PHLEBOTOMY

TECHNIQUES
PRINCIPLES IN MEDICAL LABORATORY SCIENCE 2
MLS Faculty
San Pedro College
STEPS IN BLOOD COLLECTION
1.Prepare accessioning order for the patient
2.Greet and identify the patient
3.Verify diet/drug restrictions and allergies
4.Wash hands, assemble supplies, and inspect equipment
5.Reassure the patient
6.Position the patient
7.Verify paperwork and tubes
8.Apply the tourniquet
STEPS IN BLOOD COLLECTION
9. Cleanse the venipuncture site
10. Put on gloves
11. Perform the venipuncture
12. Fill the tubes in the correct order of draw or fill the syringe
13. Remove the tourniquet
14. Dispose of sharps in the proper container.
15. If a syringe was used, fill the tubes using a transfer device in
the correct order of draw.
STEPS IN BLOOD COLLECTION
16. Label the tubes
17. Chill the sample or protect it from light (only for certain
tests)
18. Remove gloves
19. Check on the status of the patient for reactions to
phlebotomy
20. Eliminate diet restrictions
21. Time-stamp or computer-verify paperwork
22. Send the correctly-labeled tubes to the proper laboratory
departments
SKILLS USED IN APPROACHING
THE PATIENT

•SOCIAL SKILLS
•ADMINISTRATIVE/CLERICAL
SKILLS
•TECHNICAL SKILLS
 Social Skills
▪ Always be polite and friendly
with patients even if they are
rude or inconsiderate.
▪ Always introduce yourself to the
patient with your first name and
the procedure you will perform.
▪ The reputation of the entire
laboratory rests with the
phlebotomist.
 Administrative/Clerical Skills
• Used constantly and contribute to the most errors in the
health setting
• Clerical errors in result reporting and sample identification
• Drawing the correct patient’s blood and labeling it with the
patient’s name
• Area where numerous errors occur
 Technical Skills
•Obtaining blood successfully with minimal pain
•Venipuncture
•Capillary puncture
•Butterfly collection
•Arterial samples
 STEP 1:
Prepare accessioning
order for the
patient.
 PREPARE ACCESSIONING ORDER FOR THE PATIENT

•Blood collection legally begins with the test request

•First step for the pre-analytical or pre-examination
phase
•Requested by physicians and other qualified health
personnel
 TEST REQUISITION
• Patient’s complete name, age, • The department where the
and date for birth work is to be done
• Patient’s identification number • Room and bed number
• Date and time the sample is to • OPD
be obtained • Other information necessary
• Type of test to be collected • Specific time of collection,
• Accessioning number fasting procedures, dietary
restrictions, allergies, etc.
• Physician’s name
• Diagnosis
 TEST REQUISITION

• MANUAL REQUISITIONS
• Written requests/checklists
• Given to phlebotomists (in-
patients) or to the patient (out-
patient)

• COMPUTER REQUISITIONS
• Eliminates legibility errors
TEST REQUISITION

• BARCODE REQUISTIONS
• Series of black stripes and white
spaces with varying widths that
correspond to letters and
numbers
• Grouped together to represent
patient names, identification
numbers, and laboratory tests
• Can be peeled of and placed on
specimens
 ACCESSION
ORDER
• ACCESSION NUMBER
• A number to identify all
paperwork and supplies
associated with each
patient
• Can be used to trace
back that sample and
patient
 IN-PATIENTS
• Computerized print-out given to the
RECEIPT phlebotomist

of OUT-PATIENTS
the • Requests slips with test orders and are
responsible in taking them to the phlebotomy
REQUEST area
Lab personnel must ensure that all
required information is in the request
 Check to see that all the
Check required information is present
and complete

Verify the tests to be

REVIEWING Verify collected and time of
collection
the Identify diet restrictions,
REQUISITION Identify equipment or other special
circumstances that must be met
prior to collection

Determine the test status or

Determine
collection priority
 STEP 2:
Approach, identify,
and prepare the
patient
 GREETING the
PATIENT
• Gains the patient’s trust
• Decreases the patient’s
anxiety
• Improve patient compliance
• Must be done in a positive
manner
• A way to create a personal
connection with the patient
PATIENT IDENTIFICATION

