Principles of Medical Laboratory Science (PMLS 2) Any blood, body fluid, or other potentially infectious material spill

must be cleaned up using:

LABORATORY SAFETY ✓ Spill cleanup kit
✓ Common aqueous detergent
SAFETY STANDARDS AND AGENCIES ✓ 10% bleach using appropriate contact time (1 bleach: 9 water)
Occupational Safety and Health Administration (OSHA) - STEPS TO CLEAN BLOOD SPILL
Within the U.S. Department of Labor to set levels of safety and health 1. Wear PPE
for all workers in the United States. 2. Use forceps for discarding the broken glass on sharps container
Clinical and Laboratory Standards Institute (CLSI) - Nonprofits 3. Cover with absorbent paper towels
educational organization that sets voluntary consensus standards for 4. Flood area with 10% bleach solution
all areas of clinical laboratories; 5. Let sit for 10 min.
Centers for Disease Control and Prevention (CDC) - Federal 6. Clean up area with paper towels
agency that carries out mandated public health laws and reporting 7. Dispose in Biohazard bag
requirements. 8. Repeat if necessary.
College of American Pathologists (CAP) OSHA Blood-Borne Pathogens standard requires written “Exposure
TJC - The Joint Commission (formerly JCAHO) Control Plan”
ALL CLINICAL LAB SHOULD HAVE: Categories of Exposure:
• Chemical Hygiene plan a. Category I – daily exposure to blood and body fluids
• Exposure control plan b. Category II – regular exposure to blood and body fluids
• Copy of MSDS c. Category III – no exposure to blood and body fluids
Safety begins with the recognition of hazards and is achieved through Employers must offer HBV vaccine to all personnel (Category I and II)
the ff: BIOHAZARD SYMBOL
• Application of common sense
SOURCE – Hand washing, biohazardous waste
• Listen to the instructions disposal, decontamination, Specimen Bagging
• A safety-focused attitude HOST - Standard Precautions, Immunization, Healthy
• Good personal behavior lifestyle, Exposure Control Plan, Post-exposure
• Good housekeeping in all laboratory work and storage areas prophylaxis
• Continual practice of good laboratory technique. TRANSMISSION – Hand washing, PPE, Aerosol
Two primary causes of accidents: prevention, Sterile/disposable equipment, Pest Control
• Unsafe acts CHAIN OF INFECTION
• Unsafe environmental conditions Infectious Agent - Bacteria,
viruses, parasites, fungi
Safety Equipment
• Safety showers and Eyewash stations
• Fire extinguishers Susceptible Host - any person Reservoir - Dirty
surfaces/equipments, people,
especially those receiving
• Fume Hoods healthcare water, soil, animals/insects

• Biosafety Cabinets
• Complete PPE
SAFETY IN CLINICAL LABORATORY Portal of Entry - broken skin/incisions, Portal of Exit - open wounds/skin,
respiratory, mucous membranes, splatter of body fluids, aerosols
TYPES OF SAFETY HAZARD catheters and tubes
TYPE SOURCE POSSIBLE INJURY
(infections) Bacterial, fungal,
Biological Infectious agents
viral or parasitic Mode of Transmission - ingestion,
Cuts, punctures or blood-born inhalation, contact (direct or indirect)
Sharps Needles, lancets, broken glass
pathogen exposure
Chemical Preservatives and reagents
Exposure to toxic, carcinogenic CHEMICAL SPILLS: When skin contact occurs, the best first aid is to
or caustic agents
Radioactive Equipment or radioisotopes Radiation exposure flush the area with large amounts of water for at least and then seek
Ungrounded or wet equipment; medical attention.
Electronic Burns or shocks
frayed cords CHEMICAL HANDLING: Chemicals should never be mixed together
Fire/Explosive Bunsen burners, organic chemicals Burns, dismemberment
Physical Wet floors, heavy boxes, patients Falls, sprains or strains
unless specific instructions are followed, and they must be added in
BIOLOGICAL HAZARD the order specified.
