6: Circulatory System

Blood Vessels
1. Veins
2. Arteries
3. Capillaries
 
Arteries
 large, thick-walled blood vessels that propel oxygen-rich blood away from the
heart to the capillaries
→ they branch into smaller, thinner vessels called arterioles that connect
to capillaries
→ the thicker walls aid in pumping blood, maintain normal blood pressure
(BP), and give arteries the strength to resist the high pressure caused
by the contraction of heart ventricles
 Wall layers:
→ Tunic adventitia, Tunica media, Tunica intima

 Major Arteries Associated with Health Care

→ Aorta: the largest artery, branches into smaller arteries to distribute
oxygen-rich blood throughout the body
→ Radial: located near the thumb side of the wrist, the most common site
for obtaining a pulse rate
→ Carotid: located near the side of the neck, the most accessible site in an
emergency, such as cardiac arrest, to check for a pulse
→ Brachial: located in the antecubital space of the elbow, the most
common site to obtain a BP
→ Femoral: located in the groin area, may be used for arterial punctures
→ Pulmonary: the only artery that does not carry oxygenated blood
→ Coronary: supply blood to the heart muscle and is wrapped around the
exterior of the heart
 
Veins
 have thinner walls than arteries
→ have less elastic tissue and less connective tissue because the BP in the
veins is very low
 carry oxygen-poor blood, CO2, and other waste products back to the heart
 no gaseous exchange takes place in the veins, only in the capillaries
 have one-way valves to keep blood flowing in one direction as the blood flows
through the veins by skeletal muscle contraction
 the leg veins have numerous valves to return the blood to the heart against
the force of gravity
 most blood tests are performed on venous blood
 venipuncture: the procedure for removing blood from a vein for analysis
→ the veins of choice are median cubital, cephalic, and basilic that are
found in the antecubital area of the elbow
 venules: are small veins that connect capillaries to larger veins
 Wall layers:
→ Tunic adventitia, Tunica media, Tunica intima

 
Capillaries
 the smallest blood vessels
 consist of a single layer of epithelial cells to allow exchanges of oxygen, CO2,
nutrients, and waste products between the blood and tissue cells
 the blood in this site is a mixture of arterial and venous blood
 Wall layers:
→ Tunica intima
 
Heart
 located in the thoracic cavity between the lungs and slightly to the left of the
body midline that consists of two pumps to circulate blood throughout the
body
 it is enclosed in a membranous sac called pericardium
 has four chambers and is divided into right and left halves by a partition called
the septum
→ L&R Atriums: upper chamber that collect blood
→ L&R Ventricles: lower chamber that pump blood from the heart
 the right side is the "pump" for pulmonary circulation, and the left side is the
"pump" for the systemic circulation
 the heart contracts and relaxes to pump oxygen-poor blood through the heart
to the lungs and return oxygenated blood to the heart for distribution
throughout the body
 valves located at the entrance and exit of each ventricle prevent a backflow of
blood and keep it flowing in one direction

FAQs
 both veins and ventricles have valves
 the "lub-dub" of the heart is the sound from the valves closing and opening
→ "lub" is closure of the entrance valves as the ventricles contract
→ "dub" is the closure of the exit valve
→ a heart murmur is an abnormal heart sound that occurs when the
valves close incorrectly
Pathway of Blood Through the Heart
1. Blood vessels: Superior vena cava, Inferior vena cava
→ transport oxygen-poor blood to the heart
 Superior vena cava: collects blood from the upper portion of the body
 Inferior vena cava: collects blood from the lower portion of the body
2. Chamber: Right atrium
3. Valve: Tricuspid valve
4. Chamber: Right ventricle
5. Valve: Pulmonary semilunar valves
6. Blood vessels: Left and right pulmonary artery
7. Organ: Lungs
8. Blood vessels: Left and right pulmonary vein
9. Chamber: Left atrium
10. Valve: Left atrium
11. Chamber: Bicuspid (mitral) valve
12. Valve: Aortic semilunar valves
13. Blood vessels: Aorta
 

Common Veins Not Associated with Venipuncture

a. Superior vena cava: carries oxygen-poor blood from the upper body to the
heart
b. Inferior vena cava: carries oxygen-poor blood from the lower body to the
heart
c. Great saphenous: the principal vein in the leg and the longest in the body
d. Pulmonary: the only vein carrying oxygenated blood

Heart Valves Listed in Order of Blood Flow

1. Tricuspid valve
 entrance to the right ventricle
 prevents backflow into the right atrium
2. Pulmonary semilunar valve
 exit of the right ventricle
 allows blood flow into the pulmonary artery
 3. Mitral (bicuspid) valve
 entrance to the left ventricle
 prevents backflow into the left atrium
4. Aortic semilunar valve
 exit of the left ventricle
 allows blood flow into the aorta
Cardiac Cycle
 is the contraction phase (systole) and the relaxation phase (diastole) of the
cardiac muscle that occurs in one heartbeat
 cardiac muscle is under involuntary control; therefore, the electrical impulses
of the cardiac cycle are essential to produce rhythmic contraction and
relaxation of the heart
 Steps in the Cardiac Cycle
1. Sinoatrial (SA) node
 located in the upper right atrium
 it is the pacemaker of the heart and initiates the heartbeat
2. Atrioventricular (AV) node
 located in the lower interatrial septum
 receives the electrical impulse and both the right and left atria
contract forcing blood to the ventricles
3. The impulse passes to the AV bundle that separates into right and left
bundle branches.
4. In the right and left bundle branches, the impulse travels to the
Purkinje fibers covering the ventricles, causing them to contract,
forcing blood into the aorta and pulmonary artery.
5. The cycle starts again.