• Essential to accurate patient testing

• Obtaining a specimen from the wrong
patient can have serious, even fatal,
consequences
• Misidentifying a patient or specimen
can be grounds for dismissal of the
person responsible and can even lead
to MALPRACTICE lawsuit against
that person
 PATIENT
IDENTIFICATION
• Verify the name and date of
birth
• Allow the patient to state
their full name and birthdate
• Check identification
bracelets
• Check identification numbers
 PATIENT
IDENTIFICATION
• Conscious patient
• Semi-conscious, comatose or
sleeping patient
• Patient who is unconscious, too
young, mentally incompetent, or
does not speak language of
phlebotomist
• Unidentified emergency patient
 PROBLEMS in PATIENT
IDENTIFICATION
• Identification discrepancies
• Patient information does not agree with the
request or patients ID bracelet
• Missing IDs
• Sleeping patients
• Unconscious patients
• Emergency room IDs
• Identification of young, mentally incompetent,
or patients who speak another language
• Neonates and other infants
 PATIENT
PREPARATION
• Explain the procedure
• Addressing patient inquiries
• Handling patient objections
• Handling difficult patients
• Addressing needle phobia
 INTRODUCING
YOURSELF
• State your name, and your reason
• A cheerful, pleasant manner and
an exchange of small talk will
help put a patient at ease, as well
as divert attention from any
discomfort associated with the
procedure
• If you are an intern:
• Let the patient know and ask
the permission to draw blood
 OBTAINING
CONSENT

• Ask the patient’s

permission before the
procedure
• Not only for courtesy,
but is legally required
• Consent may be given
verbally or through
actions
 STEP 3:
Verify diet/drug
restrictions and
allergies
 DIET RESTRICTIONS
•FASTING
• Usually overnight
• Takes 8-12 hours
• Drinking water may not be
prohibited to avoid
dehydration
 DRUG
RESTRICTIONS
• May vary according to the tests
• Drugs may alter results
• Collection time is specified so that
enough time has passed since the
last medication dose was given
 LATEX
SENSITIVITY
• Exposure to latex can trigger life-
threatening reactions in those
allergic to it.
• All equipment used is latex-free
and that no latex items are brought
into the room
 STEP 4:
Wash/sanitize hand,
assemble supplies, and
inspect equipment
 HAND
SANITATION
• Hand hygiene plays a major role
in preventing the spread of
infection
• Gloves are usually put on after
hands were cleaned or it can be
done after cleansing the
venipuncture site
 ASSEMBLE SUPPLIES
• Choose the collection system, needle size, and tube
volume according to the age of the patient, size and
location of the vein, and amount of blood to be
collected
• Select tubes according to the tests that have been
ordered
• Select and attach the needle to the collection device
but do not remove the needle sheath (cap or cover)
at this time
• Prepare equipment for ETS, syringe, butterfly, or
capillary system of collection
• Make sure that equipment are within easy reach
 INSPECT
EQUIPMENT
• Check for expiration dates
of evacuated tubes
• Inspect tubes for any
breakage
• Verify the sterility of two-
way needles, syringe,
butterfly infusion set, and
lancet
• Move the plunger of syringe
back and forth a few times
to ensure that it moves
freely
 STEP 5:

Reassure the
patient
 REASSURE the
PATIENT
• The patient must be
reassured that the procedure
is going to be simple and only
a slight inconvenience.
• Do not tell the patient, “This
is not going to hurt.” Patients
have different levels of pain
tolerance
 STEP 6:

Position the
patient
 POSITIONING
the PATIENT
• Proper comfortable
positioning of the patient
helps them to feel more at
ease, and the phlebotomist
• Patients must be SEATED
or RECLINED position
• Because of the possibility of
fainting, a patient should
never be standing or seated
on a high or backless stool
during blood collection
 POSITIONING
the PATIENT
• Inpatients normally have
blood drawn while lying
down in their beds
• NOTE:
• A phlebotomist who
lowers a bed rail and
forgets to raise it can
be held liable if the
patient falls out of bed
and is injured.
 STEP 7:
Verify paperwork
and tubes
 STEP 8:
Apply the tourniquet
and select appropriate
venipuncture site
 APPLY the
TOURNIQUET
• Tourniquet is applied 3 TO 4 INCHES
above the intended venipuncture site to
restrict venous blood flow
• Make the veins more prominent
• Must never be left on arm for more
than a minute
• If too tight, may prevent arterial blood
flow into the area and result in failure
to obtain blood
• If too loose, its useless
 APPLY the
TOURNIQUET
• When the tourniquet is in place, ask the patient
to CLENCH OR MAKE A FIST so that the
veins in that arm become more prominent,
making them easier to locate and enter with a
needle.
• NOTE:
• PUMPING (repeatedly opening and closing the fist)
should be prohibited, as it causes muscle movement
that can make vein location more difficult; it can also
cause changes in blood components that could affect
test results.
STEPS in TOURNIQUET
APPLICATION
1. Place the tourniquet around the
arm 3–4 inches above the intended
venipuncture site.
2. Grasp one side of the tourniquet
in each hand a few inches from the
end.
3. Apply a small amount of tension
and maintain it throughout the
process.
 STEPS in TOURNIQUET
APPLICATION
4. Bring the two sides together and
grasp them both between the thumb
and forefinger of the right hand.
5. Using the left hand (thumb and
forefinger), reach over the right hand
and grasp the right side of the
tourniquet. Release that side from
the grip of the right hand.
 STEPS in TOURNIQUET
APPLICATION

6. Cross the left hand over the right hand.

7. While securely grasping 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 it into a
loop.
STEPS in TOURNIQUET
APPLICATION

8. A properly tied
tourniquet with the ends
pointing toward the
shoulder.
 STEPS in TOURNIQUET
APPLICATION

1. Wrap the tourniquet around the arm 3

to 4 inches above the venipuncture site.
2. Stretch the tourniquet tight, and cross
the ends.
3. While holding the ends tight, tuck one
portion of the tourniquet under the
other.
4. Check that the tourniquet will not come
loose. The ends of the tourniquet should
be pointed upward. Feel for the vein.
 SELECTING
A VEIN
• To locate a vein, palpate (examine
by touch or feel) the area by
pushing down on the skin with the
tip of the index finger
• When you have found a vein, roll
your finger from one side to the
other while pressing against it to
help judge its size.
• To avoid inadvertently puncturing an
artery, never select a vein that
overlies or is close to where you
feel a pulse.
 SELECTING
A VEIN
1.Upper bend of the arm
• MEDIAN CUBITAL
• CEPHALIC
• BASILIC
2.Back of the hand
3.Wrist
4.Ankle or foot
 SITES to AVOID
• Edematous arms
• Arms in casts
• Arms with IVs
• Cannulas
• Fistulas
• Areas of scarring
• Burn
• Hematoma
• Side of Mastectomy
 STEP 9:
Cleanse the
venipuncture site
 CLEANSING
the SITE
• 70% isopropyl alcohol or prepackage
alcohol swabs.
• Rub the alcohol swab in a circular motion
moving outward from the site.
• Discreetly look at the swab when finished,
if it appears excessively dirty repeat the
cleansing process with a fresh alcohol swab
• After cleansing, do not touch the site! if
the vein must be palpated again, the area
must be cleansed again.
• Allow the site to dry before inserting the
needle.
 STEP 10:

Put on gloves
 GLOVES
• Gloves are available in materials such as
latex and vinyl.
• Sterile and non-sterile gloves are
available.
• OSHA regulations require that gloves be
worn during phlebotomy procedures.
• Always wash your hands after removing
gloves.
• Be alert to latex allergies (itchy, red
hands).
 STEP 11:

Perform the
venipuncture
 ANCHORING of
VEIN
• The nondominant hand is used to
anchor (secure firmly) the vein,
while the collection equipment is
held and the needle inserted using
the dominant hand.
• This stretches the skin taut (pulled
tight or without slack), anchoring the
vein and helping to keep it from
moving or rolling to the side upon
needle entry.
 INSERTING the
NEEDLE
• Hold the prepared holder with the
bevel up.
• The needle entering the site
should not touch the thumb of the
phlebotomist.
• Position the needle in the same
direction as the vein, enter the skin
and penetrate the vein at a 15-30°
angle in one swift, smooth motion
to decrease the patient's
discomfort
 INSERTING the NEEDLE