• These microorganisms are frequently present in the specimens • This is particularly important when combining acid and water.
received in the clinical laboratory. CHEMICAL HYGIENE PLAN: OSHA also requires all facilities that
• CDC - Universal Precautions (1987) use hazardous chemicals to have a written chemical hygiene plan
o Blood and body fluid precautions should be consistently used (CHP) available to employees. The purpose of the plan is to detail the
for all patients following:
• Specimens should be “capped” during centrifugation • Appropriate work practices, Standard operating procedures, PPE,
Engineering controls, such as fume hoods and flammable safety
cabinets, Employee training equipment's and medical
consultation guidelines.
 STORAGE AND HANDLING OF CHEMICALS • Electrical Safety
FLAMMABLE/COMBUSTIBLE CHEMICALS - Classified according • Lock-out or tag malfunctioning electrical or mechanical
to flash point - the temperature at which sufficient vapor is given off equipment until serviced
to form an ignitable mixture with air • Know how to knock a shocked person loose using a
CORROSIVE CHEMICALS - Injurious to the skin or eyes by direct nonconductive material
contact or to the tissue of the respiratory and gastrointestinal tracts if ELECTRICAL PRECAUTIONARY PROCEDURES:
inhaled or ingested ✓ Use only explosion-proof equipment in hazardous atmospheres.
REACTIVE CHEMICALS - Spontaneously explode or ignite or that ✓ Be particularly careful when operating high-voltage equipment,
evolve heat or flammable or explosive gases such as electrophoresis apparatus.
CARCINOGENIC CHEMICALS ✓ Check for frayed electrical cords.
MATERIAL SAFETY DATA SHEET (MSDS) ✓ Promptly report any malfunctions or equipment
✓ Product name and identification ✓ Do not work on “live” electrical equipment.
✓ Hazardous ingredients ✓ Never operate electrical equipment with wet hands.
✓ Permissible exposure limit (PEL) Know the exact location of the electrical control panel for the
✓ Physical and chemical data electricity to your work area.
✓ Health hazard data and carcinogenic potential RADIATION HAZARD
✓ Primary routes of entry • Equipment and radioisotopes
✓ Fire and explosion hazards • Radiation Safety
✓ Reactivity data - All areas where radioactive materials are used or stored must be
✓ Spill and disposal procedures posted with caution signs, and traffic in these areas should be
✓ PPE recommendations restricted to essential personnel only.
✓ Handling - Radiation monitoring utilizes film badge or survey meter -
✓ Emergency and first aid procedures maximum permissible dose is 5000 mrem/year whole body
✓ Storage and transportation precautions MECHANICAL HAZARDS
✓ Chemical manufacturer’s name, address, and telephone number • CENTRIFUGES - must be balanced to distribute the load
✓ Special information section equally.
HAZARDOUS MATERIAL CLASSIFICATION o Never open the lid until the rotor has come to a complete stop
National Fire Protection o Safety locks on equipment should never be rendered
Association (NFPA) - has developed inoperable
the Standard System for providing • GLASS BEADS – help eliminate bumping / boilover when liquids
codes and standard information about are heated
the chemical solutions. • INFECTIOUS SHARPS - disposed in OSHA - approved
containers
P – Pull Pin DISPOSAL OF HAZARDOUS MATERIALS
A – Aim Nozzle FOUR (4) BASIC WASTE DISPOSAL TECHNIQUE
S – Squeeze Trigger/Lever • Flushing down the drain
S – Sweep Nozzle side to side • Incineration
• Landfill burial
• Recycling
CHEMICAL WASTE
• FLUSH WATER - soluble substances down the drain with large
quantities of water
• STRONG ACIDS AND BASES should be neutralized before
disposal
• FOUL SMELLING CHEMICALS should never be disposed
down the drain
• FLAMMABLE SOLVENTS - collected in approved containers
• FLAMMABLE MATERIAL - specially designed incinerators
FIRE/ EXPLOSIVE HAZARDS • SOLID CHEMICALS - landfill
The Joint Commission on Accreditation of Healthcare Organizations RADIOACTIVE WASTE
(JCAHO) requires that all health-care institutions post evacuation Depends on the type of waste (soluble or non - soluble), its level of
routes and detailed plans to follow in the event of a fire. radioactivity, and the radiotoxicity and half-life of the isotopes
• Laboratory personnel should be familiar with these procedures. involved
When a fire is discovered, all employees are expected to take the BIOHAZARDOUS WASTE
actions in the acronym Rescue Alarm Contain Extinguish • All biological waste (EXCEPT URINE) should be placed in
ELECTRICAL HAZARD appropriate containers labeled with biohazard symbol.