Electrocardiogram (ECG)
 the cardiac cycle is measured with this instrument by placing electrodes
connected to a recorder on a patient's arms, legs, and chest
 ECG measures the total time of one cardiac cycle and the timing of the atrial
and ventricular contractions and relaxations

Blood Pressure
 the pressure exerted by the blood on the walls of blood vessels during
contraction and relaxation
 systolic and diastolic readings are taken and reported in millimeters of mercury
(mm Hg)
 → systolic pressure: the higher of the two numbers and indicates the BP
during contraction of the ventricles
→ diastolic pressure: the lower number and is the BP when ventricles are
relaxed
 a BP cuff called sphygmomanometer is placed over the upper arm and a
stethoscope is placed over the brachial artery to listen to heart sounds
→ the BP cuff is inflated to restrict the blood flow in the brachial artery
and then slowly deflated until loud heart sounds are heard
 Heart rate: number of times the heart beats per minute (bpm); normal value:
60-80 times/min
 Pulse rate: number of times the arteries create a noticeable pulse as a result of
heart contraction
 
Blood and Its Components
 the body's main fluid for transporting nutrients. waste products, gases, and
hormones through the circulatory system
 an average adult has a blood volume of 5-6 liters
 blood consists of two parts: liquid portion called plasma, and a cellular portion
called the formed elements
 Plasma
 compromises approximately 55% of the total blood volume
 a clear, straw-colored fluid that is about 91% water and 9%
dissolved substances
 the transporting medium for the plasma proteins, nutrients,
minerals, gases, vitamins, hormones, and blood cells, as well as
waste products of metabolism
 Formed Elements
 45% of the total blood volume
 erythrocytes (RBCs), leukocytes (WBCs), and thrombocytes
(platelets)
 blood cells are produced in the bone marrow
 Cells originate from stem cells in the bone marrow, differentiate and mature
through several stages in the bone marrow and lymphatic tissue until they are
released to the circulating blood

 Erythrocytes
 anuclear biconcave disks, approximately 7.3 microns in diameter
 contain the protein, hemoglobin, to transport oxygen and CO2
 hemoglobin consists of heme and globin
→ heme: requires iron for its synthesis
 approximately 4.5 to 6.0 million erythrocytes per microliter (uL) of blood
 life span is 120 days
 macrophages in the liver and spleen remove old erythrocytes from the
bloodstream and destroy them; the iron is reused in new cells

Leukocytes
 provide immunity to certain diseases by producing antibodies and destroying
harmful pathogens by phagocytosis
 produced in a bone marrow from a stem cell and develop in the thymus and
bone marrow
 normal number of leukocytes for an adult is 4,500 to 11,000 per uL of blood
 there are five normal types of leukocytes:
→ Granulocytes: are the ones who have granules in the cytoplasm
(neutrophils, eosinophils, basophils) and the
→ Agranulocytes: which have no granules in the cytoplasm (Lymphocytes,
Monocytes)
 Granulocytes (present in the cytoplasm)
a. Neutrophils (40% - 60%)
 the most numerous
 Normal value:
relative count = 60-70%
absolute count = 2-7.5 x 109/L
 provide protection against infection through phagocytosis
 are called segmented or polymorphous clear cells because
the nucleus has several lobes (2-5 lobes)
 10-12 micrometers in diameter
 first phagocytic cell to respond against antigens
 lifespan in the bloodstream is 8 hours and produced every
day in the bone marrow
 predominant cells in pus
b. Eosinophils (1% - 3%)
 the granules in cytoplasm are stain red-orange, and the
nucleus has only 2 lobes
 detoxify foreign proteins and increase in allergies, skin
infections, and parasitic infections
 Normal value:
relative count = 1-3%
absolute count = 0-0.4 x 109/L
 responsible for combating infections in parasites of
vertebrates and for controlling mechanisms associated with
the allergy and asthma
c. Basophils (0% - 1%)
 the least common
 contains large granules in the cytoplasm that stain purple-
black
 release histamine in the inflammation process and heparin
to prevent abnormal blood clotting
 Normal value:
relative count = 0-1%
absolute count = 0-0.1 x 109/L
 Agranulocytes (no granules in the cytoplasm)
d. Lymphocytes (20% - 40%)
 the second most numerous
 provide the body with immune capability by means of B and
T lymphocytes
 has a large, round purple nucleus with a rim of sky-blue
cytoplasm
 increases in viral infections
 Normal value:
relative count = 20-40%
absolute count = 1.5-4.5 x 109/L
 has three types: B-cells, T-cells, and Natural Killer cells
 has three types: B-cells, T-cells, and Natural Killer cells  
→ plasma cells, derived from B-cells, produce  
antibodies
→ T-cells directly kill infected host cells, activating other
immune cells, producing cytokines and regulating the
immune response
→ NK cells play a major role in the host-rejection of
both tumors and virally infected cells
e. Monocytes (3% - 8%)
 are the largest circulating leukocytes and act as powerful
phagocytes to digest foreign material
 the cytoplasm has a fine blue-gray appearance with
vacuoles and a large, irregular nucleus
 a tissue monocyte is known as a macrophage
 increases in intracellular infections and tuberculosis
 Normal value:
relative count = 3-8%
absolute count = 0.2-0.8 x 109/L
 