• If you enter too slowly blood will leak out

at the puncture site creating a biological
hazard as well as obstructing your view of
the puncture site.
• The bevel of the needle should enter and
remain in the center of the vein.
• When you sense the “pop” or recognize the
lessening of resistance signaling that the
needle is in the vein, stop advancing it and
securely anchor the tube holder or syringe
 STEP 12:
Fill the tubes in the
correct order of draw
or fill the syringe
 COLLECTING the
BLOOD
• Presence of blood in the syringe
hub indicates that the vein has
been successfully entered.
• Blood flow into the syringe is
achieved by slowly pulling back on
the plunger gently with your free
hand.
• Pulling the plunger too hard will
collapse the vein
 COLLECTING
the BLOOD
• Maintain needle position while
the 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 and before putting
it down
 FILLING THE TUBES
1. Sodium polyanethol sulfonate (SPS) 5. Plasma separating tube (PST)
2. Citrate 6. Heparin
3. Non-additive 7. EDTA
4. Serum separator tube (SST) 8. Sodium fluoride or Potassium oxalate
 STEP 13:

Remove the
tourniquet
 RELEASE the
TOURNIQUET
• Release the tourniquet and ask the patient
to release the fist 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 presssure
• Cover site with cotton after removing
needle
• NOTE:
• Do not leave the tourniquet on for more
than 1 minute, or test results maybe
affected.
 REMEMBER:
Failure to remove the tourniquet
following venipuncture can cause
temporary or permanent injury to
the patient and is an act of
NEGLIGENCE.
 STEP 14:
Dispose of sharps
in the proper
container
 DISPOSAL of
SHARPS
• As soon as you remove needle
and apply pressure activate the
safety device
• As soon as needle safety device
is activated dispose of entire
assembly in a biohazard sharps
container.
 STEP 15:
If a syringe was used,
fill the tubes using a
transfer device in the
correct order of draw
 TRANSFER of BLOOD
to TUBES

• TRANSFER DEVICE
• 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.
• When the transfer is complete, the syringe
and transfer device are discarded in a
sharps container as a single unit.
STEP 16:

Label the
tubes
 LABELING of
TUBES
• Patient’s first and last names
• Patient’s identification number
(inpatient) or date of birth
(outpatient)
• Date and time of collection
• Phlebotomist’s Initials
• Pertinent additional information,
such as “fasting”
 LABELING of TUBES
• Tubes must be labeled in the presence
of the patient immediately after blood
collection, never before
• Label must be permanently attached to
the tube before leaving an inpatient’s
bedside or dismissing an outpatient.
• Any handwritten labeling must be done
with a permanent-ink pen.
 LABELING of TUBES

• If using a preprinted computer or bar-

code label, you will need to write the
date, time, your initials, and other
pertinent information on the label
immediately before or after attaching it
to the tube.
• Before leaving an inpatient, compare the
information on each labeled tube with
the patient’s ID band and the requisition
 STEP 17:
Chill the sample
or protect it from
light
 OBSERVE SPECIAL
HANDLING INSTRUCTIONS

• Place specimens that must be cooled

(e.g., ammonia) in crushed ice slurry
• Put specimens that must be kept at
body temperature (e.g., cold agglutinin)
in a 37°C, heat block or other suitable
warming device
• Wrap specimens that require protection
from light (e.g., bilirubin) in aluminum
foil or other light-blocking material or
place them in a light-blocking container
STEP 18:

Remove
gloves
 STEP 19:
Check on the status of
the patient for
reactions of
phlebotomy
 PATIENT
REACTIONS
•PAIN
•NERVE DAMAGE
•SYNCOPE
•NAUSEA
•DIABETIC SHOCK
•CONVULSIONS
 PATIENT
REACTIONS

• CARDIAC ARREST
• CONTINUED
BLEEING
• HEMATOMA
• SKIN ALLERGIES
• ANEMIA
 STEP 20:
Eliminate diet
restrictions and
thank the patient
 ELIMINATE DIET
RESTRICTIONS

•Patient is now
allowed to eat or
administering
medication may now
take place
 THANKING THE
PATIENT

•Do not forget to thank

the patient for their
cooperation for the
easier phlebotomy
procedure
 STEP 21:
Time-stamp or
computer-verify
work
 STEP 22:
Send the correctly
labeled tubes to
proper laboratory
departments
 SAMPLE
TRANSPORTATION
• Prompt delivery to the laboratory
protects specimen integrity
• Sample transport can be done by
• personal delivery
• pneumatic tube system
• arranged pickup by a courier service.
• The phlebotomist is typically
responsible for verifying and
documenting collection by computer
entry or manual entry in a logbook.