• Ungrounded or wet equipment; frayed cords • URINE: may be discarded by pouring it into the lab sink.
• The sink should be flashed also with water auer the urine has
been discarded. UNDERSTANDING PHLEBOTOMY
• Decontaminate the sink by 1:5 or 1:10 dilution of sodium PHLEBOTOMY - Defined as an incision or a puncture into a vein in
hypochlorite (bleach solution). order to obtain blood
• Incineration, inactivation, burial, chemical disinfection, • One of the oldest medical procedures, dating back to the early
encapsulation in a solid matrix Egyptians and was termed as “bloodletting”.
INACTIVATION: EVOLUTION OF PHLEBOTOMY
• Heat sterilization (250oC for 15 minutes) • HIPPOCRATES believed that disease was caused by an excess
• Ethylene Oxide (450-500 mg/L at 55-60oC ) of body fluids, including blood, bile, and phlegm, and that
• 2% Glutaraldehyde removal of the excess would cause the body to return to or
• 10% hydrogen peroxide maintain a healthy state, and the first-line treatment before all
• 5.25 hypochlorite (bleach) others: bloodletting.
• 10% (v/v with tap water) of common household bleach) - HBV (10 TECHNIQUES FOR BLOODLETTING:
minutes), HIV (2 minutes) ✓ suction cup devices with lancets – application of blood
DONNING AND DOFFING OF GLOVES ✓ leeches - sucking worms → HIRUDIN or HIRUDO THERAPY
✓ BARBER SURGERY - blood from an incision produced by
the barber’s razor was collected in a bleeding bowl.
• BLOODLETTING - now called “therapeutic phlebotomy” and is
used as a treatment for only a small number of blood disorders
such as hemochromatosis.
• BARBER POLE
o RED – arterial blood
o BLUE – blood in the veins
o WHITE – bandages
o DOWNWARD SPIRAL – aortic flow of the blood
PHLEBOTOMY AT PRESENT:
• Primary role of phlebotomy is the collection of blood samples for
laboratory analysis to diagnose and monitor medical conditions.
• Because of the increased number and complexity of laboratory
tests, phlebotomy has become a specialized area of clinical
PROPER HAND WASHING laboratory practice and has brought about the creation of the job
1. After completing lab work, and before leaving the laboratory. title “phlebotomist.”
2. After removing gloves. DUTIES OF THE PHLEBOTOMIST IN TODAY’S HEALTHCARE SETTING
3. Before eating, drinking, applying makeup, and changing contact PHLEBOTOMIST - a person trained to obtain blood samples
lenses, and before and after using the lavatory. primarily by venipuncture and micro techniques.