Thrombocytes
 small, irregularly shaped disks formed from the cytoplasm of very large cells in
the bone marrow called megakaryocytes
 have a life span of 9-12 days
 average number is between 140,000 and 440,000 per uL of blood
 play a vital role in blood clotting in all stages of the coagulation mechanism
  the tourniquet
should not be
left on the
patient's arm
for longer
than 1 minute
1. leaving
it on
longer
causes
discom
fort
and
affect
the
results
of
some
lab
tests
3. Disinfectant
 alcohol preps
are sterile
pads with 70%
isopropyl
alcohol
 alcohol prep

7: Venipuncture Equipment pads are used

to disinfect
Venipuncture Equipment
the patient's
1. Cotton covering
skin before
 sterile gauze should be kept in its wrapping until ready for use
puncturing
 immediately applied upon withdrawal of the needle from the
 other
venipuncture site
disinfectants
 a 2x2-inch gauze pads are used for applying pressure until the bleeding
used to
has stopped
cleanse the
 cotton balls may be used
include
 they can serve as additional protection when folded in quarters and
betadine pads
placed under a bandage
(used in blood
 a bandage or adhesive tape is placed over the puncture site when
culture
bleeding has stopped
collection) and
2. Tourniquet
swabs, which
 used to wrap around the arm to temporarily arrest blood flow to or
contain
from the arm
iodine, a more
 most used are flat latex or vinyl strips
powerful
 increases venous filling, causing veins to appear more prominent
cleanser for
 approximately 1 inch wide, & 18-20 inches long
the
 a non-disposable tourniquet must be cleaned immediately if soiled with
venipuncture
blood, use a 1:10 bleach-water dilution
area
 discard tourniquet with heavy blood contamination
4. Needles
 use 70% alcohol for frequent disinfection
 composed of the hub or plastic section, the shaft, and the bevel or
slanted tip
 vary in diameter
1. select the appropriate size based on the patient's vein and its
physical characteristics, along with the volume of blood needed
 the length may vary from 1-2 inches
1. many prefer the 1-inch needle since it gives more of a feeling of
"control" and is less frightening for the patient
 needle gauge is the diameter of the needle bore
 large (16-gauge): used to collect units of blood for transfusion; for
blood donors
 small (23-gauge): used for very small veins; the blood will flow more
slowly but the vein will less likely to collapse
 normal (21-gauge): for normal-sized veins
 smallest (<23-gauge): used for injections and intravenous (IV)
transfusions; can cause hemolysis when used for drawing blood
 the smaller the gauge
number, the bigger
the diameter of the
needle
 a 20-gauge is not
recommended for
routine blood
collection since many
patients are on blood
thinners, the use of
this needle can result
in post-puncture
bleeding and
hematoma
 using 25-gauge is not
recommended
because of the longer
time the needle is in
the vein causing the
tube to fill more
slowly, the formation
of micro-clots, and
increased frequency
of hemolysis
 needles should never
be recapped once the
shield is removed
 Three types of
needles:
a. Multiple-
sample
needle
 most
comm
on and
most
 preferred method for venous blood collection is the evacuated
system
 it is the most efficient and safest collection method
 the needle has two sharp ends: (1) designed to perform
venipuncture, (2) penetrate the rubber stopper of the collection
tube
b. Hypodermic Needle
 is attached to a syringe
 needle sizes for venipuncture are 22-gauge, 21-gauge, and 20-
gauge
 syringes are required to have a safety shield to cover the needle
immediately after use
c. Wing-tipped (Butterfly) Needle
 consists of a needle attached to a tubing with a connector on
the end, the connector attaches to a syringe or a needle holder
 there is a plastic "wings" placed between the needle and the
tubing which is used as a holder for the needle
 a plastic safety cover is moved forward over the needle when it
is removed from the vein
 this is used on fragile veins and when only a small volume of
blood is needed to be drawn
5. Needle Holder
 to hold the needle in place while it penetrates the rubber stopper of
the vacuum tube
 made of plastic, and has a variety of safety functions depending on the
manufacturer
 one holder has a hinged cover that recaps the needle, the other allows
the needle to be retracted into the holder
 these are for one-time use only, and should be discarded immediately
after use
 to provide proper puncturing of the rubber stopper and maximum
control, tubes should fit securely in the holder
6. Syringe
 used with the hypodermic or the butterfly needle
 may be used as an alternative method to the ETS for venous collection
 mostly made of plastic
 consists of a barrel and a plunger
1. the plunger is pulled back slowly to withdraw blood
2. the barrel is graduated into milliliters (mL)
 used when veins are small and fragile or when the patient's vein
presents the possibility of collapsing when ETS is used

7. Blood Transfer
Device
  a plastic holder utilized to transfer blood safely from the syringe into a
blood collection tube
 the syringe containing blood sample is locked into one end of the
holder and a collection tube is inserted and pushed into the opposite
end of the holder, allowing the luer adapter to puncture the rubber
stopper
 a needle on the syringe is not necessary to perform the transfer, the
vacuum in the tube will allow the tube to be filled with blood
8. Blood Collection Tubes
 called evacuated tubes since they contain a premeasured amount of
vacuum
 the amount of blood collected in an evacuated tube ranges from 1.8-15
mL and is determined by the size of the tube and the amount of
vacuum present
 uses vacuumized collection made of plastic or glass
 vary in size and have color-coded rubber stoppers that indicate the
type of additive in the tube
 loss of tube vacuum is primary cause of failure to obtain blood, the
venipuncture can be performed before placing the tube on the needle
 when selecting the appropriate size tube, the phlebotomist must
consider the amount of blood needed, the age of the patient, and the
size and condition of patient's veins
9. Disposal Units
 sharps disposals are made of non-penetrable plastic
 the needle holder and the needle must be disposed in one movement
per OSHA
 sharps' container must be rigid, leakproof, puncture-resistant, and
must have a biohazard symbol
1. should never be overfilled and only to the designated mark
10. Hypodermic tape
 paper tape is excellent for use on delicate skin, especially for elderly
patients
 latex-free tape should be used for people allergic to adhesive bandages
 patients are instructed to remove the bandage in about 1 hour
11. Gloves
 made of latex and non-latex and usually not sterile
 some gloves do come with powder inside to minimize perspiration
inside the gloves, but the powder could be a potential contaminant
 powder-free gloves are recommended
 change gloves every after patient

