MLSP112

PRELIMINARY TOPICS (LEC & LAB)

LECTURER: Mr. Ramon Garcia & Ms. Ruth Alonzo
CREATED BY: Kathreen Salvador [Notes: may mga notes na galing sa supplementary ppts na binigay]

Safety Equipment
COVERAGE OF PRELIM TOPICS
• Safety showers and Eyewash stations – must be
1. Laboratory Safety accessible within 100 feet or 10 secs. travel
a) Handwashing • Fire extinguishers
b) Doffing and Donning PPE • Fume Hoods – expel noxious and hazardous
2. Understanding Phlebotomy fumes
3. Dermal Puncture • Biosafety Cabinets – remove particles that may be
4. Venipuncture harmful
• Complete PPE – haircap, googles, mask, lab
LESSON 1: LABORATORY SAFETY gown
OSHA Occupational Health and Safety
TYPES OF SAFETY HAZARDS
(OCCUPATIONAL Administration within the U.S.
SAFETY AND Department of Labor to set TYPE SOURCE POSSIBLE INJURY
HEALTH levels of safety and health for Biological Infectious Bacterial, fungal,
ADMINISTRATION) all workers in the United States. agents viral, parasitic
CLSI - CLINICAL Educational organization that Sharps Needles, Cuts, punctures,
AND LABORATORY sets voluntary consensus lancets, broken blood-borne
STANDARDS standards for all areas of glass pathogen exposure
INSTITUTE clinical laboratories; Chemical Preservatives, Exposure to toxic,
reagents carcinogenic, caustic
CDC - CENTERS carries out mandated public agents
FOR DISEASE health laws and reporting Radioactive Equipment, Radiation exposure
CONTROL AND requirements. radioisotopes
PREVENTION Electrical Ungrounded, Burns, shocks
CAP - COLLEGE OF wet equipment,
AMERICAN frayed cords
PATHOLOGISTS Fire/explosive Bunsen Burns,
burners, dismemberment
TJC - THE JOINT All Clinical Lab should have: organic (amputation)
COMMISSION - Chemical Hygiene plan chemicals
(FORMERLY ➔ entails how to Physical Wet floors, Falls, sprains, strains
JCAHO) handle or store heavy boxes,
chemicals
patients,
- Exposure control plan disorganized
➔ response to spilling space
and exposure to virus
and bacteria
BIOLOGICAL HAZARD
- Copy of MSDS ➔
Material Safety Data
- These microorganisms are frequently present in
Sheet
the specimens received in the clinical laboratory.
o CDC- Universal Precautions (1987)
Safety begins with the recognition of hazards and is
▪ Blood and body fluid precautions
achieved through the ff:
should be consistently used for all
patients
1. Application of common sense - Specimens should be “capped” during
2. Listen to the instructions centrifugation
3. A safety-focused attitude - Any blood, body fluid, or other potentially
4. Good personal behavior infectious material spill must be cleaned up using:
5. Good housekeeping in all laboratory work and o Spill clean-up kit
storage areas o Common aqueous detergent
6. Continual practice of good laboratory technique. o 10% bleach using appropriate contact
time
Two primary causes of accidents:
STEPS TO CLEAN BLOOD SPILL
1. Unsafe acts – e.g., improper disposal of
hazardous materials 1. Wear PPE
2. Unsafe environmental conditions – e.g., no 2. Use forceps for discarding the broken glass on
biosafety cabinets, fume hoods sharps container
 3. Cover with absorbent paper towels flammable or
4. Flood area with 10% bleach solution explosive gases
5. Let sit for 10 min. Carcinogenic Chemicals Cancer-caustic
6. Clean up area with paper towels substances
7. Dispose in Biohazard bag
8. Repeat if necessary. MATERIAL SAFETY DATA SHEET