4. Before all activities involving hand contact with mucous Major traditional duties and responsibilities of the phlebotomist
membranes or skin breaks. include:
5. Immediately after accidental skin contact with blood, body fluids, 1. Correct identification and preparation of the patient before
or tissues. sample collection
HAND WASING STEPS 2. Collection of the appropriate amount of blood by venipuncture or
1. Wet hands with warm water. dermal puncture for the specified tests
2. Apply antimicrobial soap. 3. Selection of the appropriate sample containers for the specified
3. Rub to form a lather, create friction, and loosen debris. tests
4. Thoroughly clean between fingers, including thumbs, under 4. Correct labeling of all samples with the required information
5. Finger nails and rings, and up to the wrist, for at least 20 5. Appropriate transportation of samples back to the laboratory in
seconds. a timely manner
6. Rinse hands in a downward position. 6. Effective interaction with patients and hospital personnel
7. Dry with a paper towel. 7. Processing of samples for delivery to the appropriate laboratory
8. Turn off faucets with a clean paper towel to prevent departments
recontamination. 8. Performance of computer operations and record-keeping
pertaining to phlebotomy
9. Observation of all safety regulations, quality control checks, and
preventive maintenance procedures
10. Attendance at continuing education programs
11. Monitoring the quality of samples collected on the units
12. Performing and monitoring point-of-care testing (POCT)
 TRAITS THAT FORM THE PROFESSIONAL IMAGE OF THE GENERAL APPEARANCE GUIDELINES
PHLEBOTOMIST 1. Clothing and lab coats must be clean and unwrinkled.
DEPENDABLE, COOPERATIVE, COMMITTED 2. Clothing worn under the laboratory coat should meet institutional
requirements. Lab coats must be completely buttoned and completely
• Laboratory testing begins with sample collection and relies on the
cover clothing.
phlebotomist to report to work whenever scheduled and on time 3. Shoes must be clean, polished, closed toed, and skid-proof.
• Failure to appear or arriving late puts additional pressure on the 4. If jewelry is worn, it must be conservative. Dangling jewelry including
staff members present. earrings can be grabbed by a patient or become tangled in bedside
• Be willing to demonstrate your commitment to your job and your equipment. Many institutions do not permit facial piercings and tattoos;
cooperation to assist fellow employees. if present, they must be completely covered. Makeup must also be
• A committed phlebotomist attends staff meetings, reads conservatively applied.
pertinent memoranda, and observes notices placed on bulletin 5. Perfume and cologne are usually not recommended or must be kept to
a minimum. Many persons are allergic to certain fragrances. Remember
boards or in newsletters.
the phlebotomist works in close contact with the patient and the smell
COMPASSIONATE, COURTEOUS, RESPECTFUL of perfume can be particularly disturbing to a sick person.
• Phlebotomists deal with sick, anxious, and frightened patients 6. Hair including facial hair must be clean, neat, and trimmed. Long hair
every day. must be neatly pulled back.
• They must be sensitive to their needs, understand a patient’s 7. Personal hygiene is extremely important because of close patient
concern about a possible diagnosis or just the fear of a needle, contact, and careful attention should be paid to bathing and the use of
and take the time to reassure each patient. deodorants and mouthwashes.
• A smile and a cheerful tone of voice are simple techniques that 8. Fingernails must be clean and short. Based on the Centers for Disease
Control and Prevention (CDC) Hand washing Guidelines, artificial nail
can put a patient more at ease.
extenders are not allowed.
• Courteous phlebotomists introduce themselves to the patients
before they approach them.
COMMUNICATION SKILLS
• This also aids in identifying the patient as you can then ask them
• Good communication skills are needed for the phlebotomist to
to state their name in the same conversation.
function as the liaison between the laboratory and the patients,
• Phlebotomists must also understand and respect the cultural
their family and visitors, and other health-care personnel.
diversity of their patients.
• Cultural diversity includes not only language but also religious
THE THREE COMPONENTS OF COMMUNICATION:
beliefs, customs, and values.
To introduce them, explain the procedure, reassure the
• Do not expect every patient to respond to you in the same way patient, and help assure the patient that the procedure is being
and do not force your mannerisms and approach on them. competently performed.