FAQs
 CLSI recommends centrifugation of clotted tubes and anticoagulated tubes and
separation of the serum or plasma from the cells within 2 hours
 poor mixing of tubes may produce a sample with micro clots that could yield
inaccurate results, while vigorously mixing the sample can cause hemolysis
and make the sample unacceptable for testing
 Gel separation tubes must always be stored and transported in an upright
position to facilitate clotting and prevent hemolysis
 coagulation factors are destroyed in samples remaining at room temperature
for extended periods of time
Routine Venipuncture
 1. Organization of workload
a. Prioritize orders
 the orders must be placed in the proper order of collection:
1. STAT: collected and delivered to lab immediately
2. Timed: collected as close to the specified collection time
as possible
3. ASAP
4. Routine collections
b. Review the Collection Requisition
 check for special comments on the collection order or for
posted instructions in the patient's room
 
2. Interacting with the patient
a. Greet the patient
 if the patient is sleeping, attempt to wake the patient up before
collecting blood sample
 if the patient asks questions concerning the tests that have
been ordered, instruct the patient to direct such questions to
the physician
 if the patient should be unconscious, always address the
patient using the same manner and protocol as if he were
awake since they may be capable of hearing and understanding
even though they cannot respond
 if physicians and members of the clergy are present, one
should return at another time unless the sample is stat or timed
 if there are family visitors present, they should be given the
option to step outside
 if the patient is unavailable, check with the nursing station
 if the sample must be collected at a particular time, it
may be possible to draw blood from the patient within
the area
b. Identify the patient
 absolute patient identification is mandatory for every collection
 Inpatients: compare the patient's identification bracelet with
the collection order form
 Outpatients: ask the patient to state his or her name and
birthdate
 Unidentified Emergency Patients: a temporary means of
identifying the patient must be established and attached to the
patient's body
c. Verify diet restrictions and time requirements
 some tests have requirements such as fasting or a special diet
prior to blood collection; do not collect a blood sample if such
requirements have not been met
d. Position the patient
 the patient should be positioned so as to be comfortable before
the venipuncture
 Inpatients: raise or lower the patient's bed so that it will
be at a comfortable level
 Outpatients: the patient should be seated in the
drawing chair and the arm not bent at the elbow
3. Preparing the venipuncture
a. Select the venipuncture site
 the most used veins are the superficial veins located in the
forearm and hand
 the larger median cubital and cephalic veins are often
used, an alternative may be the basilic vein which should
take great care since the vein lies near the median nerve
and the brachial artery
 other veins in the anterior surface of the forearm, as well as in
the wrist and hand, are acceptable sites for venipuncture
provided that the site has no scarring, hematoma, burn, or
edema
 the veins on the palm side of the wrist should not be used
 a healthy vein will feel "bouncy" to the touch when it is
palpated
 a thrombosed vein, which will not provide an adequate blood
sample, feels cordlike and has no spring or bounce
 applying a tourniquet and closing the patient's hand into a fist
will cause the veins to fill and become more prominent
 do not pump the fist; opening and closing the fist rapidly
can cause localized hemoconcentration
b. Feel, Roll, Trace, Palpate
 feel the vein with your index finger of the non-dominant hand
 roll your finger back and forth to determine its size; trace to
determine its path; palpate to determine resiliency
 do not leave the tourniquet for more than 1 minute since this
will cause erroneous results as well as discomfort for the patient
c. Complicating factors
a. Intravenous therapy
 blood collected from this site will be diluted with the
fluid being administered and cause erroneous results
 if intravenous lines are running in both arms, ask the
patient's nurse to turn off the IV line for a minimum of 2
minutes, or apply the tourniquet below the intravenous
site and select a vein other than the one with the
intravenous line
b. Mastectomy
 a mastectomy causes lymphostatsis in the arm
→ lymphostasis is a lack of fluid drainage and can cause
erroneous test results: lymphedema is a lifelong risk
for mastectomy patient
c. Hematoma
 this is painful to the patient and may cause erroneous
results
d. Scar tissue
 difficult to penetrate with a needle and may be painful
to the patient
e. Fistula/Cannula
f. Thrombosed vein
g. Edematous arms or hands
h. Blood transfusions
i. Burned areas
 d. Assemble collection supplies
 ETS is the most commonly used system for collecting blood
specimens
 the syringe/needle setup is used for patients with fragile veins
since this minimizes the pressure exerted against the vein wall

If blood flow is not be established, take the following steps:

a. Change the position of the needle. Press the tip of the needle slightly
downward. The bevel may be pressing against a vein wall, preventing
flow of blood into the needle.
b. Pull the needle slightly backward. The bevel may have gone through
the vein completely.
c. Slightly rotate the needle to the left or right. The bevel may be against
the vein’s wall.
d. Try another tube. The vacuum may have been lost in the first tube.
e. Loosen the tourniquet to increase the flow of blood.
f. Do not probe. If a second venipuncture is to be attempted, use a new
setup that includes a new needle and fresh gauze, alcohol pads, and
tubes.
→ Do not attempt a venipuncture more than twice. Notify the
patient or the patient’s nurse that another phlebotomist will be
dispatched to obtain the specimen.

