PMLS LAB EXAM 3 (ETS Venipuncture)

• Review and accession test request.

  Rationale:

  A test request is reviewed for completeness, date and time of collection, status, and priority. The accession process records the request and assigns it a unique number used to identify the specimen and related processes and paperwork.
• Approach, identify, and prepare patient.

  Rationale:

  The right approach for a successful patient encounter includes a professional bedside manner, being orga- nized and efficient, and looking for signs that convey important inpatient information or infection-control precautions.

  Correct ID is vital to patient safety and meaningful test results. Name, DOB, and MR number must be veri- fied and matched to the test order and inpatient’s ID band.Preparing the patient by explaining procedures and addressing inquiries helps reduce patient anxiety.
• Verify diet restrictions and latex sensitivity.

  Rationale:

  Test results can be meaningless or misinterpreted and patient care compromised if diet requirements have not been met. In such cases, consult the physician or nurse before proceeding.

  Exposure to latex can trigger a life-threatening reaction in those allergic to it, so it is vital that no latex items be used on a latex-sensitive patient or even brought into the room.
• Sanitize hands.

  Rationale:

  Proper hand hygiene plays a major role in infection control by protecting the phlebotomist, patient, and others from contamination. Gloves are sometimes put on at this point. Follow facility protocol.
• Position patient, apply tourniquet, and ask patient to make a fist.

  Rationale:

  Proper positioning is important to patient comfort and venipuncture success. Place the patient’s arm downward in a straight line from shoulder to wrist to aid in vein selection and avoid reflux as tubes are filled.

  A tourniquet placed 3–4 in. above the antecubital area enlarges veins and makes them easier to see, feel, and enter with a needle.

  A clenched fist makes the veins easier to see and feel and helps keep them from rolling.
• Select vein, release tourniquet, ask patient to open fist.

  Rationale:

  Select a large, well-anchored vein. The median cubital is the first choice, followed by the cephalic. The basilic should not be chosen unless no other vein is more prominent in either arm. Releasing the tourniquet and opening the fist helps prevent hemoconcentration.
• Clean and air-dry site.

  Rationale:

  Cleaning the site with an antiseptic such as 70% isopropyl alcohol helps avoid contaminating the specimen or patient with skin-surface bacteria picked up by the needle during venipuncture. Letting the site dry naturally permits maximum antiseptic action, prevents contamination caused by wiping, and avoids stinging on needle entry and specimen hemolysis from residual alcohol.
• Prepare equipment and put on gloves.

  Rationale:

  Selecting appropriate equipment for the size, condition, and location of the vein is easier after vein selection. Preparing it while the site is drying saves time.

  Attach a needle to an ETS holder. Put the first tube in the holder now (see step 10) or wait until after needle entry.

  According to the OSHA BBP standard, gloves must be worn during phlebotomy procedures.
• Reapply tourniquet, uncap and inspect needle.

  Rationale:

  The tourniquet aids needle entry. Pick up the tube holder with your dominant hand, placing your thumb on top near the needle end and fingers underneath. Uncap and inspect the needle for defects and discard it if flawed.
• Ask patient to remake a fist, anchor vein, and insert needle.

  Rationale:

  The fist aids needle entry. Anchoring the skin so the needle enters easily and with less pain, and keeps the vein from rolling. Anchor by grasping the arm just below the elbow, supporting the back of it with your fingers. Place your thumb 1–2 in. below and slightly beside the vein and pull the skin toward the wrist. Warn the patient. line with the vein and insert it into the skin using a smooth forward motion. Stop when you feel a decrease in resistance, often described as a “pop,” and press
• Establish blood flow, release tourniquet, ask patient to open fist.

  Rationale:

  Blood will not flow until the needle pierces the tube stopper. Place a tube in the holder and push it part way onto the needle with a clockwise twist. Grasp the holder’s flanges with your middle and index fingers, pulling back slightly to keep the holder from moving, and push the tube onto the needle with your thumb.

  Releasing the tourniquet and opening the fist allows blood flow to normalize (see step 6).
• Fill, remove, and mix tubes in order of draw.

  Rationale:

  Fill additive tubes until the vacuum is exhausted to ensure correct blood-to-additive ratio and mix them immediately upon removal from the holder using 3 to 8 gentle inversions (depending on type and manufacturer) to prevent clot formation.

  Follow the CLSI order of draw to prevent additive carryover between tubes.
• Place gauze, remove needle, activate safety feature, and apply pressure.

  Rationale:

  A clean, folded gauze square is placed over the site so pressure can be applied immediately after needle removal.

  Remove the needle in one smooth motion without lifting up or pressing down on it. Immediately apply pressure to the site with your free hand while simultaneously activating the needle safety feature with the other to prevent the chance of a needlestick.
• Discard collection unit.

  Rationale:

  According to OSHA, the needle and the tube holder must go into the sharps container as a unit because removing a needle from the holder exposes the user to sharps injury.
• Label tubes.

  Rationale:

  To avoid mislabeling errors, label tubes before leaving the bedside or dismissing the patient.
• Observe special handling instructions.

  Rationale:

  For accurate results, some specimens require special handling such as cooling in crushed ice (e.g., ammonia), transportation at body temperature (e.g., cold agglutinin), or protection from light (e.g., bilirubin).
• Check patient’s arm and apply bandage.

  Rationale:

  The patient’s arm must be examined to verify that bleeding has stopped. Just because bleeding has stopped on the skin surface does not mean that the site has stopped bleeding from the vein. The site must be checked for signs of bleeding beneath the skin. If bleeding persists beyond 5 minutes, notify the patient’s nurse or physician. If bleeding has stopped, apply a bandage and advise the patient to keep it in place for at least 15 minutes.
• Dispose of used and contaminated materials.

  Rationale:

  Materials such as needle caps and wrappers are normally discarded in the regular trash. Some facilities require that contaminated items such as blood-soaked gauze be discarded in biohazard containers.
• Thank patient, remove gloves, and sanitize hands.

  Rationale:

  Thanking the patient is courteous and professional. Gloves must be removed in an aseptic manner and hands washed or decontaminated with hand sanitizer as an infection-control precaution.
• Transport specimen to the lab.

  Rationale:

  Prompt delivery to the lab protects specimen integrity and is typically achieved by personal delivery, transportation via a pneumatic tube system, or by a courier service.