PHLEBOTOMY

OBJECTIVES
1. Theory and practice of phlebotomy
2. How to interact professionally with
the patient
3. Occupational health hazard and the
appropriate safety precaution
4. Ideal blood collection site during
venipuncture
5. Materials to prepare during
venipuncture
6. Different phlebotomy procedures
7. Complications that may occur
THEORY AND PRACTICE OF PHLEBOTOMY
-

Ancient practice of blood letting

Withdraw of blood from a vein, artery
or the capillary bed for lab analysis
or blood transfusion
Venipuncture is under phlebotomy

PHLEBOTOMIST
-

1. Confidentiality
- Avoid gossiping about the patient
2. Attitude
- Tone of voice and facial expression
will determine how patient will
respond to you
- Always be polite, friendly, calm and
considerate
3. Image
- Appearance
- Your personal appearance will also
affect the impression
4. Safety
BLOOD BORNE PATHOGENS
-

Trained to collect blood and other

specimens
Prepare specimen for testing
Interacts with the patient and
healthcare professionals
Plays a vital role in patient
management

LAB WORKFLOW CYCLE

Lab test
ordered

PROFESIOLANLISM

Order
received

Prepare the
necessary
things to be
used

Infectious microorganism which live

in bloodstream
You can be exposed to: HEPA B,
HIV, HEPA C

SAFETY PRECAUTIONS
1. Standard precautions
- Treat all body fluids as potentially
infectious
- Semen, vaginal discharge, saliva,
sputum, peritoneal, pericardial,
pleural fluids
- Sweat & tears are not infectious
2. Personal Protective Equipment
- Lab coat, gloves, face masks

Transport
specimen
back to the
lab

Draw blood
and label

Identify
patient

Access and
process the
specimen

Perform test

Result
reported to
the doctor

Treat

3. Hand washing
- Most important infection control
measure
- HAPPY BIRTHDAY 3X: considered as
adequate
- Wash hands before, after and
between all patient contacts
- Be sure to turn off faucets using a
paper towel
- Remove rings
- Stand by the sink but dont touch it
- Apply soap and rub
- Both sides between fingers and
around knuckles, under the
fingernails

Rinse in a downward motion

Dry hand by paper towel

4. Hazardous waste disposal

- All needles and other sharps must be
disposed properly.
5. Needle stick prevention act
- Safety devices should always be
encouraged

SERUM
-

BLOOD COLLECTION SITES

-

common sites: all located at the

antecubital fossa (best area to do
venipuncture)
a) Median cubital: Best vein to
target, well anchored, prevent
the vein from rolling
b) Cephalic: potential for rolling
c) Basilic: last option, potential
for rolling and very painful

Centrifuged whole blood with no

anticoagulant
Contains same substance as plasma
except for the coagulation proteins
because they are left behind in the
blood clot

EQUIPMENTS FOR VENIPUNCTURE

1. Phlebotomy tray
- Tubes, syringes, needles, cappilets,
alcohol swab, sharp collector,
lancets, vacutainer set
- Always filled out, organized and
sanitized

BLOOD COLLECTION TUBES

BLOOD COMPONENTS
-

Circulating Whole Blood is a mix of

plasma and cellular components

Glass or plastic with a rubber stopper

It has a vacuum so that blood will
flow into the tube
Anticoagulated
Rubber stoppers are also color coded
It will indicate a different kind of
anticoagulant

1. RED
- No anticoagulant
- For Blood Bank, Chemistry,
Toxicology, Serologic
- Dont invert after filling

PLASMA
-

Centrifuged whole blood

Plasma, buffy coat (wbc and platelet)
, rbc

BLOOD CLOT
-

When a blood sample is left standing

without anticoagulant

2. LAVENDER
- Anticoagulant: EDTA ( Ethylene
Diamine tetraacetic acid)
- Hematology studies
- Glycosylated haemoglobin
- Should be completely filled

3.
-

Must be inverted after filling (FIGURE

OF 8 [8-10 times])

LIGHT BLUE
Anticoagulant: Sodium Citrate
Coagulation studies (clotting studies)
Invert immediately after filling

