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ROUTINE
VENIPUNCTURE AND
SPECIMEN HANDLING
A lecture by:
Maximo B. Axibal, Jr.
MD FPSP
Objectives
Describe the venipuncture process:
Proper patient ID procedures
Proper equipment selection/ use
Proper labeling procedures & completion of
laboratory requisitions
Order of draw for multiple tube phlebotomy
Preferred venous access sites, & factors to
consider in site selection, & ability to differentiate
between the feel of a vein, tendon & artery
Objectives
Patient care following completion of
venipuncture
Safety & infection control procedures
Quality assurance issues
Identify the additive, its function, volume, &
specimen considerations to be followed for each
of the various color coded tubes
List 6 areas to be avoided when performing
venipuncture & the reasons for the restrictions
Objectives
Summarize the problems that may be
The Art of
Phlebotomy
PHLEBOTOMY
Procedure wherein blood is collected
Role
Roleof
ofthe
thephlebotomist
phlebotomist
PRO for the laboratory
Patients window to the laboratory
Critical link between patient, patients
SCOPE OF PHLEBOTOMY
Skin puncture
Venipuncture
Arterial puncture
Bleeding time
VENIPUNCTURE
PROCEDURE
Complex procedure (knowledge & skill)
Phlebotomist establishes a routine of her/
his own
Essential steps for successful collection
procedure:
ID patient
Assess patient's physical disposition (i.e.
diet, exercise, stress, basal state)
VENIPUNCTURE
PROCEDURE
Check requisition form for requested tests,
VENIPUNCTURE
PROCEDURE
Recognize complications associated w/
procedure
Assess need for sample recollection &/or
rejection
Label collection tubes at bedside or
drawing area
Promptly send specimens w/ requisition to
the laboratory
ORDER FORM/
REQUISITION
Requisition form must accompany each
ORDER FORM/
REQUISITION
Source of specimen (microbiology, cytology,
EQUIPMENT
Evacuated Collection Tubes:
Designed to fill w/ a predetermined vol of
blood by vacuum
Rubber stoppers (color coded according to
additive content)
Various sizes are available
Blood should NEVER be poured from 1 tube to
another (tubes can have different additives or
coatings)
EQUIPMENT
Needles
Gauge # = bore
size
For evacuated
systems, use w/ a
syringe, single
draw or butterfly
system
Holder/ Adapter
(vacutainer)
Tourniquet
Wipe off with
alcohol & replace
frequently
Alcohol Wipes
70% isopropyl
alcohol
EQUIPMENT
Povidone-iodine
NEVER be
broken, bent, or
recapped
Should be placed
in proper disposal
unit IMMEDIATELY
after use
EQUIPMENT
Gloves (latex, rubber, vinyl) to protect
ORDER OF DRAW
To avoid cross-
contamination of
additives between
tubes
Recommended
tube (yellow-black
stopper)
2nd- non-additive
tube (red stopper or
SST)
ORDER OF DRAW
3rd- coagulation tube (light blue
stopper)
NEVER the first tube drawn
If a coagulation assay is the only test
ordered, draw a non-additive tube
(red stopper or SST) first, then draw
the light blue stopper tube
ORDER OF DRAW
Last draw- additive tubes in this order:
PROCEDURAL ISSUES
PATIENT RELATIONS & IDENTIFICATION:
Phlebotomist's role (A Professional),
PROCEDURAL ISSUES
PATIENT RELATIONS & IDENTIFICATION:
Proper patient ID MANDATORY
In-patient able to respond, ask full name &
PROCEDURAL ISSUES
PATIENT RELATIONS & IDENTIFICATION:
Speak w/ the patient during the process.
VENIpuncture SITE
SELECTION
Median cubital & cephalic veins of arm (most
frequent)
Wrist & hand veins also acceptable
Areas to be avoided:
Extensive scars (burns & surgery)
Upper extremity on side of previous
mastectomy
Hematoma- If another site not available, collect
specimen distal to hematoma
VENIpuncture SITE
SELECTION
Areas are to be avoided:
IVT/ BT- collect from opposite arm if possible.
