Phlebotomy

Autism Society of America | Santa Barbara Chaptrer

Phlebotomy

PHLEBOTOMY

Phlebotomy the ABA way 3/20/03

Written by Marilee Brew & Sally Femino. We devised this program when my son needed his blood drawn; he otherwise would have required anesthesia. This information may be distributed to anyone that might want it. Please make adaptations to the needs of the student as necessary. If you have any suggestions, questions, or encounter problems, please feel free to write Marilee at brew@massmed.org

Materials needed:
Potent reinforcers. You want the child to associate this procedure with getting something fantastic!

(Rubber) Velcro Tourniquet ---Get from your doctor or www.MooreMedical.com (MM) $2.99 each

Butterfly infusion set (needle with plastic tubing attached. The lab usually uses this)--Get from MD

1 or 2 empty phlebotomy tubes—Get from your doctor

NOTE: Optional but very helpful: long I.V. arm board –Get from MD or MM 3 x 18 inch (6 for $9.25) & duct tape to attach

Velcro (either "sew on" or "sticky-back") to arm board in 2 places. I used ¾ inch wide Velcro (6 inches rough & 6 inches smooth) for the hand, & 1 ½ inch Velcro on the upper forearm (8" plus 8"). . To make the Velcro attachment, place one piece right side up & the other piece right side down, and sew the ends together, overlapping by about 1 inch so that they can stick to each other. When determining placement of the upper forearm Velcro attachment, do not put it too high up the arm in order not to interfere with the blood drawing. See photo pg 3. Also make sure rough velcro will not touch child’s skin.

Alcohol wipe to clean the skin area prior to needle stick

Small tube of 4% lidocaine (ELI-max). It is kept behind the pharmacy counter at CVS Acton (978 264 9130). You do not need a prescription to buy it (about $15, I recall). OR 5% lidocaine ointment (50 gm) for $3.19 at Moore Medical. 20 to 30 minutes before the procedure, apply lidocaine to skin & cover with

Teguderm, a non-absorbable dressing—(or some other covering that won’t absorb the cream. Do not use

gauze). This can be found in the first aid aisle at CVS. Keep teguderm in place with

Saran wrap –(don’t forget to do BOTH elbow areas) & secure all with

Tape –either duct tape or packaging tape will suffice

Rubber gloves, such as those used by the tech. Also found at local drug store.

Bandaid to be applied at end of procedure

Procedure:

Use the usual techniques of breaking down the tasks & gradually adding steps & increasing the time involved. VIP to generalize to different people (complete strangers if possible) & unfamiliar places.

Note: Part A and Part C can be taught in either order or started at the same time. Teach Part B only after Part A so child doesn’t feel "trapped" while learning blood drawing procedure.

PART A: TEACHING TOLERANCE OF BLOOD DRAWING

Either have child wear short-sleeved shirt or teach him to take his arm out of his sleeve & not redress during the procedure (the latter is probably preferable so that when Part B is used, the child is less likely to try to remove the saran wrap if it is out of sight.)
Start with getting child to tolerate tourniquet. Let him feel it, see it on you or another person etc. Say you are going to play "hug arm", or something similar. Make it fun. Gradually increase time that tourniquet is in place (eventually increase to 3-4 minutes.)

Add gently tapping the antecubital fossa (where blood will be drawn). Always inform child what you are doing along each step of the procedure (ex: "I am tapping your arm)

Add tapping while wearing gloves

Add wiping with the alcohol swab.

Add showing him the butterfly (keep the cover on the needle for now)

Add taking the cover off & briefly show him the needle. Initially reward, replace cover, & put aside.

Add demonstrating the needle stick on a cloth doll so that the child can see the needle going into the doll’s "skin." He will then know what to expect and will not be afraid. (The correct way to hold the needle is by squeezing together the wings of the butterfly such that the wings are above the needle.)

Add pretend poking the child with the cover on the needle. Prior to each pretend poke, show him needle

With the needle cover attached, (so you don’t accidentally stick the child), pretend to poke plus pretend to attach the blood tubes to the butterfly, such as is done in actual phlebotomy. "Here comes the red juice!"

Pretend to withdraw the needle from the arm. IF USING ARM BOARD, TEACH PART B NOW. Remove tournequit. Apply pressure & bandaid to site

PART B (OPTIONAL, but VERY STRONGLY SUGGESTED) USING THE ARMBOARD

Teach child to rest his arm on the armboard with palm up. Start without having the Velcro attached to the armboard. Initially have child keep his arm on the board for 1-2 sec. Reward. Increase time
Tape Velcro to the underside of the armboard. (see photos for positions)

Teach child to "hold on to" or "squeeze" the Velcro in his palm. It will give him something to do.

Repeat the phlebotomy procedure using arm board.

Apply pressure to antecubital fossa with bandaid or gauze. Undo Velcro attachments. Have child bend arm at elbow & elevate.

PART C: TEACHING TOLERANCE OF ANESTHETIC CREAM & WRAP

Teach child to tolerate having some white cream or lotion applied to his antecubital fossa (front elbow)
Add teguderm-type material.

Add saran wrap, using tape to secure it. Increase tolerance so that he will be accustomed to keeping it in place for 20 to 30 minutes on both arms.

Note: Call the phlebotomy lab ahead of time to find out if there is a "less busy" time. Make sure you or the lab has the necessary paperwork. Ask technician if he can have whatever tubes he needs ready ahead of time. Ask the technician if you & child can enter the room first (with your reinforcers) to get used to the surroundings. Then have technician(s) enter the room one at a time, say hi & give child a reinforcer, then leave. Then have tech(s) reenter the room quietly & do the phlebotomy.

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