4. GREEN
- Anticoagulant: Sodium/Lithium
Heparin
- For test requiring whole blood or
plasma for the detection of blood
ammonia levels

5. GRAY
- Inhibitor for glycolysis +
Anticoagulant
- Inhibitor: Sodium Flouride +
Potassium oxalate (PLASMA)
- Na EDTA + NaFl (PLASMA)
- NaFl (SERUM)
- For glucose, lactate and alcohol
determination

7. BLACK
- Anticoagulant: Citrate
- For Erythrocyte Sedimentation Rate

8. ROYAL BLUE
- Only the top is colored royal blue but
the anticoagulant is dictated by the
label
- Heparin (green), Na EDTA (lavender)
or no anticoagulant (red)
- Designed to contain no
contaminating substances
- For trace elements and toxicology
studies

BLOOD CULTURE BOTTLES

-

Blue: aerobic (adult)

Lavender: anaerobic (adult)
Pink: pedia

6. YELLOW
- As a blood culture bottle containing
antibiotic removing device
- Or used in other test aside from
blood culture
- Anticoagulant: Acid citrate dextrose
- Inactivates complements, DNA
studies, paternity testing, HLA
phenotyping
SAFETY

Rubber stopper and plastic shield to

prevent accidental spill

SIZES

Size= gauge (Bore diameter)

The larger the needle the smaller the
gauge number
21 or 22 are used

Adult: 3-10 ml
Pedia: 2-4 ml
Tubes for fingersticks or heelsticks or less
It contains Expiration date, amount of blood
to be dispensed
VACUTAINER SYSTEM
-

It can be used for multiple tubes

HOLDERS: A plastic holder must be used

with the evacuated tube system

NEEDLE COMPONENTS
-

Tip bevel up

SINGLE DRAW NEEDLES

-

Needles that come up with syringes

MULTIPLE DRAW NEEDLES

-

Needles that come up with the

vacutainer system

NEEDLES WITH BUILT IN SAFETY DEVICES

NEEDLE HOLDERS WITH BUILT IN
PROTECTION

SYRINGES: tip, barrel, plunger

An internal blunt needle that is

activated with pressure once the last
tube has been filled
Automatically move forward
significantly decreasing the risk for
needle stick injury

BUTTERFLY NEEDLE
-

Winged infusion set

Difficult venipunctures including
pediatric draws
With a syringe or a holder and
vacuum collection tube system
21,23,25 gauge

SYRINGE WITH BUILT IN SAFETY DEVICES

BUTTERFLY WITH BUILT IN SAFETY

FEATURES
NEEDLE GAUGE: Black- 22, Green-21

Number one cause of needle stick

injury

LANCETS
-

Difficult venipunctures including

pediatric draws

OTHER MATERIALS:
-

TOURNIQUES
STERILE ALCOHOL PADS
BANDAGING MATERIALS: micropore
GLOVES: worn for all procedures
requiring vascular access, nonpowdered latex gloves
SHARP DISPOSAL BIN
MARKING PEN

TECHNIQUE OF VENIPUNCTURE
1. GREETING
- Always greet the patient in a
professional friendly manner
- Good initial impression will earn the
patient trust and makes it easier and
more pleasant to draw a good
specimen
- Identify the patient correctly
- Identify yourself
- Good verbal, listening skills
2. PATIENT IDENTIFICATION
- Name, medical record number, date
of birth or order/ requisition match
those on the patient armband
- Verify the name of the patient by
asking his/her full name
- Properly identify patient and
specimen labelling
- Never rely in the patients name on
the door or above the bed. Patients
are frequently moved from one room
to room
3. POSITION THE PATIENT
- Comfortable position
- Avoid hyperextending the elbow
(difficult palpation)
4. APPLYING THE TOURNIQUE

3-4 Fingerbreadths above the elbow

Should be tight enough to stop the
flow of blood
1-2 minutes
Make a fist and not pumping because
it can cause hemoconcentration

5. CHOOSE A SITE
- Median cubital vein
- If not accessible use cephalic or
basilica vein
- If not accessible: veins on the back of
the hands
- Use a much smaller needle for
smaller veins
- Non dominant hand for palpation of
the vein
NEVER DRAW FROM THESE AREAS
-