FAQs
 If a hematoma should form, release the tourniquet immediately and withdraw
the needle, preventing excessive
bleeding under the skin. Apply pressure to the venipuncture site.
 If multiple tubes are to be collected, insert additional tubes using the correct
order of draw
→ The Clinical Laboratory Standards Institute (CLSI) no longer
recommends drawing a discard tube when only a PT or a PTT is
ordered. According to CLSI, a discard tube is not required when the
citrate tube is the first or only tube drawn, unless special factor assays
are being collected or when drawing through a winged collection set.

Performing the venipuncture using Syringe or Butterfly Technique

→ the procedure is basically the same as for the ETS
→ the butterfly or winged-tipped infusion device is most commonly used
for small, fragile veins
→ a 23-gauge needle is used most frequently for small, fragile veins

 
10: Venipuncture Complications
1. Patient Complications
 Apprehensive patients
→ ask the help of the nurse who is taking care of the patient to
help calm the person
→ assistance from a nurse or parent is required when getting
blood from a child
 Fainting/Syncope
→ it is the spontaneous loss of consciousness caused by
insufficient blood flow to the brain
→ triggers can be sight of blood, having blood drawn, fear of
bodily injury, standing for long periods of time, heat exposure,
and exertion
→ If a patient begins to faint during the procedure, immediately
remove the tourniquet and needle, and apply pressure to the
venipuncture site
→ In the inpatient setting, notify the nursing station as soon as
possible.
→ In the outpatient area, make sure the patient is supported and
that the patient lowers his or her head.
→ Outpatients who have been fasting for prolonged periods
should be given something sweet to drink (if the blood has been
collected) and required to remain in the area for 15-30 minutes
→ All incidents of syncope should be documented following
institutional policy.
 Seizures
→ if this occurs, the tourniquet and needle should be removed,
pressure applied to the site, and help summoned
→ restrain the patient only to the extent that injury is prevented
→ do not attempt to place anything in the patient’s mouth
 Petechiae
→ are small, non-raised red hemorrhagic sports that serve as
indications of a coagulation disorder, such as low platelet count
or abnormal platelet function
 Allergies
 Vomiting
→ Instruct the patient to breathe deeply and slowly and apply cold
compresses to the patient’s forehead.
→ If the patient vomits, stop the blood collection and provide the
patient with an emesis basin or wastebasket and tissues.
→ Give an outpatient water to rinse out his or her mouth and a
damp washcloth to wipe the face.
 Additional Patient Observations
 Patient Refusal
→ patients have the right to refuse blood withdrawal
→ If the patient continues to refuse, this decision should be
written on the requisition form and the form should be left at
the nursing station or the area stated in the institution policy
2. Tourniquet Application
 consider routinely using latex-free, single-use tourniquets
 application for the tourniquet for more than 1 minute will interfere
with some test results
→ tourniquet should be releases as soon as the vein is accessed
 tourniquet application and fist clenching are not recommended when
drawing samples for lactic acid determination
 releasing the tourniquet as soon as blood begins to flow into the first
tube can sometimes result in the inability to fill multiple collection
tubes
 Hemoconcentration
→ prolonged tourniquet time cause hemoconcentration because
the plasma portion of the blood passes into the tissue, which
results in an increased concentration of protein-based analytes
in the blood
→ tests most likely to be affected are those measuring:
 large molecules, such as plasma proteins and lipids, RBCs
 substances bound to protein such as iron, calcium,
magnesium
 analytes affected by hemolysis, including potassium,
lactic acid, and enzymes

3. Areas to be avoided
a. Damaged veins
 veins that contain thrombi or have been subjected to numerous
venipunctures often feel hard and cord-like (sclerosed) and
should be avoided
→ they may have blocked (occluded) and have impaired
circulation
b. Hematoma
 this indicates that blood has accumulated in the tissue
surrounding a vein during or following venipuncture
 blood collected from this site is old and hemolyzed
 collect below the hematoma if there is no other vein available
c. Edema
 areas containing excess tissue fluid (edema) may cause sample
to be contaminated with tissue fluid and yield inaccurate results
 may be cause by heart failure, renal failure, inflammation or
infection
d. Burns, Scars, and Tattoos
 areas prone to infection
 they have decreased circulation and can yield inaccurate results
 these are difficult to palpate and penetrate
 tattooed areas contain dyes that can interfere in testing
e. Mastectomy
 this can be harmful to the patient and cause inaccurate results
 In the case of a double mastectomy, the physician should be
consulted as to an appropriate site, such as the hand. It may be
possible to perform the tests from a fingerstick with a
physician’s permission.
 f. Obesity was disconnected
 veins on obese patients are often deep and difficult to palpate
 the cephalic vein is more prominent and easier to palpate
 a BP cuff may work better as a tourniquet when a vinyl or latex is
too short
→ do not probe to find the vein as that can be painful to the
patient and cause hemolysis by destroying RBCs
 use a syringe with a 11/2-inch needle for more control
g. IV Therapy
 if a patient is receiving IV fluids in an arm vein, blood should be
drawn from the other arm to avoid contaminating the sample
with IV fluid
 if an arm containing an IV must be used for collection, select the
site below the IV insertion point and preferably a different vein
 CLSI recommends having the nurse turn off the IV infusion for 2
minutes and the phlebotomist may apply the tourniquet
between the IV and the site to perform venipuncture
 if blood is collection from IV line, the nurse should turn off the
IV drip for at least 2 minutes. The first 5 mL of blood drawn
must be discarded since it may be contaminated with IV fluid
h. Heparin and Saline Locks
 are winged infusions sets connected to a stopcock or cap with a
diaphragm that can be left in a vein up to 48 hours to provide a
means for administering medications and for obtaining blood
samples
→ the device must be flushed with heparin or saline
periodically and after use to prevent blood clots from
developing in the line
 the first 5mL of blood drawn must be discarded
 do not collect blood through these devices for coagulation
testing since the residual heparin can affect test results
i. Cannulas and Fistulas
 patients receiving renal dialysis have a permanent surgical
fusion of an artery and a vein called fistula in one arm, and this
arm should be avoided to prevent infection