VENIpuncture SITE
SELECTION
Areas are to be avoided:
Cannula/ fistula/ heparin lock- consult 1 st
attending physician
Edematous extremities
PERFORMANCE OF A
VENIpuncture
Approach patient in a friendly, calm manner.
PERFORMANCE OF A
VENIpuncture
Position the patient (sit on a chair, lie down
PERFORMANCE OF A
VENIpuncture
Prepare patient's arm using an alcohol prep.
CLEANSE BY MOVING
ALCOHOL PREP PAD IN
CONCENTRIC CIRCLES
AWAY FROM SITE
PERFORMANCE OF A
VENIpuncture
When last tube to be drawn is filling,
remove tourniquet
Remove needle from patient's arm using a
swift backward motion
Press down on the gauze once needle is
out of the arm, applying adequate pressure
to avoid formation of a hematoma
PERFORMANCE OF A
VENIpuncture
Dispose of contaminated materials/
supplies in designated containers
Mix & label all appropriate tubes at patient
bedside
Deliver specimens promptly to the
laboratory
ADDITIONAL
CONSIDERATIONS
To prevent a hematoma:
Puncture only uppermost wall of vein
Remove tourniquet before removing needle
Use major superficial veins
Make sure needle fully penetrates upper most
ADDITIONAL
CONSIDERATIONS
To prevent hemolysis:
Mix tubes w/ AC additives gently 5-10 times
Avoid drawing blood from a hematoma
Avoid drawing plunger back too forcefully, if
ADDITIONAL
CONSIDERATIONS
Indwelling Lines or Catheters:
Potential source of test error
Most lines are flushed w/ a solution of
ADDITIONAL
CONSIDERATIONS
Hemoconcentration due to:
Prolonged tourniquet application (no > 2
minutes)
Massaging, squeezing, or probing a site
Long- term IVT
Sclerosed or occluded veins
ADDITIONAL
CONSIDERATIONS
Prolonged Tourniquet Application:
Primary effect is hemoconcentration of non-
ADDITIONAL
CONSIDERATIONS Patient
Preparation
Factors:
Therapeutic Drug Monitoring:
Pharmacologic agents have patterns of
ADDITIONAL
CONSIDERATIONS Patient
Preparation
Factors:
Effects of Exercise:
Muscular activity w/ transient & longer term
ADDITIONAL
CONSIDERATIONS Patient
Preparation Factors:
Diurnal Rhythms:
but decreased in PM
Serum Fe levels drop in AM
Check timing of variations for desired
collection point
ADDITIONAL
CONSIDERATIONS Patient
Preparation Factors:
ADDITIONAL
CONSIDERATIONS Patient
Preparation Factors:
Other Factors:
Age
Gender
Pregnancy
according to age
YOURSELF
Universal Precautions:
Wear gloves & lab coat/ gown when handling
YOURSELF
YOURSELF
TROUBLESHOOTING
GUIDELINES:
IF AN INCOMPLETE
COLLECTION OR NO
BLOOD IS OBTAINED:
Change position of
needle (Move it
forward)
May not be in the lumen
TROUBLESHOOTING
GUIDELINES:
Or move it
backward
May have
penetrated too
far
TROUBLESHOOTING
GUIDELINES:
Adjust the angle
Bevel may be
TROUBLESHOOTING
GUIDELINES:
Loosen tourniquet
Try another tube
It may be obstructing
blood flow
There may be no
vacuum in the one
being used
Veins sometimes roll
away from the point
of the needle &
puncture site
TROUBLESHOOTING
GUIDELINES:
IF BLOOD STOPS
TROUBLESHOOTING
GUIDELINES:
Needle may have
Hold equipment
RXN
SYMPTOMS
FIRST AID
Fainting
Dizziness, pallor,
Rx tourniquet
sweating,
unconsciousness
SYMPTOMS
FIRST AID
vomiting
Same
Hematoma
Swelling;
purple color
at site
Nausea/
5 min. if needed
SYMPTOMS
Tetany
Muscular
FIRST AID
twitches
Inhale &
& spasms
exhale into
paper bag
placed around
mouth & nose
separated by centrifugation
USES: Chemistries, Immunology &
Serology, BB (Xmatch)
(PST) w/ Li heparin