VERBAL SKILLS
HONESTY, INTEGRITY, COMPETENCE Barriers to verbal communication that must be considered
include physical handicaps such as hearing impairment; patient
• The phlebotomist should never hesitate to admit a mistake, emotions; and the level of patient education, age, and
because a misidentified patient or mislabeled sample can be language proficiency.
critical to patient safety. Looking directly and attentively at the patient
Encouraging the patient to express feelings, anxieties, and
• Patient confidentiality must be protected, and patient
concerns
information is never discussed with anyone who does not have a LISTENING Allowing the patient time to describe why he or she is
professional need to know it. SKILLS concerned
• Phlebotomists must demonstrate competence in the procedures Providing feedback to the patient through appropriate
responses
they are trained to perform. Encouraging patient communication by asking question
• However, overconfidence in one’s abilities can result in serious Include facial expressions, posture, and eye contact
errors. Never perform a procedure that you have not been If you walk briskly into the room, smile, and look directly at the
NON-VERBAL patient while talking, you demonstrate positive body language.
trained to perform. SKILLS OR This makes patients feel that they are important and that you
• When faced with this situation do not hesitate to ask for BODY care about them and your work
assistance from someone more experienced. LANGUAGE Allowing patients to maintain their zone of comfort (space) is
important in phlebotomy even though you must be close to
ORGANIZED, RESPONSIBLE, FLEXIBLE
them to collect the sample.
• Phlebotomists need to organize their collection equipment and
maintain well-stocked collection tray or station. VERBAL COMMUNICATION BARRIERS
• They must also organize and prioritize their work. 1. Hearing Impairment
APPEARANCE • Speak loudly and clearly.
• Phlebotomists should be neat and should have clean-looking • Look directly at patient to facilitate lip – reading
appearance that portrays a professional attitude to the patient. 2. Patient Emotions
• Remember first impressions are lasting impressions often made • Speak calmly and slowly.
within 30 seconds and the phlebotomist represents the entire • Do not appear rushed or uninterested
laboratory staff. 3. Age and Education levels
• Avoid medical jargon, you are collecting a blood sample rather
than performing a phlebotomy.
• Use age appropriate phrases
4. Non- English Speaking EXERCISE
• Locate a hospital-based interpreter. • Increased activity of muscle enzymes
• Use hand signals, show equipment, etc. • Elevated concentration of sex hormones
• Remain calm, smiling and reassuring. • Elevated concentration of steroids
TELEPHONE SKILLS STRESS
• The phlebotomy department frequently acts as a type of • Nervous patient before sample collection may increase levels of
switchboard for the rest of the laboratory because of its location adrenal hormones, increase WBC counts, decrease serum iron,
in the central processing area. and markedly affect arterial blood gas (ABG) results.
• This is a prime example of the phlebotomist’s role as a liaison for SMOKING
the laboratory, and poor telephone skills affect the image of the • Acute effects: increase in glucose, BUN, cholesterol and
laboratory. triglycerides
To observe the rules of proper telephone etiquette: • Chronic effects: Increase in blood hemoglobin values
✓ Answer the phone promptly and politely, stating the name of the (carboxyhemoglobin) Decrease in IgG, IgA, and IgM - weak
department and your name. immune system
✓ Always check for an emergency before putting someone on hold, ALTITUDE
and return to calls that are on hold as soon as possible. • RBC counts and hemoglobin (Hgb) and hematocrit (Hct) levels are
✓ Keep writing materials beside the phone to record information increased in high-altitude areas such as the mountains where
such as the location of emergency blood collections, requests for there are reduced oxygen levels.
test results, and numbers for returning calls. AGE AND GENDER
✓ Make every attempt to help callers, and if you cannot help them, • Laboratory results vary between infancy, childhood, adulthood,
transfer them to another person or department that can. and the elderly - gradual change in the composition of body fluids.