3.  Technical Complications
a. Failure to obtain blood
 needle position
 bevel against the wall of the vein
 needle too deep
 needle too shallow
 collapsed vein
 needle beside the vein
 faulty evacuated tube
b. Collection attempts
 when blood is not obtained from the initial venipuncture, one
should select another site, either the other arm or below the
previous site and repeat the procedure using a new needle
 if the second puncture is not successful, do not make another
attempt, notify the nursing station and request that another
phlebotomist perform the venipuncture
 a. Nerve Injury
 this can be caused by incorrect vein selection or improper venipuncture
technique and may result in loss of movement to the arm or hand
 the most critical permanent injury is damage to the median
antebrachial cutaneous nerve
 errors in technique include:
 blind probing
 selecting high-risk sites
 employing an excessive angle of needle insertion (>30 degrees)
 lateral direction of the needle
 excessive manipulation of the needle
 movement by the patient while the needle is in the vein
 the symptoms are treated with a cold ice pack initially and then warm
compresses to the area
b. Iatrogenic Anemia
 a condition of blood loss caused by treatment
 can occur when large amounts of blood are removed for testing at one
time or over a period of time
c. Hemolyzed Samples
 hemolysis is detected by the presence of pink or red plasma or serum
 rupture of the RBC membrane releases cellular contents into the serum
or plasma and produces interference with many tests results
 will affect the test results of analytes such as potassium and lactic acid
that are particularly sensitive to hemolysis
d. Reflux of Anticoagulant
 reflux of a tube anticoagulant can occur when there is blood backflow
into a patient's vein from the collection tube
 this problem can be avoided by keeping the patient's arm and the tube
in a downward position and allowing the collection tubes fill from the
bottom up

11: Dermal Puncture

Composition of Capillary Blood
 a mixture of arterial and venous blood
 contains small amounts of interstitial and intracellular fluids
 capillary blood is high in glucose, while low in total protein, potassium, and
calcium

Dermal Puncture Equipment

1. Lancets
 poor mixing of tubes may produce a sample with micro clots that could yield
inaccurate results
 vigorously mixing the sample can cause hemolysis and make the sample
unacceptable for testing
 Gel separation tubes must always be stored and transported in an upright
position to facilitate clotting and prevent hemolysis
 fine, sharply pointed needles used to prick the skin
 several color-coded lancets are available in varying puncture depths
and widths to accommodate low, medium, and high blood flow
requirements
 recommended depth is 2 mm and the width is 2.5 mm
 1. Microsample containers  do not use
 Capillary tubes/Microhematocrit tubes fingers on the
→ small tubes used to collect approximately 50-75 uL of blood for side of
performing a microhematocrit test mastectomy
→ plain or coated with ammonium heparin tubes, and they are
color coded
 red band for heparinized tubes
 blue band for plain tubes
→ Heparinized tubes should be used for hematocrits collected by
dermal puncture, and plain tubes are used when the test is
being performed on blood from a lavender stopper (EDTA) tube
→ use of glass capillary tubes is not recommended
 Micro-collection tubes/Microtainer
→ provide a larger collection volume and present no danger from
broken glass
→ a variety of anticoagulants and additives, including separator gel
→ tubes are color coded the same way as ETS
→ microtainer tubes are design to hold approximately 600 uL of
blood
2. Others
 Alcohol pads, Heel warmer, Sharp's container, Dry cotton, Gauze

