Phlebotomy Techniques

Whole Blood
has Plasma and formed elements
(unclotted)
Blood
Serum
• Liquid portion of clotted blood
• Without anticoagulant
• Contains albumin and globulin
Plasma
• Liquid portion of unclotted blood
• With anticoagulant
• Contains albumin, globulin and fibrinogen
Preexamination Variables
• Diet
-The tests most affected are glucose and triglycerides.
- Serum or plasma collected from patients shortly after a meal may
appear cloudy or turbid (lipemic) due to the presence of fatty
compounds such as meat, cheese, butter, and cream.
-Alcohol consumption  transient elevation in glucose and  chronic
consumption  liver function tests and triglycerides
-Caffeine  hormone levels
• Posture
- Can cause variations in some blood constituents, such as cellular
elements, plasma proteins, compounds bound to plasma proteins, and
high molecular weight substances.
• Exercise
- Increased activity of muscle enzymes
- Elevated concentration of sex hormones
- Elevated concentration of steroids
• Stress
-nervous patient before sample collection may increase levels of adrenal
hormones, increase WBC counts, decrease serum iron, and markedly affect
arterial blood gas (ABG) results.
• Smoking
- Acute effects : increase in glucose, BUN, cholesterol and triglycerides
-Chronic effects: Increase in blood hemoglobin values (carboxyhemoglobin)
Decrease in IgG, IgA, and IgM  weak immune system
• Altitude
-RBC counts and hemoglobin (Hgb) and hematocrit (Hct) levels are increased
in high-altitude areas such as the mountains where there are reduced oxygen
levels.
• Age and Gender
-Laboratory results vary between infancy, childhood, adulthood, and the
elderly  gradual change in the composition of body fluids.
-Hormone levels vary with age and gender
-RBC, Hgb, and Hct values  higher in male patients
• Pregnancy
-caused by the physiological changes in the body including increases in
plasma volume.
• Alcohol ingestion
Venipuncture
 EVACUATED TUBE
SYSTEM
• Blood is collected directly into the
evacuated tube, eliminating the need for
transfer of specimens and minimizing the
risk of biohazard exposure
INCLUDES:
• Double-pointed needle
• Needle holder
• Color-coded evacuated tubes
NEEDLES
• Needle size varies by both length and
gauge (diameter)
• Needle gauge: refers to the diameter
of the needle bore.
• The smaller the gauge number the
bigger the diameter of the needle.
• Needles should be visually examined
before use to determine if any
structural defects, such as
nonbeveled points or bent shafts,
are present.
NEEDLE HOLDERS
• made of rigid plastic and may be designed to act as a safety shield for
the used needle.
• Occupational Safety and Health Administration (OSHA) directs that
holders must be discarded with the used needle.
NEEDLE DISPOSAL SYSTEMS
• To protect phlebotomists from accidental
needlesticks by contaminated needles
• Rigid, puncture-resistant, leak-proof
disposable “sharps” containers labeled
BIOHAZARD that are easily sealed and
locked when full.
COLLECTION TUBES
• Evacuated tubes
- also known as Vacutainers and are available
in glass and plastic.
- Contain a premeasured amount of vacuum
for blood collection
- The amount of blood collected in an
evacuated tube ranges from 1.8 to 15 mL and
is determined by the size of the tube and the
amount of vacuum present.
Evacuated tubes
Order of Draw
The order of draw as recommended by the CLSI for both the evacuated tube
system and when filling tubes from a syringe is:
• Blood cultures (yellow stopper tubes, culture bottles)
• Light blue stopper tubes (sodium citrate)
• Red/gray, gold stopper tubes (serum separator tubes), red stopper plastic
tubes (clot activator), and red stopper glass tubes
• Green stopper tubes and light green (plasma separator tubes) (heparin)
• Lavender stopper tubes (EDTA)
• Gray stopper tubes (potassium oxalate/sodium fluoride)
• Yellow/gray or orange stopper tubes (thrombin clot activator)
 Syringe
• Routinely used for venipuncture range
from 2 to 20 mL
• For single draw
• For drawing blood from patients with
small or fragile veins.
Parts of a
Syringe
Reminder:
• Blood drawn in a syringe is immediately transferred to appropriate
evacuated tubes to prevent the formation of clots.
• It is not acceptable to puncture the rubber stopper with the syringe
needle and allow the blood to be drawn into the tube.
WINGED BLOOD
COLLECTION SETS
• for performing venipuncture
from very small or very
fragile veins often seen in
children and in the geriatric
population
*Reminder:
• Always hold the apparatus by
the needle wings and not by
the tubing.
Other Venipuncture Equipment
• Tourniquets • Slides
• Vein locating devices • Antimicrobial hand gel
• 70% isopropyl alcohol, iodine • Marking pen
swabs
• 2x2 inch gauze pads
• Bandage or adhesive tape
• Phlebotomy collection tray
Venipuncture Procedure
• Checking Requisition forms
- provide the phlebotomist with the information needed to correctly identify
the patient, organize the necessary equipment, collect the appropriate
samples, and provide legal protection.
- Patient’s name, age and gender
- Patient’s date of birth
- Patient’s location
- Ordering health-care provider’s name
- Tests requested
- Requested date and time of sample collection
• Greeting the patient
-Phlebotomists should introduce themselves and explain that they will be
collecting a blood sample.
• Patient Identification
-The most important procedure in phlebotomy
• Patient Preparation
- Positioning the Patient: supine (lying) or sitting upright positions
- Position of the Phlebotomist: remains in the standing position for better
and greater freedom of movement and control of the situation
- If a fasting specimen is required, confirm that the fasting order has been
followed
• Tourniquet application
-maximum amount of time the tourniquet should remain in place is 1 minute
to avoid hemoconcentration.
• Site selection
Antecubital fossa- The preferred site for venipuncture and is located
anterior and below the bend of the elbow.
3 major veins
Median cubital vein- vein of choice because it is large and does not tend to
move when the needle is inserted
Cephalic vein- usually more difficult to locate, except possibly in larger
patients, and has more tendencies to move.
Basilic vein- the least firmly anchored; has a tendency to “roll” and
hematoma formation is more likely to occur.
• Quite often the veins cannot be seen but usually felt by touching or palpating
with the index finger of the non dominant hand
• They will reveal themselves as elastic tubes beneath the surface of the skin.
 Arrangement of veins in
the antecubital fossa
• H-shaped pattern
- includes the cephalic, median
cubital, and basilic veins in a pattern
that looks like a slanted H.
• M-shaped pattern
- Includes the cephalic, median
cephalic, median basilic, and basilic
veins.
Areas to Be Avoided
• Damaged Vein
• Hematoma
• Edema
• Burns, Scars and Tattoos
• Mastectomy
• Obesity
• IV Therapy
• Heparin and Saline Locks
• Cannulas and Fistulas
• Cleansing the site
-Cleansing is performed with a circular motion, starting at the inside of the
venipuncture site and working outward in widening concentric circles about 2 to
3 inches.
• Assembling equipment
• Examine the Needle
-visually examined for any defects such as a nonpointed or rough (barbed) end.
• Anchoring the Vein
-Place the thumb 1 or 2 inches below and slightly to the left of the insertion site
and the four fingers on the back of the arm and pull the skin taut.
• Inserting the Needle
-bevel up, at an angle of 15 to 30 degrees depending on the depth of the vein.
• Filling the Tubes
• Removal of the needle
-Place folded gauze over the venipuncture site and withdraw the needle in a smooth
swift motion. Apply pressure to the site as soon as the needle is withdrawn.
*Never draw out the needle without removing first the tourniquet to avoid
hematoma
• Disposal of the needle
• Labeling the tubes
- Patient’s name and identification number
- Age and Gender of the Patient
- Date and time of collection
- Phlebotomist’s initials
• Checking the patient’s arm
-examine the patient’s arm to be sure the bleeding has stopped.
-adhesive bandages/micropore tape over a folded gauze square.
• Completing the Venipuncture procedure
-deliver the sample to the laboratory in satisfactory condition and all
appropriate paperwork should be completed
 • Immediate Local Complications
Localized hemoconcentration or Venous stasis
Remedy: One minute application of tourniquet

