PMLS2

• Venipuncture


  Process of collecting or "drawing" blood from the vein of patient for laboratory testing purposes
• Phlebotomist


  Possess knowledge and skills to perform venipuncture since they will perform procedure as their part of their duties and responsibilities
• Test request process


  1. The first step of the pre-examination phase is that the test result must come from a physician

  2. Request form includes information on the type of test ordered, special instruction or conditions during the pre- examination and examination phase

  3. This form will be a part of the patient's medical record and can be referred to, should issues regarding the test arise
• Types of requisitions used

  • Manual requisition
  • Computerized form
• Manual requisition


  • Have parts for request, report and billing
  • This form serves as back-up when the computerized system fails
• Computerized form


  • Includes patient information, test status and details that are useful for the test
  • Computer generated labels for the collection tube are made available with which the phlebotomist must note the time of collection and confirm the information in affixing his/her initials

  
• Required information in the requisition form


  • Name of the physician who ordered the test
  • Patient's full name including the middle initial
  • The medical record number for inpatients
  • Birthday and age of the patient
  • Room number and bed number if in patient
  • Type of test ordered
  • Date when the test is to be performed
  • Billing information (if required)
  • Test status
  • Special precaution
• Barcode


  • Barcode, which is scanned into a computer using a special device with a laser
  • The code is processed and interpreted
  • The use of these codes greatly in minimizing clerical errors
• Common test status designations

  • Stat
  • Routine
  • Timed
  • Fasting
  • Repeat
• Venipuncture steps


  1. Review and accession the test request

  2. Approach, identify and prepare the patient

  3. Verify the patient's diet restrictions and latex sensitivity

  4. Sanitize hands

  5. Position the patient, apply the tourniquet, and ask patient to make a fist

  6. Select vein, release tourniquet, and ask patient to open fist

  7. Clean and air-dry the site

  8. Prepare the equipment and put on gloves

  9. Reapply the tourniquet, uncap, and inspect the needle

  10. Ask the patient to remake a fist, anchor to vein, and insert needle

  11. Establish the blood flow, release the tourniquet, and ask the patient to open fist

  12. Fill, remove, and mix the tubes in order of draw or fill the syringe

  13. Place gauze, remove the needle, activate the safety feature, and apply pressure
• Proper "Beside Manner" And Handling Special Situations Associated with Patient Contact


  • Phlebotomists should organize the test request according to priority and preparation of necessary supplies and equipment from the collection round
  • Check for the signs and warnings (no taking of blood pressure or venipuncture in the arm)
  • Beside manner is a behavior of a health worker as perceived by the patient which is applicable to both in- and out-patient settings
  • The following practices of phlebotomist show proper beside manner: Knock on the door gently before entering the room, Make a good impression by greeting the patient warmly, Stay organized and have all the supplies available and approach the patient in a professional manner that goes well with having a neat appearance, Maintain a calm expression as most patients are afraid of blood collection, Introduce yourself and explain the procedure, Obtain the verbal or expressed consent of the patient before proceeding with the test, Remain compassionate and professional during the procedure
• Importance Of Proper Patient Identification

  • Misidentifying patients, can be a reason or cause for a phlebotomists dismissal or lawsuit against him on the ground of malpractice
  • When identifying patients, confirm the name and date of birth of the patients. It must be matched to the identification bracelet that was given
  • If the patient's fast-asleep phlebotomist should wake up the patent gently for proper identification. Ask for the help of a relative, nurse or physician in identifying the patient. Make sure to note the name of the patient to confirm his/her identity
  • If the patient is young, mentally incapacitated, or has a language barrier, a phlebotomist should ask a relative, attendant or nurse to identify the patient
  • IDS bands used for newborns or babies under 2 years old placed in the lower leg
• Patient Preparation For Testing

  • A phlebotomist should explain the test procedure to the patient and confirm that the patient understood what has been discussed
  • Informed consent advocacy, a verbal or expressed consent should be obtained before proceeding with the collection
  • Best to direct a patient's inquiries on the purpose or result of the test to the patient's nurse or physician to avoid any miscommunication
  • If the patient objects to collection, respect the right of the patient to refuse testing
  • The refusal should be noted in the test request and the authorized personnel should be informed about the refusal
  • A patient must be treated with care under all circumstances, and the phlebotomist must remain calm and professional even if the patient is being difficult or is exhibiting needle-phobia. Special attention should be given to minimize the trauma
• Verifying Fasting and Other Diet Requirements