 
Dermal Puncture Procedure
 collection via dermal puncture must be noted on the requisition form
a. Patient Position
 must be seated or lying down with the hand supported on a firm
surface; palm up and fingers pointed downward for fingerstick
 for heel stick, infants should be lying on the back with the heel in a
downward position
b. Site Selection
 primary dermal puncture sites are:
→ medial and lateral areas of the plantar (bottom) surface of the
heel (<1 year)
→ near the center of the third and fourth fingers on the palmar
side of the nondominant hand (1 year & adults)
 dermal puncture sites should not be callused, scarred, bruised,
edematous, cold or cyanotic, or infected
 punctures should never be made through previous puncture sites since
this can introduce microorganisms into the puncture and allow them to
reach the bone
c. Summary of Dermal Puncture Site Selection
 use the medial and lateral areas of the plantar surface of the heel
 use the central fleshy area of the 3rd or 4th finger
 do not use the back of the heel
 do not use the arch of the foot
 do not puncture through old sites
 do not use areas with visible damage
 do not use fingers on newborns or children younger than 1 year
 do not use swollen sites
 do not use earlobes
  applying
pressure
about 1/2 inch
away from the
d. Warming the Site puncture site
 warm the finger or heel from which the sample is to be taken for frequently
optimal blood flow produces
→ primarily required for patients with very cold or cyanotic fingers better blood
 moisten a towel with warm water (42°C) or activating a commercial flow than
heel warmer and covering the site for 3-5 minutes pressure very
e. Cleansing the Site close to the
 cleanse with 70% isopropyl alcohol, using a back-and-forth motion site
 allow the alcohol to dry on the skin, failure in doing so will: → do not scoop
 causes a stinging sensation for the patient the blood in
 contaminates the sample order to avoid
 Hemolyzes RBCs hemolysis
 prevents formation of a rounded blood drop because blood will
mix with the alcohol and run down the finger
 povidone-iodine is not recommended
f. Performing the Puncture
a. Heel puncture
 heel is held between the thumb and index finger of the
nondominant hand, with the index finger held over the heel and
the thumb below the heel
b. Finger puncture
 finger is held between the nondominant thumb and index
finger, with the palmar surface facing up and the finger pointing
downward to increase blood flow
c. Puncture device position
 choose a puncture device corresponding the size of the patient
 do not indent the skin when placing the lancet of the puncture
site
 the blade of the puncture device should be aligned to cut across
(perpendicular to) the grooves of the fingerprint or heel print
since this aids in the formation of a rounded drop
→ one firm puncture is less painful for the patient than two
"mini" punctures
g. Sample Collection
 wipe the first drop of blood with gauze to prevent contamination with
tissue fluids and residual alcohol
 do not "milk" the site: blood should be freely flowing
 alternately apply pressure and release it to obtain satisfactory blood
flow
 Capillary tubes and micropipettes: hold the end of the tube
near the drop of blood horizontally while being filled via
capillary action
→ when tubes are filled, they are sealed with sealant clay
or designated plastic caps
 Micro-collection/microtainer: slanted down and blood is
allowed to run through the scoop and down the side of the tube
→ the tip of the container is placed beneath the puncture
site and touches the underside of the drop
  blood smears are
needed for the
microscopic
examination of blood
cells that is
performed for the
differential blood cell
count, special staining
procedures, and
nonautomated
reticulocyte counts
 bleeding time test is
performed to
evaluate platelet
number and function
 the patient's
h. Order of Collection vascular
1. Capillary blood gases integrity,
2. Blood smear ingested
3. EDTA tubes medications
4. Other anticoagulated tubes (aspirin), and
5. Serum tubes phlebotomist'
i. Bandaging the patient s technique
 pressure is applied to the puncture site with gauze influence the
 the finger or heel is elevated and pressure is applied until the bleeding accuracy of
stops the test
 do not use bandage for children younger than 2 y/o since they might
remove it and place it in their mouths or may cause irritation on their Collection of Newborn
skin Bilirubin
j. Labeling the sample  one of the most
 microsamples must be labeled with the same information required for frequently
venipuncture samples performed tests on
k. Completion of the procedure newborns
 dispose all used materials in appropriate containers  bilirubin is a very
 observe special handling and sample priorities light-sensitive
chemical and is
Key points rapidly destroyed
 samples from newborn bilirubin levels must be collected at the correct time when exposed to
and protected from light to prevent the bilirubin from breaking down light
 hemolysis must be avoided  Hyperbilirubinemia:
 mandatory newborn screening tests are performed by dermal puncture on caused by Hemolytic
the heel for genetic, metabolic, hormonal, and functional disorders Disease of the Fetus
 blood is collected on filter paper and sent to a reference laboratory for and Newborn (HDFN)
testing where the liver of
 capillary blood gases are collected in the pipette in infants and small children the newborn is not
from the heel or finger often developed
 samples must be collected quickly and without air spaces in the pipette (premature) to
that would expose the sample to room air causing inaccurate results process bilirubin
 heparinized pipettes are mixed with a magnetic stirrer "flea" and round produced from the
magnet that is moved up and down the tube normal breakdown
of RBCs
 samples must be collected quickly and protected from excess light during and
after collection
 use amber-colored tubes or wrap tube with carbon paper
 when collecting from neonates, turn off the UV
 Kernicterus: a
condition in newborn
where excess indirect
bilirubin in the blood
goes to the brain
damaging it
 infants who appear
jaundiced are
frequently placed
under an ultraviolet
light (UV) to lower
the level of circulating
bilirubin
 bilirubin may
decrease as much as
50% in a blood
sample that has been
exposed to light for 2
hours

Newborn Screening
 this is the testing of
newborn babies for
genetic, metabolic,
hormonal,
functional, disorders
that can cause
physical disabilities,
mental retardation,
or even death
 NBS can test 50
metabolic disorders
from blood collected
by heel stick and
placed on special
designed filter paper
 are
performed on
blood
collected by
dermal
puncture
  ideally collected 24-72 hours after birth (before the baby is released
from the hospital)
 do not touch the area inside the circle or touch the dried blood spots)
 heel stick is performed in the routine manner (1st drop of blood is wiped
away)
 a large drop of blood is then applied directly onto a filter paper circle
 blood is applied to only one side of the filter paper
 allow to dry the blood at room temperature
 NBS in the PH have 6 basic tests, including screening for:
 Phenylketonuria (PKU), Congenital Adrenal Hyperplasia (CAH),
Congenital Hyperthyroidism (CH), Glucose-6-Phosphate
Dehydrogenase Deficiency, Galactosemia (Gal), and Maple Syrup
Disease (MSUD)
 Phenylketonuria (PKU): caused by the lack of the enzyme
needed to metabolize the amino acid phenylalanine to tyrosine,
which accumulates and causes problems with brain development
and mental retardation
 Congenital Hyperthyroidism (CH): a thyroid hormone deficiency
present at birth; delays in growth and brain development that
produce mental retardation can be avoided by the use of oral
doses of thyroid hormone within the first few weeks after birth
 Galactosemia: a genetic metabolic disorder caused by the lack of
the liver enzyme needed to convert galactose (sugar in milk) into
glucose