OSHA Blood-Borne Pathogens standard requires written • Product name and identification
“Exposure Control Plan” • Hazardous ingredients
• Permissible exposure limit
CATEGORIES OF EXPOSURE • Physical and chemical data
• Health hazard data and carcinogenic potential
a. Category I – daily exposure to blood and body
• Primary routes of entry
fluids
• Fire and explosion hazards
b. Category II – regular exposure to blood and body
• Reactivity data
fluids
c. Category III – no exposure to blood and body • Spill and disposal procedures
fluids • PPE recommendations
• Handling
Employers must offer HBV vaccine to all personnel • Emergency and first aid procedures
(Category I and II) • Storage and transportation precautions
• Chemical manufacturer’s name, address and
CHEMICAL HAZARD telephone number
• Special information section
Chemical spills: When skin contact occurs, the best first
aid is to flush the area with large amounts of water for at NFPA LABELLING SYSTEM
least 15 mins and then seek medical attention.
- The National Fire Protection Association (NFPA)
Chemical Handling: Chemicals should never be mixed has developed the Standards System for providing
together unless specific instructions are followed, and they codes and standard information about the
must be added in the order specified. (Important when chemical/solutions.
combining acid and water) - RED DIAMOND – flammability hazard (based on
flash point)
Chemical Hygiene Plan: OSHA requires all facilities that • (4) - below 73°F
use hazardous chemicals ➔ written chemical hygiene plan • (3) - below 100°F
(CHP) available to employees. • (2) - above 100°F, but not exceeding
200°F
- Appropriate work practices, Standard operating • (1) – above 200°F
procedures, • (0) – Will not burn
- PPE, Engineering controls, such as fume hoods - BLUE DIAMOND – health hazard
and flammable safety cabinets • (4) - Deadly
- Employee training equipment’s • (3) – Extreme danger
- Medical consultation guidelines. • (2) - Hazardous
• (1) – slightly hazardous
STORAGE AND HANDLING CHEMICALS • (0) – normal material
- YELLOW DIAMOND: reactivity hazard
Flammable/Combustible Classified according • (4) – may deteriorate
Chemicals to flash point- the
• (3) – shock & heat may deteriorate
temperature at which
• (2) – violent chemical change
sufficient vapor is
• (1) – unstable if heated
given off to form an
ignitable mixture with • (0) – stable
air - WHITE DIAMOND – special precautions
Corrosive Chemicals Injurious to the skin • OXY – oxidizer
or eyes by direct • ACID – Acid
contact or to the • ALK – Alkali
tissue of the • COR – corrosive
respiratory and • W – use no water
gastrointestinal tracts • - radiation
of inhaled or
ingested
Reactive Chemicals Spontaneously
explode or ignite or
that evolve heat or
 Electrical Precautionary Procedures:

• Use only explosion-proof equipment in hazardous

atmospheres.
• Be particularly careful when operating high-voltage
equipment, such as electrophoresis apparatus.
• Check for frayed electrical cords.
• Promptly report any malfunctions or equipment
• Do not work on “live” electrical equipment.
• Never operate electrical equipment with wet
hands.
• Know the exact location of the electrical control
panel for the electricity to your work area.

RADIATION HAZARD

Equipment and radioisotopes Radiation Safety

- All areas where radioactive materials are used or

stored must be posted with caution signs, and
traffic in these areas should be restricted to
essential personnel only.
- Radiation monitoring utilizes film badge or survey
meter- maximum permissible dose is 5000