  • Phlebotomists should verify if there are special instructions on the diet of the patient that need to be followed such as fasting for about 8 to 10 hours
  • During fasting, the patient may be allowed to drink water to avoid dehydration
  • It is best to advise the doctor if the patient has not been able to follow the fasting requirement so a decision could be made if the collection will proceed as scheduled
• Verifying Latex Sensitivity


  • A patient with an allergic reaction to latex can have life-threathening reactions upon exposure
  • It is important to check all pieces of equipment used on the patient are latex-free, and there are no latex items in the room
• Tourniquet application


  1. Place the tourniquet 3 to 4 inches or about 4 to 5 finger widths from the intended puncture site

  2. Hold one side of the tourniquet in each hand. It should be a few inches from the end

  3. Apply a little tension so that it will be snug when tied

  4. Bring the two sides together. Hold both ends between the thumb and forefinger of the right hand

  5. Reach over the right hand and grasp the right side of the tourniquet between the thumb and forefinger of the left hand and release it from the grip of the right hand

  6. Near the left index finger, cross the left end over the right. Hold both sides together between the thumb and forefinger of the left hand, close to the patient's arm

  7. While securely holding both sides, use either the left middle finger or the right index finger to tuck a portion of the left side under the right side and pull into a loop

  8. Tie the tourniquet properly with its ends pointing toward the shoulder

  9. Release Tourniquet and Ask Patient to Open Fist
• Steps in equipment preparation for different venipuncture procedure

  1. Evacuated Tube System

  2. Winged Infusion Set (Butterfly)

  3. Syringe System
• Establishing Blood Flow


  1. Press on the collection tube into the tube holder

  2. Make sure that the needle has completely penetrated the stopper

  3. Push the tube with the thumb while the middle and index fingers straddle and grasp the flanges of the tube holder slightly pulling it back

  4. Let the blood flow into the tube
• Releasing the Tourniquet and Asking Patient to Open Fist


  Release the tourniquet and ask the patient to release his/her fist
• Fill, Remove, and Mix the Tubes in Order of Draw or Fill the Syringe


  1. The phlebotomist should make sure that the required volume has been collected

  2. Tubes that contain additives must be inverted gently several times to mix the content

  3. The tourniquet must be released before removing the needle
• Place Gauze, Remove the Needle, Activate the Safety Feature, and Apply Pressure

  1. Fold a gauze square into fourths and place it lightly over the site where the needle is inserted. Do not apply pressure

  2. Remove the needle and activate the safety feature (if applicable) while simultaneously applying pressure with your free hand. The arms should be extended or raised
• Label the Tubes


  1. Patient's complete name (first and last names)

  2. Date of birth

  3. ID number (if applicable)

  4. Date and time of collection

  5. Initials of the phlebotomist

  6. Additional information such as "fasting"

  
• Pediatric Puncture


  • Special attention is necessary when performing pediatric venipuncture involving children below two years old
  • To minimize pain and trauma of the patients, this procedure should be limited to superficial veins only
• Challenges faced when dealing with pediatric patients

  • Veins that are usually small and underdeveloped making it difficult to draw blood. A considerable risk of damage could be permanent if proper procedure is not followed. There is also the risk of anemia since the volume of blood in the body is smaller
  • Dealing with the parents or guardians could also be a challenge. The phlebotomist should exhibit a warm and caring approach and it would be good to ask the parents or guardians about the child's past blood collection experience. They should be allowed to stay in the room with the child if they want to
  • The phlebotomist should take a slow approach and determine the level of anxiety of the patient to gain the latter's trust. The procedure should be explained clearly using terms that the child could easily understand, emphasizing that the young patient should keep still during the procedure. It is also useful to offer some form of reward for the patient's cooperation
• Eutectic mixture of local anesthetics (EMLA)


  Used for pain interventions. This comes in cream and oral forms and takes about an hour to take effect and anesthetize the area
• Several ways to restrain the movement of the patient