✓ Provide accurate and consistent information by keeping current • Hormone levels vary with age and gender
with laboratory policies, looking up information published in • RBC, Hgb, and Hct values - higher in male patients
department manuals, or asking a supervisor. PREGNANCY
✓ Speak clearly and make sure you understand what the caller is • caused by the physiological changes in the body including
asking and that he or she understands the information you are increases in plasma volume.
providing. • Alcohol ingestion
VENIPUNCTURE
Phlebotomy Techniques EVACUATED TUBE SYSTEM (ETS)
• Blood is collected directly into the evacuated tube, eliminating
the need for transfer of specimens and minimizing the risk of
biohazard exposure
WHOLE BLOOD - has Plasma and formed INCLUDES:
elements (unclotted) ✓ Double-Pointed Needle
✓ Needle Holder
✓ Color-coded Evacuated tubes
BLOOD NEEDLES
SERUM • Needle size varies by both length and gauge (diameter)
• Liquid portion of clotted blood • Needle gauge: refers to the diameter of the needle bore.
• Without anticoagulant • smaller the gauge number = bigger the diameter of the needle
• Contains albumin and globulin • Needles should be visually examined before use to determine if
PLASMA any structural defects, such as nonbeveled points or bent shafts,
• Liquid portion of unclotted blood are present.
• With anticoagulant
• Contains albumin, globulin and fibrinogen
PRE-EXAMINATION VARIABLES
DIET
• The tests most affected are glucose and triglycerides
• Serum or plasma collected from patients shortly after a meal may
appear cloudy or turbid (lipemic) due to the presence of fatty
compounds such as meat, cheese, butter, and cream.
• Alcohol consumption → transient elevation in glucose and -
chronic consumption → liver function tests and triglycerides
• Caffeine → hormone levels NEEDLE HOLDERS
POSTURE • Made of rigid plastic and may be designed to act as a safety shield
• Can cause variations in some blood constituents, such as cellular for the used needle.
elements, plasma proteins, compounds bound to plasma • OSHA → holders must be discarded with the used needle.
proteins, and high molecular weight substances.
NEEDLE DISPOSAL SYSTEMS • plasma separator tubes and heparin (Green stopper tubes and
• To protect phlebotomists from accidental needlesticks by light green)
contaminated needles • EDTA (Lavender stopper tubes)
• Rigid, puncture-resistant, leak-proof disposable “sharps” • potassium oxalate/sodium fluoride (Gray stopper tubes)
containers labeled BIOHAZARD that are easily sealed and locked • thrombin clot activator (Yellow/gray or orange stopper tubes)
when full.
COLLECTION TUBES SYRINGE
• Evacuated tubes, also known as Vacutainers and are available in • Routinely used for venipuncture range from 2 to 20 mL
glass and plastic. • For single draw
• Contain a premeasured amount of vacuum for blood collection • For drawing blood from patients with small or fragile veins.
• The amount of blood collected in an evacuated tube ranges from
1.8 to 15 mL and is determined by the size of the tube and the PARTS OF A SYRINGE
amount of vacuum present.
EVACUATED TUBES SUMMARY REMINDER:
STOPPER ✓ Blood drawn in a syringe is
ANTICOAGULANT/ADDITIVE SAMPLE TYPE LABORATORY USE
COLOR immediately transferred to appropriate
Ethylenediaminetetra acetic Whole blood/
Lavender
acid (EDTA) plasma
Hematology evacuated tubes to prevent the
Whole formation of clots.
Pink EDTA Blood bank
Blood/plasma ✓ It is not acceptable to puncture the
Molecular
White EDTA and gel Plasma rubber stopper with the syringe needle
diagnostics
Light blue Sodium citrate Plasma Coagulation and allow the blood to be drawn into the
Red/gray,
Clot activator and gel Serum Chemistry
tube.
gold
Ammonium heparin
Whole
Green Lithium heparin Chemistry
blood/plasma
Sodium heparin WINGED BLOOD COLLECTION SETS
Light green, • For performing venipuncture from very small or very fragile veins
Lithium heparin and gel Plasma Chemistry
green/black
Blood bank, often seen in children and in the geriatric population
Red (glass) None Serum chemistry, • REMINDER: Always hold the apparatus by the needle wings and
serology not by the tubing.