mrem/year whole body

MECHANICAL HAZARDS
FIRE/EXPLOSIVE HAZARD Centrifuges - must be balanced to distribute the load
equally
- The Joint Commission on Accreditation of
Healthcare Organization (JCAHO) all health-care - Never open the lid until the rotor has come to a
institutions post evacuation routes and detailed complete stop
plans to follow in the event of a fire. - Safety locks on equipment should never be
- Laboratory personnel should be familiar with these rendered inoperable
procedures.
✓ Rescue Glass beads – help eliminate bumping/boil over when
✓ Alarm liquids are heated
✓ Contain
✓ Extinguish
Infectious sharps - disposed in OSHA approved containers
Class A Ordinary - Pressurized water
Fire combustible extinguisher 4 BASIC WASTE DISPOSAL TECHNIQUES
materials - Dry chemical
extinguisher 1. Flushing down the drain
Class B Flammable - Dry chemical 2. Incineration
Fire liquids/gases extinguisher 3. Landfill burial
& petroleum - Carbon dioxide 4. Recycling
products extinguisher
Class C Energized - Carbon dioxide Chemical Waste
Fire electrical extinguisher
equipment - Halon extinguisher - Flush water-soluble substances down the drain
- Dry chemical with large quantities of water
extinguisher - Strong acids and bases should be neutralized
Class D Combustible/ - Metal X before disposal
Fire reactive - Foul smelling chemicals should never be disposed
metals down the drain
• Flammable solvents- collected in approved
ELECTRICAL HAZARD containers
• Flammable material- specially designed
• Lock-out or tag malfunctioning electrical or incinerators
mechanical equipment until serviced • Solid chemicals- landfill
• Know how to knock a shocked person loose using
a non-conductive material Radioactive Waste
 • Depends on the type of waste (soluble or no 4. After touching a patient, and
soluble), its level of radioactivity, and the radio 5. After touching patient surroundings
toxicity and half-life of the isotopes involved
STEPS IN HANDWASHING (recommended by WHO)
Biohazardous Waste
a. Wet hands with water
• All biological waste (EXCEPT URINE) should be b. Apply single shot of soap
placed in appropriate containers labeled with c. Rub hands palm to palm
biohazard symbol. d. Rub back of each hand with the palm of other the
• URINE: may be discarded by pouring it into the lab hand with fingers interlaced
sink. e. Rub palm to palm with fingers interlaced
• The sink should be flashed also with water f. Rub with backs of fingers to opposing palms with
after the urine has been discarded. fingers interlocked
• Decontaminate the sink by 1:5 or 1:10 g. Rub each thumb clasped in opposite hand using
dilution of sodium rotational movement
• hypochlorite (bleach solution). h. Rub tips of fingers in opposite palm in circular
• Incineration, inactivation, burial, chemical motion
disinfection, i. Rub each wrist with opposite hand
j. Rinse hands with water
• encapsulation in a solid matrix
k. Dry thoroughly
Inactivation
- Skin should always be properly dried to avoid risk
of chapping particularly during cold weather.
• Heat sterilization (250oC for 15 minutes) Ethylene - Clean towels should be available at all times –
Oxide dirty towels mean exposing the skin to more dirt
• (450-500 mg/L at 55-60oC) and the risk of infection.
• 2% Glutaraldehyde - Ideally, disposable paper towels should be used,
• 10% hydrogen peroxide as the use of ‘communal’ towels can lead to
• 5.25 hypochlorite (bleach) contamination.
• 10% (v/v with tap water) of common household
bleach) – HBV (10 minutes), HIV (2 minutes) PERSONAL PROTECTIVE EQUIPMENT (PPE)