MODE OF ACTION: Anticoagulates w/
Li heparin; Plasma separated w/ PST
gel at bottom of tube
USES: Chemistries
remove Ca
USES: Hematology (CBC) & BB
(Xmatch); requires full draw- invert 8 X
to prevent clotting & platelet clumping
remove Ca
USES: Coagulation tests (PT & APTT),
full draw required
inactivation
USES: HLA tissue typing, paternity
testing, DNA studies
of microorganisms
USES: Microbiology - aerobes,
anaerobes, fungi
remove Ca
USES: Westergren Sedimentation Rate;
requires full draw
(required to fulfill
physician orders)
Adults (required to
chemotherapy
Some geriatric patients
Obese patients
Drug addicts
Severe burn patients
Patients w/ clotting tendencies
BB procedures
ESR
Blood cultures
Coagulation studies
lacerates venules,
arterioles &
capillaries (mixture
of venous & arterial
blood + intracellular/
interstitial fluids)
Due to Arterial
Pressure, higher
portion of blood
collected by skin
puncture is arterial
More pronounced when
skin is prewarmed
before puncture
(arterialization of
capillary blood)
Puncture Sites:
Most frequent:
Lateral surface of Heel
children
Fleshy area of distal
portion of index,
middle & ring finger
Most adults will
prefer non-dominant
hand
Precautions:
Never perform capillary puncture of:
Earlobe
Central area of the infant's heel
Finger of a small infant
Swollen, cyanotic, scarred, w/ rashes or
Precautions:
Isopropyl alcohol must DO NOT use Betadine
falsely elevate K,
phosphorus & UA
levels
PERFORMANCE OF A
FINGERSTICK
Follow steps 1- 5 as for venipuncture
Best sites: 3rd & 4th fingers of non-dominant
hand
Do not use tip or center of finger (less soft
tissue, vessels & nerves are located, & bone
closer to surface)
2nd (index) finger (thicker, callused skin)
5th finger (less soft tissue overlying bone)
PERFORMANCE OF A
FINGERSTICK
Use sterile lancet, skin puncture just off center
Puncture Sites:
Incision made should run
PERFORMANCE OF A
FINGERSTICK
Cap, rotate & invert collection device to mix
blood collected
Have patient hold a small gauze pad over
puncture site for a couple of minutes to stop
bleeding
Follow steps 14- 16 as venipuncture
BLOOD COLLECTION ON
BABIES:
Recommended location
APPROPRIATE TECHNIQUE
FOR
GRASPING FOOT FOR
HEELSTICK
BLOOD COLLECTION ON
BABIES:
Prewarm infant's heel (42oC, 3 to 5 mins) to
BLOOD COLLECTION ON
BABIES:
Use sterile blood lancet, puncture side of the
BLOOD COLLECTION ON
BABIES:
Wipe away 1st drop of blood w/ clean, dry
cotton
Newborns do not often bleed immediately,
use gentle pressure to produce a rounded
drop of blood (excessive pressure or heavy
massaging cause blood to become diluted
with tissue fluid
Fill capillary tube(s) or micro collection
device(s) as needed.
BLOOD COLLECTION ON
BABIES:
When finished, elevate heel, place a piece of
Heelstick Technique:
Inspect heel &
avoid areas w/
previous
scarring or
damage
Heelstick Technique:
Preheat area w/
commercial
heel warmer or
moist warm
washcloth
Heelstick Technique:
Grasp foot so heel
is exposed
between thumb &
index finger
Disinfect w/
alcohol
Wipe dry w/ sterile
2x2 gauze pads
Heelstick Technique:
Gently squeeze heel to
Heelstick Technique:
Wipe 1st drop
of blood to
reduce tissue
fluid
contamination
Heelstick Technique:
Allow drops to collect
Heelstick Technique:
Apply gentle
Order of Draw:
Blood gases
EDTA - Lavender
Blood film
Other additives
Clot tubes - Red top