hand and
lateral forearm
Dorsal metacarpal
v. of the hand
Dorsal digital vv.
Dorsal venous arch
of the hand
Dorsal aspects of
the digits of the
hand
Dorsal venous arch
of the hand
Dorsal didgital vv.
And
dorsal
metacarpal vv.
Cephalic v. laterally,
basilica v. medially
Dorsal aspects of
the digits and the
superficial
structures of the
dorsal of the hand
Median antebrachial
v.
Superficial of the
palm and anterior
forearm
Median cubital v. or
basilica v.
Palm;
forearm
Median cubital v.
Cephalic
Basilica
Superficial part of
the
hand
and
forearm
Ante
median
brachial,
anterior
Head; neck; upper
limb; anterior chest
wall
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anterior
Notes
Medium antecubital
v. is variable in size
– it may be large or
absent
Basilica
v.
communicated with
deep veins of the
forearm
through
perforating
veins,
especially in cubital
region.
At its origin, the left
brachiocephalic v.
receives
the
thoracic duct; at its
origin, the right
brachiocephalic v.
receives the right
lymphatic duct
Median cubital vein
usually shunts some
of
the
blood
collected by the
cephalic v. to the
basilica v.
Dorsal metacarpal
v.
drains
the
adjacent sides of
the two digits.
Dorsal venous arch
is visible through
the thin skin on the
dorsum of the hand
Median antecubital
v. is variable in sizeit may be large or
absent
A
median
anterbrachial vein
occurs occasionally
and when present,
it may drain into
the median cubital
vein.
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PHLEBOTOMY
Selected Veins of the Lower Limb – Listed Alphabetically
Tributaries
Drains into
Regions
Drained
Dorsal digital vv.
Dorsal
venous
arch of the foot
Dorsal aspects of
the digits of the
foot
Dorsal
venous
arch of the foot
Dorsal digital vv.
And
dorsal
metatarsal vv.
Great saphenous
v. medially, small
saphenous
v.
laterally
Greater
saphenous v.
Medial end of
dorsal
venous
arch of foot,
perforating
communications
with deep veins,
superficial
circumflex
iliac
v.,
superficial
external
pudendal v.
Dorsum of
digits and
superficial
structures of
dorsum of
foot
Femoral v.
Skin
and
superfiaicl fascia
of the medial
side of the foot
and leg; skin and
super…
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