Scarred, abraided or inflamed skin

Arms containing IV catheters :
Pricking or close the unimportant IV
line
Edematous sites (prick)
Occluded or sclerotic veins (prick or
access other veins)
Shunts/ fistula: can dislodge the AVF

6. CLEASING THE SITE

- Isopropyl alcohol swab
- Outward expanding spiral starting
with the actual venepuncture site
- Allow the alcohol to dry (wet area
can cause painful venepuncture)
7.
-

ATTACH NEEDLE HOLDER

Insert needle in 15 degree angle
Insert the tube
Correct Blood to anticoagulant ratio

8.
-

BLOOD WONT FLOW

May not be in the vein
Through and through
Vein not hit
Needle is in the wall of the vein

TROUBLESHOOTING
Push the needle forward or backward
Adjust the angle
Loosen the tourniquet
Try another tube
Re-anchor the vein: Hold the vein in
two sides and guide your needle

OTHER PROBLEMS
Hematoma

Fingerstick should not be performed

in children under 1 year old instead
do heelstick

FINGERSTICK
Arterial blood collected: apply firm
pressure for more than 5 mins.
Make sure bleeding has stopped
before leaving the patient

MULTIPLE TUBE COLLECTION

4th (ring)/ middle finger

Puncture should be done
perpendicular to the finger print
Discard the first drop of blood
(contain tissue fluids)

ORDER OF DRAW: Vacutainer system

To avoid the contamination of the
anticoagulant from other tube.
I.
II.
III.
IV.
V.

Sterile/ Blood cultures

Blue
Red
Serum separator tube (yellow)
Other:
a. Green
b. Lavender
c. Gray
d. Yellow
e. Black
9. REMOVING THE NEEDLE
- Release the tourniquet before
withdrawing the needle
- Withdraw needle in a single quick
movement
- Apply pressure
- Bandage
- Dispose sharps and hazardous waste
in proper containers
- Label specimen at the bedside (first
and last name of the patient, date
and time of collection, initials of the
phlebotomist)
- Wash hands
10.THANK THE PATIENT

SYRINGE SPECIMEN COLLECTION

-for patients with delicate veins
FINGERSTICK-SPECIMEN COLLECTION
-

Safety lancet : manufactured to

control the depth and to minimize
trauma

HEELSTICK
-

Small children and infants

Use the sides of the foot
Discard first drop of blood
Dont apply adhesive tape or
bandages because it can cause
contact dermatitis to the baby

BUTTERFLY
-

Same principle used

WHAT TO DO?
1. PATIENT REFUSING BLOOD WORK
- Convince the patient
- Inform the nurse and the patient will
be asked to sign a refusal for
venipuncture
2. FAINTING
- Lie down and put a pillow beneath
the knees
- Monitor pulse rate and blood
pressure
- If the patient is seated: Place the
head between the knees
- Apply cold compress

3.
-

UNSATISFATORY SPECIMENS
Misleading results
Rejected
Do another venipuncture
CAUSES: HEMOLYZED, CLOTTED,
INSUFICIENT, MISLABLED

HEMOLYSIS
-

Too small needle for a relative bigger

vein
Pulling the plunger too rapidly
Dispensing the blood to the tube
rapidly
Shaking of the tube too hard

CLOT
-

Inadequate mixing
Delay in expelling of blood

INSUFICIENT VOLUME
-

Vein collapse
Needle coming out
Loss of vacuum in the tube

LABELLING ERRORS
-

Most common cause of errors

Immediately rejected
CAUSES: failure to identify the
patient correctly, not labelled the
specimen properly after collection

10 COMMANDMENTS IN
VENIPUNCTURE
1. Thou shall protect
thyself from injury
2. Thou shall identify thy
patient
3. Thou shall stretch the
skin of the puncture
site
4. Thou shall puncture
skin at about a 15
degree angle
5. Thou shall glorify the
median vein
6. Thou shall invert tubes
containing
anticoagulant
immediately after
collection
7. Thou shalt attempt to
collect specimen only
from an acceptable
site
8. Thou shall label
specimen at the bed
side
9. Thou shall know when
to quit
10.Thou shall treat
patient like they are
family.