Syncope or Fainting
Remedy: Let the patient lie down
Patient
Failure to obtain blood
Complications Needle Position
Bevel Against the Wall of the Vein
Needle Too Deep/ Too Shallow
Collapsed Vein
Needle Beside the Vein
Faulty Evacuated Tube
 • Delayed Local Complications
- Thrombosis of veins- Formation of blood clots
inside the lumen of the vein due to trauma
- Thrombophlebitis- Inflammation of the vein due
to thrombus as manifested by an inflammatory
reaction on the outer skin surface
- Hematomas- Blue or black skin discoloration
commonly due to repeated trauma or puncture
Patient of the veins
Complications • General Delayed Complications- Serum
Hepatitis, AIDS
Prevention:
• Use of disposable syringe or vacutainer set
• Follow the procedures from the Universal
Precautions in handling infectious
specimens
 • Collection Attempts
-When blood is not obtained from the initial
venipuncture, the phlebotomist should select another
site. Repeat the procedure using a new needle
• Nerve Injury
-Temporary or permanent nerve damage can be caused
by incorrect vein selection or improper venipuncture
technique and may result in loss of movement to the
Other arm or hand and the possibility of a lawsuit.
• Iatrogenic Anemia
Complications - pertains to a condition of blood loss caused by
treatment. An anemia can occur when large amounts
of blood are removed for testing at one time or over
a period of time.
• Hemolyzed Samples
-Rupture of the red blood cell membrane releases
cellular contents into the serum or plasma and
produces interference with many test results
Special Blood
Collection
Collection Priorities
• Routine Samples- are usually collected early in the morning but can
be collected throughout the day during scheduled “sweeps”
(collection times) on the floors or from outpatients.
• ASAP Samples-means “as soon as possible.” The response time for
the collection of this test sample is determined by each hospital or
clinic and may vary by laboratory tests.
• Stat Samples - sample is to be collected, analyzed, and results
reported immediately.
• FASTING SAMPLE- npo (nothing per orem); “nothing by mouth”
-FBS
-Lipid Profile
• TIMED SAMPLES
-Glucose Tolerance Tests
-2-Hour Oral Glucose Tolerance Test
- Lactose Tolerance Test
• Blood Culture
ARTERIAL PUNCTURE
• Generally used for the determination of blood oxygen, carbon dioxide
tension and blood pH (Blood Gas Analysis).
• Blood collected is called arterial blood or oxygenated blood
• Special training is required for this procedure
• Tourniquet is not required
• After removing the needle, apply moderate pressure with 2 x 2 sterile
gauze until bleeding ceases
• Insert needle (still attached to syringe) in stopper to prevent air from
entering needle
Arterial Puncture: Sites of puncture
• Radial artery
• Femoral artery (fem tap)
• Brachial artery
• Scalp artery
• Umbilical artery
 Modified Allen Test

• Before performing a radial