  1. An infant is wrapped in the blanket

  2. A toddler is usually seated on his/her parent's lap

  3. For children, a second person commonly leans over the child who is in a lying position
• Geriatric Venipuncture


  • Geriatric or elderly patients need special attention because they may have special conditions such as arthritis, diabetes, Parkinson's disease, stroke, atherosclerosis, and dementia, which make blood drawing a challenge
  • Another problem is their hearing, visual, or mental impairment
  • The elderly also have thinner skin and smaller muscles which cause the veins to roll easily. Note that as a person ages, his/her veins lose their elasticity, making them prone to collapse during this kind of procedure
  • The healthcare institution also has to consider safety issues like the space requirement for walkers and wheelchairs, and maintenance of non-slip clutter-free floors for the elderly. The wheels of a patient's wheelchair must be locked during the procedure
• Procedure for Venipuncture on an Elderly Patient


  1. Identify the patient properly and confirm the patient information. Ask the attendant or relative if necessary

  2. Carefully select which needle to use (short draw or butterfly needle)

  3. Apply the tourniquet carefully to make sure that the skin will not be damaged

  4. Make sure that the present site is not the site from a previous venipuncture

  5. Avoid rubbing the site vigorously during cleaning

  6. Prevent the vein from rolling by anchoring it firmly during the venipuncture

  7. Hold the pressure over the site and take note that the bleeding in the elderly patients can take a longer time to stop than in younger patients
• Dialysis Patients


  • Use the dorsum of the hand of patients undergoing hemodialysis to preserve the veins of the arms for hemodialysis access
  • The phlebotomist should comply and select another site other than the arm used with an arteriovenous (AV) fistula
• Long-term Care Patients


  • Long-term care services are provided to patients who cannot perform regular daily activities due to their health condition. These can be assisted-living with the help of relatives or friends, which could be in their private homes or in community-based rehabilitation facilities such as an adult day-care center
• Home-care Patients


  • Home health services are for patients who need medical attention and assistance from health professionals from time to time
  • Home care phlebotomists are independent, flexible, with exceptional interpersonal and organizational skills, and can carry all the necessary equipment with them during house calls
• Hospice Patients


  • Hospice care is for patients who need end-of-life care, and mostly have a prognosis of six months or less. The phlebotomist should work with extra care with these patients, treating them kindly and with respect, giving these dying patients comfort and dignity
• Pre-analytical Testing Phase


  Includes procedures such as laboratory handling and identification, which take place prior to any laboratory testing. In this phase, proper control measures are placed to avoid subsequent issues. It starts when the doctor's order is given and ends when the laboratory testing has officially commenced
• Laboratory Test


  • Is used by physicians to diagnose and monitor the presence of a disease
  • The physicians compare the results to a reference range or reference interval. This range shows the high and low limits of result values as compared to healthy individuals. Several factors are considered as part of the reference interval study or the interpretation of the data obtained
• Basal state


  Is ideal in establishing reference range since it represents the condition of the metabolism of the body early in the morning or after approximately 12 hours of fasting. This can be influenced by age, gender, and conditions of the body
• Physiological Variables that Influence Laboratory Test Results

  • Age
  • Altitude
  • Dehydration
  • Diet
  • Diurnal Variation
  • Drug Therapy
  • Exercise/IM injection
  • Fever
  • Gender
  • Jaundice
  • Intramuscular Injection
  • Position
  • Pregnancy
  • Smoking
  • Stress
  • Temperature and humidity
• Problem Areas to Avoid and Troubleshooting in the Site Selection

  • Burns, scars, and tattoos
  • Damaged Veins
  • Edema
  • Hematoma
  • Mastectomy
  • Obesity
• Vascular Access Sites and Devices

  • Arterial Line
  • Arteriovenous Shunt or Fistula
  • Blood-sampling Device
  • Heparin or Saline Lock
  • Intravenous (IV) Sites
  • Central Vascular Access Devices (CADs)
• Intravenous (IV) line


  A thin plastic tube or catheter inserted into a vein in the forearm to inject a volume of fluids into the bloodstream
• The phlebotomist should avoid collecting blood from the arm with IV because the blood collected could be contaminated with IV fluid. If blood collection is necessary, the collection site should be below the IV. Take note that collection of blood from previously known IV sites should be avoided for 24 to 48 hours.