Chemistry,
Red (plastic) Clot activator Serum
serology •
Yellow/gray, OTHER VENIPUNCTURE EQUIPMENT
Thrombin Serum Chemistry
orange ✓ Tourniquets
Potassium oxalate/ sodium Chemistry glucose
fluoride
Plasma
tests, alcohol ✓ Vein locating devices
Gray ✓ 70% isopropyl alcohol, iodine swabs
Sodium Fluoride Serum
Sodium fluoride/ Na2,EDTA Plasma ✓ 2x2 inch gauze pads
Chemistry lead
Tan K2EDTA Plasma
tests
✓ Bandage or adhesive tape
Sodium heparin Plasma Chemistry trace ✓ Phlebotomy collection tray
Royal blue
K2EDTA Plasma elements, ✓ Slides
toxicology, and
Clot activator Serum ✓ Antimicrobial hand gel
nutrient analyses
Sodium polyanethol ✓ Marking pen
Whole blood Blood bank
Yellow Sulfonate (SPS)
Acid citrate dextrose (ACD) Whole blood
VENIPUNCTURE PROCEDURE
Hematology
Black Sodium citrate Whole blood sedimentation 1. CHECKING REQUISITION FORMS
rates • provide the phlebotomist with the information needed to
Red/light
gray, clear
None Discard Tube correctly identify the patient, organize the necessary equipment,
Light Molecular collect the appropriate samples, and provide legal protection.
Sodium citrate, gel Plasma
blue/black diagnostics o Patient’s name, age and gender
Molecular
Red/green Sodium heparin, gel Plasma o Patient’s date of birth
diagnostics
Chemistry, o Patient’s location
Orange Thrombin, gel Serum
serology o Ordering health-care provider’s name
o Tests requested
ORDER OF DRAW o Requested date and time of sample collection
The order of draw as recommended by the CLSI for both the evacuated 2. GREETING THE PATIENT
tube system and when filling tubes from a syringe is: • Phlebotomists should introduce themselves and explain that they
• Blood cultures (yellow stopper tubes, culture bottles) will be collecting a blood sample.
• sodium citrate (Light blue stopper tubes) 3. PATIENT IDENTIFICATION
• serum separator tubes (Red/gray, gold stopper tubes), clot • The most important procedure in phlebotomy
activator (red stopper plastic tubes), and red stopper glass tubes
4. PATIENT PREPARATION 8. ASSEMBLING EQUIPMENT
• Positioning the Patient: supine (lying) or sitting upright positions 9. EXAMINE THE NEEDLE
• Position of the Phlebotomist: remains in the standing position for
• visually examined for any defects such as a non-pointed or rough
better and greater freedom of movement and control of the
(barbed) end.
situation
10. ANCHORING THE VEIN
• If a fasting specimen is required, confirm that the fasting order
• Place the thumb 1 or 2 inches below and slightly to the left of the
has been followed
insertion site and the four fingers on the back of the arm and pull
5. TOURNIQUET APPLICATION
the skin taut.
• Maximum amount of time the tourniquet should remain in place
11. INSERTING THE NEEDLE
is 1 minute to avoid hemoconcentration.
• bevel up, at an angle of 15 to 30 degrees depending on the depth
6. SITE SELECTION
of the vein.
• ANTECUBITAL FOSSA - The preferred site for venipuncture 12. FILLING THE TUBES
and is located anterior and below the bend of the elbow.
13. REMOVAL OF THE NEEDLE
3 MAJOR VEINS • Place folded gauze over the venipuncture site and withdraw the
• MEDIAN CUBITAL VEIN - vein of choice because it is large and needle in a smooth swift motion. Apply pressure to the site as
does not tend to move when the needle is inserted soon as the needle is withdrawn.
• CEPHALIC VEIN - usually more difficult to locate, except • Never draw out the needle without removing first the tourniquet
possibly in larger patients, and has more tendencies to move. to avoid hematoma
• BASILIC VEIN - the least firmly anchored; has a tendency to 14. DISPOSAL OF THE NEEDLE
“roll” and hematoma formation is more likely to occur.