Capillary Blood Gas

 arterial blood is preferred sample for blood gases and pH levels in adults,
while blood gases is performed on capillary blood for young children
 blood is collected from the plantar area of the heel or big toes, and the palmar
area of the fingers
 it is essential to warm (40°C-42°C for 3-5 minutes) the collection site to
arterialize the sample
→ the concentration of arterial blood is also increased when collection
site is warmed
 samples are collected in heparinized blood gas pipettes/capillary tubes (plugs
or clay sealants are needed for both ends of the pipettes)
→ magnetic stirrer "flea" and circular magnet are used to mix the sample
 pipettes/capillary tubes should be completely filled (no air bubbles)
→ fille the
pipette in less
than 30 secs
 place tubes
horizontally in an ice
in order to slow the
WBC metabolism
and change in pH
and blood gas
concentration

Blood Smear
  in dermal puncture, blood smear should be collected before other samples to
avoid platelet clumping
 when samples are collected via venipuncture, the smear is usually made in the
laboratory from the EDTA tube
→ this is made within 1 hour of collection to avoid cell distortion
→ the EDTA tube must be mixed for 2 minutes
 a properly prepared smear has:
 smooth film of blood that covers 1/2 to 2/3 of the slide
 does not contain ridges or holes
 has lightly feathered edge without streaks

Bleeding Time
 performed to measure the time required for platelets to form a plug
strong enough to stop bleeding from an incision
 considered only as a screening test (abnormal results are followed by
additional testing)
 Standard Bleeding Time called the Ivy Method is performed by making
incision on the volar surface of the forearm, and inflating a blood
pressure cuff to 40 mm Hg to control blood flow to the area
 the length of the BT is increased when the platelet count is low, when
platelet disorders affect the ability of the platelets to stick to each
other to form a plug, and in persons taking aspirin and certain other
medications
 automated incision devices produce standardized incision of 1mm in
depth and 5mm in length
 ingestion of aspirin, medications containing salicylate (aspirin), and
drugs such as ethanol, dextran, streptokinase, streptodornase, and
various herbs within the last 7-10 days of the test may cause a
prolonged bleeding time

13: Point-Of-Care Test

Point-of-Care Testing (POCT)
 referred as alternate site testing, near-patient testing, decentralized testing,
bedside testing, or ancillary testing
 it is the performance of laboratory tests at the patient's bedside or nearby
rather than in a central lab
 this is particularly beneficial to patient care in the critical care or ICU, operating
suites, emergency department, or neonatal ICU
→ other locations include satellite laboratories, physician offices,
ambulatory clinics, ambulances/helicopters, long-term care facilities,
workplace screenings, health affairs, dialysis centers, and home settings
 Factors that have motivated the practice of POCT:
→ increased acuteness of inpatient illnesses that require a faster
turnaround time (TAT) of results
 the shorter the TAT, the sooner the health-care provider can
treat the patient
→ decreased
length of
hospital stays
that require
 the increased performance of procedures and care on an outpatient
basis
 this is well-suited for the concepts of decentralization of laboratory testing and
cross-training of personnel to perform certain tests at the patient's bedside
→ the immediate availability of test results provides convenience to both
the patient and the health-care provider by decreasing the time
required for diagnosis and treatment, resulting in faster patient
recovery

Advantages of POCT
 generates quicker results
 easy to use devices
 convenient to patients
 eliminates specimen transport
 contributes to rapid diagnosis
 minimally invasive
 
Disadvantages of POCT
 loss of quality results
 overpriced tests
 non-qualified staff reading the results
 multiplication of tests to avoid errors
 recording of results

Types of POCT
1. Waived Tests
 simple procedures cleared by the FDA for home use
 employ methodologies that are easy to perform and the likelihood or
erroneous results is negligible
 pose no reasonable risk of harm to the patient if the test is performed
incorrectly
 are considered simple to perform and interpret and require no special
training or educational background, and require only minimum
 tests included:
 blood glucose
 reagent strip or tablet reagent urinalysis
 erythrocyte sedimentation rate (nonautomated)
 fecal occult blood
 hemoglobin by copper sulfate (nonautomated)
 ovulation tests
 spun hematocrit
 urine pregnancy test
2. Moderate Complexity
 more difficult than waived tests that require documentation of training
in testing principles, instrument calibration, and QC
 requires that personnel have a minimum of a high school diploma or
equivalent
 tests included:
 CBC
 electrolyte profiles
 chemistry profiles
 urinalysis
  automated immunoassays
 urine drug screen
 many lab tests in chemistry and hematology have been assigned to this
category
 facilities assigned to this complexity are subject to proficiency testing
and on-site inspections
3. High Complexity
 require sophisticated instrumentation and a high degree of
interpretation by the testing personnel
 personnel must have formal education with a degree in laboratory
science
 most tests performed in microbiology, immunology,
immunohematology, and cytology are in this category
 tests included:
 RT-PCR
 gene chip arrays
 peripheral smears
 multiplexed analyses
 dot blots
 viral loads
 expression arrays
 CGH arrays
4. Provider-Performed Microscopy Procedures
 included certain procedures that can be performed in conjunction with
any waived test and includes clinical microscopy procedures only
 the tests can be performed only by physician's assistants, nurse
practitioners, midwives, physicians, and dentists during a patient's
examination
 laboratories performing these tests must meet the moderate
complexity requirements for proficiency testing, patient test
management, QC, and QA as required by the accreditation agency