PROPER HAND WASHING TECHNIQUE 1. Gloves - worn to protect the health-care worker’s
hands from contamination by patient body
- A simple but effective way to prevent infections substances
- Clean hands can stop the spread of germs from • protect the patient from possible
one person to another, and throughout an entire microorganisms on the health-care
community worker’s hands
• Be alert for warnings of latex allergy in
When to handwash? patients
2. Laboratory gown - worn to protect the clothing and
- At the end of each work/school period skin of health-care workers from contamination by
- Before each break patient body substances
- Before eating or preparing food • Prevent the transfer of microorganisms out
- After going to the restroom of patient room
- Whenever hands are dirty or contaminated 3. Masks, Goggles, and Face Shields
- After completing lab work, and before leaving the • worn to protect against inhalation of
laboratory. droplets containing microorganisms from
- After removing gloves. infective patients
- Before eating, drinking, applying makeup, and • worn to protect the mucous membranes of
changing contact lenses, and before and after the mouth, nose, and eyes from splashing
using the lavatory. of body substances
- Before all activities involving hand contact with
mucous membranes or skin breaks. DONNING PROTECTIVE PERSONAL EQUIPMENT
- Immediately after accidental skin contact with
blood, body fluids, or tissues. 1. Gown is put on first and tied at the neck and waist
2. Put face protection over nose and mouth
Healthcare workers MUST follow stricter hand 3. Masks with ties are fastened at the top, adjusted
washing process (5 Moments of Hand Hygiene by to the nose and mouth, tied at the neck and
WHO) refitted.
4. When needed, googles and face shields are put
1. Before touching a patient, on after the mask
2. Before clean/aseptic procedures, 5. Gloves are put on last and securely pulled over
3. After body fluid exposure/risk the cuffs of the gown
 DOFFING PROTECTIVE PERSONAL EQUIPMENT HOSPITAL ORGANIZATIONS

1. Since gloves are the most contaminated, they are - Phlebotomists may be scheduled to work at one of
removed FIRST these areas or patients from these areas may be
2. The first glove is pulled off using the gloved hand, referred to the laboratory for sample collection
so it will end up inside in the gloved hand - May range in size (in terms of bed capacity)
3. Remove the second glove by sliding the ungloved - May vary in extent of services provided
finger inside of the glove and remove w/o touching
the outside of the glove CLASSIFICATION OF HOSPITALS
4. Dispose in a biohazard container
5. Untie the gown and remove it by touching only the ACCORDING TO Government
inside of the gown OWNERSHIP
6. Dispose of the gown in biohazard container - Created by law
7. Remove the mask only touching the ties or bands
8. Unfasten the lower tie first so that the mask will - May be under: National
not fall forward while removing the lower tie. Government, LGU, DOH,
Dispose in a biohazard container State Universities and
Colleges
LESSON 2: UNDERSTANDING PHLEBOTMY
Private
Phlebotomy
- Owned, established, and
- incision or a puncture into a vein in order to obtain operated with funds from
blood donation, principal,
- One of the oldest medical procedures, dating back investment, or other means
to the early Egyptians and was termed as by any individual,
“bloodletting”. corporation, association, or
- Greek = “Phleb” (vein) and “tomia” (to cut) organization

Evolution of Phlebotomy ACCORDING TO General

SCOPE OF SERVICES
- Hippocrates believed that disease was caused by - equipped with the service
an excess of body fluids, including blood, bile, and capabilities supporting board
phlegm, and that removal of the excess would certified/ eligible medical
cause the body to return to or maintain a healthy specialists in, but not limited
state. to the following:
- was considered one way to effectively cure the
body of most ills • Clinical Services
- Techniques for bloodletting: • Emergency Services
• suction cup devices with lancets • Outpatient Services
• application of blood sucking worms, called • Ancillary and
“leeches,” Support Services
• barber surgery, in which blood from an
incision produced by the barber’s razor Specialty
was collected in a bleeding bowl.
- Bloodletting is now called “therapeutic - May be devoted to the
phlebotomy” and is used as a treatment for only a treatment of the following:
small number of blood disorders such as
hemochromatosis. 1. A particular type of illness
or for a particular condition
Phlebotomy at present requiring a range of
treatment.
- Primary role of phlebotomy is the collection of
blood samples for laboratory analysis to diagnose 2. Patients suffering from a
and monitor medical conditions. particular disease of a
- Because of the increased number and complexity particular organ or group of
of laboratory tests, phlebotomy has become a organs.
specialized area of clinical laboratory practice and
has brought about the creation of the job title 3. Treatment of patients
“phlebotomist.”
belonging to a group such as
children, women, elderly or
REVIEW OF HEALTHCARE FACILITIES others
 PHYSICIAN OFFICE LABORATORIES must be proven in a
malpractice suit
- Consist of several primary care physicians or may 4 factors must be proven to
specialize in a particular medical specialty claim negligence
- Phlebotomists employed here may be responsible 1. Duty
for processing and packaging samples to be sent 2. Breach of duty
to the hospital laboratory 3. Causation
4. Damages
HEALTH MANAGEMENT ORGANIZATIONS (HMOS) Defamation - spoken or *Be wary of the following
written words that can that may cause the patient
injure a person’s to file
- Managed care group practice centers that provide
reputation malpractice/negligence:
a large variety of services. 1. Nerve injury
- Phlebotomists are employed as part of the clinical 2. Hemorrhage
laboratory staff - From accidental
arterial puncture
REFERENCE LABORATORIES - From inadequate
pressure to the vein
- Large, independent reference laboratories contract 3. Drawing from
with health-care providers and institutions to inappropriate
perform both routine and highly specialized tests. locations
- Phlebotomists are hired to collect samples from 4. Injuries occurring
patients referred to the reference laboratory when a patient
faints
BLOOD DONOR CENTERS 5. Death of a Patient
caused by
- Phlebotomists collect, label and prepare blood, misidentification of
plasma and other components for transfusions a patient or sample
Libel - false defamatory
PATIENTS RIGHTS & TORTS writing that is published
Slander - false and
malicious spoken word
A. Patient’s rights (DOH)
Invasion of Privacy - is
1. Right to Appropriate Medical Care and
the violation of the
Humane Treatment.
patient’s right to be left
2. Right to Informed Consent.
alone
3. Right to Privacy and Confidentiality.
and the right to be free
4. Right to Information
from unwanted exposure
5. Right to Choose Health Care Provider and
to public view.
Facility
6. Right to Self-Determination
7. Right to Religious Belief CLINICAL LABORATORY & HIERARCHY
8. Right to Medical Records
9. Right to Leave Anatomical Area
10. Right to Refuse Participation in Medical
Research a. Cytology - process and examine tissue and body
11. Right to Correspondence and to Receive fluids for the presence of abnormal cells
Visitors b. Histopathology/ Histology Section - process and
12. Right to Express Grievances stain tissue from biopsies, surgery, autopsies, and
13. Right to be informed of His Rights and frozen sections
Obligations as a Patient c. Cytogenetics - Chromosome studies are
performed to detect genetic disorders
B. Tort Law - wrongful act committed by one person
against another that causes harm to the person or Clinical Area
his or her property
a. Hematology - Cellular elements, red blood cells
INTENTIONAL TORT UNINTENTIONAL TORT (RBCs), white blood cells WBCs), and platelets
Assault - threat to touch Medical Malpractice - (Plts) are enumerated
another person without misconduct or lack of skill b. Coagulation - Overall process of hemostasis is
his or her consent and by a health-care evaluated
with the intention of professional that results in c. Clinical chemistry - May perform electrophoresis,
causing fear of harm injury to the patient. therapeutic drug monitoring and enzyme
Battery - actual harmful Negligence - as failure to immunoassays to measure substances
touching of a person give reasonable care by the d. Blood Bank (Immunohematology) - blood may be
without his or her consent health-care provider, collected, stored, and prepared for transfusion;
 blood-typing and antigen and antibodies 15. Evaluation of protocols associated with sample
procedures collection
e. Serology (Immunology) - Performs tests to 16. Performing electrocardiograms
evaluate the body’s immune response 17. Performing measurement of patient’s vital signs
f. Microbiology - Responsible for the identification of 18. Collection of arterial blood samples
pathogenic microorganisms and for hospital 19. Collection of samples from central venous access
infection control devices (CVADs)
g. Urinalysis - Routine screening procedure to detect
disorders and infections of the kidney and to CHARACTERISTICS OF PHLEBOTOMIST
detect metabolic disorders
h. Phlebotomy 1) Dependable, cooperative, committed
i. Sample Processing 2) Compassionate, courteous, respectful
3) Integrity, honesty, competence
Laboratory Personnel 4) Organized, responsible, flexible
5) Neat appearance (Clothing, Hygiene)
1. Pathologist - Acts as a consultant to physicians; 6) Communication
Has direct responsibility all areas of the laboratory • Verbal Skills
2. Chief-Medical Technologist - Responsible for • Nonverbal Skills - body language
overall technical and administrative management 7) Respecting Cultural Diversity
of the laboratory
3. Technical Supervisor - MLS with experience and LESSON 3: PHLEBOTOMY TECHNIQUES – DERMAL
expertise related to the particular laboratory PUNCTURE
section or sections
4. Medical Laboratory Scientist - Performs laboratory Dermal Puncture
procedures that require independent judgment and - Puncturing the skin to obtain blood from the
responsibility with minimal technical supervision capillary bed
5. Medical Laboratory Technician - Performs routine
laboratory procedures according to established Capillary - mixture of arterial and venous blood; may
protocol under the supervision of a technologist contain small amounts of interstitial and intracellular
6. Phlebotomist - Collects blood from patients for fluids
laboratory analysis
WHEN TO DO CAPILLARY PUNCTURE?
DUTIES & RESPONSIBILITIES OF A PHLEBOTOMIST

1. Correct identification and preparation of the patient - Fragile veins - usually reserved for intravenous
before sample collection therapy, chemotherapy or dialysis
2. Collection of the appropriate amount of blood by - Several unsuccessful venipunctures
venipuncture or dermal puncture for the specified - Thrombotic (increase clotting tendencies) or clot
tests forming deficiencies (slow or decrease clotting)
3. Selection of the appropriate sample containers for - No visible veins
the specified tests - Burns
4. Correct labeling of all samples with the required - Obese patients
information - Apprehensive patients
5. Appropriate transportation of samples back to the - Patients requiring home glucose monitoring and
laboratory in a timely manner point-of-care tests
6. Effective interaction with patients and hospital
personnel WHEN NOT TO DO CAPILLARY PUNCTURE?
7. Processing of samples for delivery to the
appropriate laboratory departments - When patient is severely dehydrated
8. Performance of computer operations and record- • Less blood flow in the capillaries
keeping pertaining to phlebotomy - Shock
9. Observation of all safety regulations, quality • Increase plasma leakage
control checks, and preventive maintenance - Patient has poor blood circulation
procedures - Test requires more blood
10. Attendance at continuing education programs • Examples: Erythrocyte Sedimentation
11. Monitoring the quality of samples collected on the Rate (ESR), coagulation studies, blood
units cultures
12. Performing and monitoring point-of-care testing
(POCT)
CAPILLARY PUNCTURE ORDER OF DRAW
13. Training other health-care personnel to perform
phlebotomy
1. Blood gas specimen
14. Monitoring the quality of samples collected on the
2. Slides
units
3. Ethylenediaminetetraacetic acid (EDTA) micro
collection tubes
 • Affected by platelet aggregation as well as • Large quantities of blood removed can lead to
the clotting process cardiac arrest & can rapidly cause anemia
4. Other additives
Example: heparin, sodium fluoride FINGER PUNCTURE SITES
5. Serum micro collection tubes • adults and children > 1 year of age
• fleshy areas located near the center of the third
EQUIPMENT and fourth fingers on the palmar side of the
nondominant hand
Dermal Puncture Devices • Must not be parallel to the grooves or fingerprints
to form a solid drop of blood (if not, blood will run
- Lancets from the fingers)
- Feather lancet
- Blood lancet PROCEDURE TO FOLLOW
- Auto lancet
- depth of the puncture is much less important than 1. Identify the patient
the width of the incision 2. Select a puncture site
3. Warm the site
Micro sample containers • Warming dilates the blood vessels and
increases arterial blood flow.
- Capillary tubes
• Moistening a towel with warm water (42°C) or
• microhematocrit tubes activating a commercial heel warmer and
• used to collect approximately 50 to 75 μL covering the site for 3 to 5 minutes effectively
of blood warms the site
• Red band: heparin or sodium heparin • Warming the site before sample collection
additive tubes increases blood flow as much as sevenfold,
• Blue band: plain or non-additive tubes thereby producing a sample that is very close
- Micro collection tubes (Microtainer) to the composition of arterial blood
• hold approximately 600 μL of blood o Excessive squeezing of the puncture
site (“milking”) may cause hemolysis
SITE SELECTION or increase contamination of interstitial
• heel fluid
• distal segments of third and fourth fingers 4. Disinfect the puncture site
• earlobes are not recommended • cleansed with 70% isopropyl alcohol, using a
• choice of a puncture area is based on the age and circular motion.
size of the patient • should be allowed to dry on the skin for
• points to consider maximum antiseptic action, and the residue
o accidental contact with the bone, followed may be removed with gauze to prevent
by infection or inflammation (osteomyelitis interference
or osteochondritis) • Failure to allow the alcohol to dry
o areas should not be callused, scarred, o Causes a stinging sensation for the
bruised, edematous, cold or cyanotic, or patient
infected o Contaminates the sample
o Hemolyzes RBCs
o Prevents formation of a rounded blood
drop because blood will mix with the
alcohol and run down the finger
5. Make a quick down-and-up motion with the lancet
to firmly puncture skin
• should be well supported and held firmly
w/o squeezing the puncture area
• HEEL PUNCTURE
o held between the thumb and index
HEEL PUNCTURE SITES finger of the non-dominant hand,
• newborn or infants < than 1 year with the index finger held over the
• contains more tissue than the fingers; has heel and the thumb below the heel
not yet become callused from walking • FINGER PUNCTURE
• should not be performed in other areas of the foot o finger is held between the non-
➔ can cause damages to nerves, tendons, dominant thumb and index finger,
cartilage with the palmar surface facing up
• Medial lateral plantar surface of the heel and the finger pointing downward
• Infants have small amount of blood (2-pound to increase blood flow
infant only has blood volume of 150 mL); every 10 • Newborn: only 0.35 to 1.6 mm below
mL of blood loss is equivalent to 4 mg of iron the skin
 • Adult: 3.0 mm o Patient’s date of birth
6. Collect the blood sample
• first drop of blood must be wiped away o Patient’s location
with a clean gauze o Ordering health-care provider’s name
• Blood should be freely flowing from the o Test(s) requested
puncture site ➔ Alternately applying o Requested date and time of sample
pressure to the area and releasing collection
• Use either capillary tubes or micro o Status of sample
collection tubes to collect the sample o Other information:
▪ Number and type of collection
Capillary tubes and Micropipettes tubes
▪ Special collection information
• capillary tubes and micropipettes are held Ex: Fasting – 8-12 HRS, Latex
horizontally while being filled ➔ prevent air Sensitivity
bubbles ▪ Special patient information
• presence of air bubbles limits the amount of blood Ex: Areas to be avoided in
that can be collected per tube and will interfere collection
with blood gas determinations • Identify the patient and explain the procedure to
• sealed with sealant clay or designated plastic caps be performed
- Identification is made by comparing information
Micro collection tubes obtained verbally and from the patient’s wrist ID
band with the information on the requisition form
- Ask questions that are not answerable with “yes”
• slanted down during the collection, and blood is
or “no”
allowed to run through the capillary collection
- Never verify information from an ID band that is
scoop and down the side of the tube
not attached to the patient or collect a specimen
• DO NOT SCOOP THE BLOOD
from an inpatient who is not wearing an ID band
• tip of the collection container is placed beneath the - Always ask the patient if he or she is allergic to
puncture site and touches the underside of the latex OR has had previous problems w/
drop venipuncture
• WORK QUICKLY ➔ blood that takes more than 2 • Patient can sign refused to be extracted
minutes to collect may form micro clots in an (RTE) – if it has needle phobia
anticoagulated micro collection container - Verify if the patient has fasted (normal 8-10 hrs.);
must return to basal state (ideal time to collect
LESSON 4: PHLEBOTOMY TECHNIQUES – blood)
VENIPUNCTURE
ASSEMBLY & PREPARATION OF EQUIPMENT
Venipuncture

• Most frequently performed procedure in • Must always wash your hands

phlebotomy • Gloves and PPE must be worn when performing a
• Syringe method venipuncture procedure
• Evacuated tube system (ETS) or closed system • Check equipment for defects
method • Check needle and syringe if properly screwed
• Butterfly or winged needle method • Extra tubes should be near at hand
• Do not place collection tray on patient’s bed
Vein - A blood vessel that carries blood that is low in • Needle selection is considered:
oxygen content from the body back to the heart GAUGE HUB GAUGE HUB
- Presence of deoxyhemoglobin (deoxygenated COLOR COLOR
form of hemoglobin) in venous blood makes 18g Pink 23g Dark blue
venous blood appear dark 19g Light yellow 24g Purple
- Transports blood from various regions of the body 20g Yellow 25g Orange
to the heart 21g Dark green 26g Brown
22g Black 27g Gray
VENIPUNCTURE PROCEDURE
TORNIQUET APPLICATION
PATIENT IDENTIFICIATION & PREPARATION • End points must be towards the shoulder, not
touching the puncture site.
• Initial torniquet application is 1 Minute ONLY!
• Must begin with obtaining the receipt of requisition
o Too tight - may prevent arterial blood flow
form
into the area and result in failure to obtain
- Required Information on A Requisition:
blood
o Patient’s full name
o Identification number
 o When used during palpating (preliminary • Veins of longitudinal sinus or sagittal sinus;
vein selection), must release and reapply femoral vein; saphenous vein; veins on the dorsal
after 2 minutes portion of the hand
• When the tourniquet is in place, ask the patient to • NEVER USE: veins on the underside of the wrist
clench or make a fist ➔ veins in that arm become
more prominent, making them easier to locate and SITE AREAS TO AVOID
enter with a needle
• Pumping (repeatedly opening and closing the fist) - Damaged Veins
should be prohibited → it causes muscle - Hematoma
movement that can make vein location more - Edema
difficult; it can also cause changes in blood - Burns, Scars, Abrasions and Tattoos
components that could affect test results - Arm on the same side of a Mastectomy or fistula
- Intravenous veins (for IV Therapy)
SITE SELECTION
PERFORMING THE VENIPUNCTURE
• Antecubital fossa veins
• H-shaped pattern - cephalic, median • Position the patient that is convenient and safe for
cubital, and basilic veins in a pattern that the procedure
looks like a slanted H • Place a pillow or towel under the patient’s arm for
• M-shaped pattern - cephalic, median better support and to position the arm in a straight
cubital, and basilic veins line downward
• Examine the needle
o Make sure the bevel is facing up (BEVEL
UP)
o Make sure that the hypodermic needle is
attached
• Palpate the area in a vertical and horizontal
direction to locate a large vein and to determine
the depth, direction, and size.
• Clean the site w/ 70% isopropyl alcohol in
concentric circles moving outward and allow it to
air dry (3x inner, 3x outer)
• Assemble the equipment as the alcohol is drying
• Pull the plunger back to ensure that it moves
freely; push forward to remove air in the syringe
• Inspect the needle before insertion to the puncture
site
• Ask the patient to remake a fist, and anchor the
vein by placing the thumb of the nondominant
hand 1 to 2 (or 3-4) inches above the site and
pulling the skin taut ➔ to ensure that the vein
does not fold or move
• Insert the needle into the vein at a 15–30-degree
angle
• Pull the plunger slowly to collect the appropriate
amount of blood
• Must remove the torniquet first before needle
• Cover the puncture site with gauze, remove the
needle smoothly, and apply pressure
3 Major Veins • Never recap the needles (fishing method) →
Median located near the center; preferred vein Remove the needle from the syringe and discard it
cubital for venipuncture; least painful due to in the sharps container
less nociceptor & bruises less easily • Fill tubes in the correct order. Mix anticoagulated
Cephalic lateral; second choice; hard to palpate tubes as soon as they are removed from the
but fairly well anchored & the only vein transfer device.
can be felt in obese • Label the tubes and confirm identification with the
Basilic medial; not well anchored & rolls easily; patient (name, age, gender, date & time of
high risk of puncturing median collection, phlebotomist’s initials) (never pre-label
cutaneous nerve or the brachial artery the tube)
• Examine the patient’s arm to be sure the bleeding
• Leg, ankle, and foot veins are sometimes used ➔ has stopped. Put adhesive bandages/micro pore
has to have permission of the patient’s physician tapes over folded gauze square
 • Deliver the sample to the lab in satisfactory • instruct the patient to breathe deeply and
condition & all appropriate paperwork should be slowly; apply cold compresses to the
completed patient’s forehead
• If the patient vomits: stop the blood
VENIPUNCTURE COMPLICATIONS & PRE- collection and provide an emesis basin or
EXAMINATION VARIABLES wastebasket and tissues
7. Nerve injury
Sleeping & unconscious patients • Permanent injury to the median
antebrachial cutaneous nerve
• should be gently awakened • SIGNS
• Nursing personnel can assist patient ▪ Shooting pain
▪ Electric-like tingling/numbness
Unavailable patients running up or down the arm or in
the fingers of the arm
• Seek assistance from attending nurse/ nurse
station to locate patient DELAYED LOCAL COMPLICATIONS

Young & cognitively impaired patients a. Thrombosis of veins - Formation of blood clots
inside the lumen of the vein due to trauma
• Ask the patient’s nurse, relative, or a friend to b. Thrombophlebitis - Inflammation of the vein
identify the patient caused by thrombus
c. Hematoma - Blue or black skin discoloration
PATIENT COMPLICATIONS commonly due to repeated trauma or puncture of
the veins
IMMEDIATE LOCAL COMPLICATIONS
OTHER COMPLICATIONS
1. Fainting (Syncope)
• spontaneous loss of consciousness Collection Attempts - when blood is not obtained from
caused by insufficient blood flow to the the initial venipuncture, the phlebotomist should select
brain another site. Repeat the procedure using a new needle
• SIGNS:
▪ Paleness Of the Skin Iatrogenic Anemia - to a condition of blood loss caused
▪ Hyperventilation by treatment; can occur when large amounts of blood are
▪ Lightheadedness removed for testing at one time or over a period of time.
▪ Dizziness
▪ Nausea Errors in inserting the needle
▪ Feeling Of Warmth/Cold
▪ Clammy Skin o Bevel too far, needle partially inserted
2. Failure of blood to enter the syringe due to: o Remedy: Change the position of the
a. Excessive pull of plunger ➔ collapsed needle, move needle forward or backward
vein o Vein may be deeper or needle have
b. Going through the vein reaching the penetrated too far
musculature o Bevel against the vein wall
c. Very small angle of entry o Remedy: Adjust the angle
3. Hemoconcentration Or Venous Stasis o Needle on the side of the rolled vein
• Increase in the number formed elements o Remedy: Re-anchor the vein
in blood due to decrease plasma volume o Vein rolled away from the point of the
• Happens on prolonged tourniquet needle and puncture site
application o Collapsed vein
4. Seizures o Remedy: Pull plunger slowly
• Tourniquet and needle should be o Vacuum too great or plunger pulled
removed, pressure applied to the site, and quickly
summon help. o Torniquet is too tight or too close to the
• Restrain the patient only to the extent that site
injury is prevented.
• Document the incident
5. Petechiae
• Small, nonraised red hemorrhagic spots
• May have prolonged bleeding following
venipuncture
6. Vomiting
 OTHER IMPORTANT NOTES TO REMEMBER

1. If hematoma forms under the skin adjacent to the

puncture site, release the torniquet to the puncture site and
withdraw the needle immediately then apply firm pressure

2. If blood is bright red (arterial blood) rather than dark red

(venous blood), apply firm pressure for more than five
minutes

3. Arm must not be bent after extraction

⎯ Bending of the arm may cause ecchymoses

o Bruising or discoloration caused by
COMMON DIFFICULTIES ENCOUNTERED DURING
seeping of the blood underneath the skin
COLLECTION AND PROCESSING OF BLOOD
4. Dispose sharps in a red puncture proof sharps container
Hemolysis (MUST BE AVOIDED!)

- invalidates determination due to color change 5. Dispose other infectious wastes in a yellow bag
- Most constituents, such as SGOT, LDH, Acid
Phosphatase and Potassium are present in large 6. Labelling must be done after collection
amount in erythrocytes
- directly interfere in a chemical determination by ⎯ Name of patient
inhibiting an enzyme such as lipase ⎯ Age
⎯ Gender
Lipemia or Lactescense ⎯ Date and time of collection
⎯ Initials of phlebotomist
- caused by transient rise in chylomicrons following
a meal containing fat 7. If antiseptic is not allowed to dry before needle insertion
- causes interference with large number of chemical
analyses because of turbidity ⎯ Burning or tingling sensation
- disturbs investigations in: ⎯ Hemolysis
o amylase ⎯ Minimize the effect of the antiseptic
o bilirubin
o protein
8. Torniquet application
o SGOT
o SGPT
⎯ Must not be longer than 1 minute (< 60 seconds)
SYRINGE METHOD ORDER OF DRAW ⎯ If torniquet application is too near, vein may
collapse
- The order of draw as recommended by the CLSI ⎯ If torniquet application is too far, ineffective
for both the evacuated tube system and when
filling tubes from a syringe is: 9. Patient identification is the most important step
COLOR ADDITIVE INVERSIONS
Yellow, Sodium polyanethol
blood sulfonate (SPS),
8
culture acid citrate dextrose
bottles (ACD)
Light blue Sodium citrate 3-4
a. No additive a. 0
– glass tube
Red
b. Clot activator – plastic b. 5
tube
Clot activator, gel
Gold 5-6
separator
Light
Lithium heparin 8-10
green
Green Heparin 8-10
Ethylenediaminetetraacet
Lavender 8-10
ic acid (EDTA)
Potassium oxalate,
Gray 8-10
sodium fluoride