15. LABELING THE TUBES
Quite often the veins cannot be seen but usually felt by touching or
palpating with the index finger of the non-dominant hand ✓ Patient’s name and identification number
They will reveal themselves as elastic tubes beneath the surface of the ✓ Age and Gender of the Patient
skin. ✓ Date and time of collection
ARRANGEMENT OF VEINS IN THE ANTECUBITAL FOSSA ✓ Phlebotomist’s initials
16. CHECKING THE PATIENT’S ARM
• examine the patient’s arm to be sure the bleeding has stopped.
adhesive bandages/micropore tape over a folded gauze square.
17. COMPLETING THE VENIPUNCTURE PROCEDURE
• deliver the sample to the laboratory in satisfactory condition and
all appropriate paperwork should be completed.

PATIENT COMPLICATIONS
Immediate Local Complications
Localized
Remedy: One minute application of
hemoconcentration or
tourniquet
Venous stasis
Syncope or Fainting Remedy: Let the patient lie down
• Needle Position
• Bevel Against the Wall of the Vein
Needle Too Deep/ Too Shallow
Failure to obtain blood
Collapsed Vein
H-SHAPED PATTERN - includes the cephalic, median cubital, and • Needle Beside the Vein
basilic veins in a pattern that looks like a slanted H. • Faulty Evacuated Tube
M-SHAPED PATTERN - Includes the cephalic, median cephalic, Delayed Local Complications
median basilic, and basilic veins. Formation of blood clots inside the lumen
Thrombosis of veins
of the vein due to trauma
AREAS TO BE AVOIDED Inflammation of the vein due to
• Damaged Vein • Obesity thrombus as manifested by an
• Hematoma • IV Therapy Thrombophlebitis
inflammatory reaction on the outer skin
• Edema • Heparin and Saline Locks surface
• Burns, Scars and Tattoos • Cannulas and Fistulas Blue or black skin discoloration
• Mastectomy Hematomas commonly due to repeated trauma or
7. CLEANSING THE SITE puncture of the veins
• Cleansing is performed with a circular motion, starting at the
inside of the venipuncture site and working outward in widening
concentric circles about 2 to 3 inches.
 General Delayed Complications ARTERIAL PUNCTURE: SITES OF PUNCTURE
Prevention: ✓ Radial artery
• Use of disposable syringe or ✓ Femoral artery (fem tap)
vacutainer set ✓ Brachial artery
Serum Hepatitis, AIDS
• Follow the procedures from the ✓ Scalp artery
Universal Precautions in handling ✓ Umbilical artery
infectious specimens
Other Complications MODIFIED ALLEN TEST
When blood is not obtained from the • Before performing a radial artery puncture, the Modified Allen
initial venipuncture, the phlebotomist Test is performed to determine if the ulnar artery is capable of
Collection Attempts
should select another site. Repeat the providing collateral circulation to the hand.
procedure using a new needle
Temporary or permanent nerve damage
can be caused by incorrect vein selection
or improper venipuncture technique and
Nerve Injury
may result in loss of movement to the
arm or hand and the possibility of a
lawsuit.
Pertains to a condition of blood loss
caused by treatment. An anemia can
Latrogenic Anemia occur when large amounts of blood are
removed for testing at one time or over a
period of time.
Rupture of the red blood cell membrane
releases cellular contents into the serum
Hemolyzed Samples
or plasma and produces interference
with many test results

SPECIAL BLOOD COLLECTION

COLLECTION PRIORITIES
• ROUTINE SAMPLES - are usually collected early in the morning
but can be collected throughout the day during scheduled
“sweeps” (collection times) on the floors or from outpatients.
• ASAP SAMPLES - means “as soon as possible.” The response DERMAL PUNCTURE
time for the collection of this test sample is determined by each • