CC LAB: PHLEBOTOMY

• Steps in blood collection:
• Prepare accessioning order for the patient
• Greet and identify the patient
• Verify diet/drug restrictions and allergies
• Wash hands, assemble supplies, and inspect equipment
• Reassure the patient
• Position the patient
• Verify paperwork and tubes
• Apply the tourniquet and select appropriate venipuncture site
• Apply the tourniquet three to four inches above the intended venipuncture site to restrict venous blood flow
• • Vein options: median cubital, cephalic, basilic, back of the hand, wrist, ankle or foot
  • Site selection in arms:
  • Median cubital vein is the first choice due to size, anchoring, pain level, and bruising likelihood
  • Cephalic vein is the second choice, large but less anchored and more painful than median cubital
  • Basilic vein is the third choice, easy to palpate but not well anchored
• Steps in tourniquet application:

  • Wrap the tourniquet around the arm three to four inches above the venipuncture site
  • Stretch the tourniquet tight and cross the ends
  • Tuck one portion of the tourniquet under the other while holding the ends tight
  • Check that the tourniquet will not come loose, with the ends pointed upward
  • Selecting a vein:
  • Palpate the area to locate a vein
  • Roll your finger against the vein to judge its size
  • Avoid selecting a vein close to a pulse to prevent puncturing an artery
• Cleanse the venipuncture site
• Put on gloves
• Reapply the tourniquet, uncap and inspect the needle
• Perform the venipuncture
• Establish blood flow, release tourniquet and open fist
• Fill the tubes in the correct order of draw or fill the syringe
• Use a transfer device if syringe method is done
• Remove the tourniquet
• Dispose of sharps in the proper container
• Label the tubes
• Chill the sample or protect it from light (only for certain tests)
• Remove gloves
• Check on the status of the patient for reactions to phlebotomy
• Eliminate diet restrictions
• Time-stamp or computer-verify paperwork
• Send the correctly labeled tubes to the proper laboratory departments
• Sites to avoid for venipuncture:

  • Edematous arms
  • Arms in casts
  • Arms with IVs
  • Cannulas
  • Fistulas
  • Areas of scarring
  • Side of mastectomy
• Steps to cleanse the venipuncture site:

  • Use 70% isopropyl alcohol or prepackaged alcohol swabs
  • Rub the alcohol swab in a circular motion moving outward from the site
  • After cleansing, do not touch the site; if the vein must be repalpated, the area must be cleansed again
  • Allow the site to dry before inserting the needle
  • To prevent contamination, do not dry the alcohol with unsterile gauze, fan the site with your hand, blow on it, or touch the site after cleaning
• Information about gloves:

  • Available in materials such as latex and vinyl
  • Sterile and non-sterile gloves are available
  • OSHA regulations require gloves to be worn during phlebotomy procedures
  • Always wash hands after removing gloves
  • Be alert to latex allergies (itchy, red hands)
• Anchoring of vein during venipuncture:

  • Nondominant hand is used to anchor the vein firmly while the collection equipment is held and the needle is inserted using the dominant hand
  • This stretches the skin taut, anchoring the vein and preventing it from moving or rolling to the side upon needle entry
• Inserting the needle during venipuncture:

  • Hold the prepared holder with the bevel up
  • Position the needle in the same direction as the vein, enter the skin at a 15-30° angle in one swift, smooth motion
  • Advancing the needle too slowly prolongs discomfort and may cause blood to leak out
  • The bevel of the needle should enter and remain in the center of the vein
  • Stop advancing the needle when you sense the "pop" or recognize the lessening of resistance indicating the needle is in the vein
• Establishing blood flow during venipuncture:

  • Presence of blood in the syringe hub indicates successful entry into the vein
  • Blood flow is achieved by slowly pulling back on the plunger gently
  • Maintain needle position while tubes or syringe are filling
  • If the tube contains an additive, mix it by gently inverting as soon as it is removed from the tube holder
• Filling tubes in the correct order of draw:

  1. Sodium polyanethol sulfonate (SPS)

  2. Citrate

  3. Non-additive

  4. Serum separator tube (SST)

  5. Plasma separating tube (PST)

  6. Heparin

  7. EDTA

  8. Sodium fluoride or Potassium oxalate

  • No transferring of blood from one tube to another
  • Do not attempt to collect a new tube if the previous one was not filled to the desired amount
• Using a transfer device if syringe method is done:

  • Transfer device is similar to an ETS holder but has a permanently attached needle inside
  • After the device is attached to the syringe, an ETS tube is placed inside it and advanced onto the needle until blood flows into the tube
  • Discard the syringe and transfer device in a sharps container as a single unit after the transfer is complete
• Removing the tourniquet and needle after venipuncture:

  • Release the tourniquet as soon as blood flows freely into the first ETS tube or is established in the syringe
  • Tourniquet must be removed before removing the needle from the arm and apply pressure
  • Apply pressure for 3 to 5 minutes or until bleeding stops
  • Do not leave the tourniquet on for more than 1 minute to avoid affecting test results
• Properly labeling tubes for blood samples:

  • Include patient's first and last names, patient's identification number or date of birth, date and time of collection, phlebotomist's initials, and pertinent additional information such as "fasting"
  • Label must be permanently attached to the tube before leaving the patient's bedside
  • Handwritten labeling must be done with a permanent-ink pen
  • Do not prelabel tubes
• Checking on the status of the patient for reactions of phlebotomy:

  • Patient reactions may include pain, nerve damage, syncope, nausea, diabetic shock, convulsions, cardiac arrest, continued bleeding, hematoma, skin allergies, and anemia
  • To prevent hemolysis, mix tubes with anticoagulant additives gently, avoid drawing blood from a hematoma, avoid drawing the plunger back too forcefully, ensure the venipuncture site is dry, and avoid traumatic venipuncture
• Eliminating diet restrictions and thanking the patient:

  • Patient is now allowed to eat or take medication
  • Thank the patient for their cooperation during the phlebotomy procedure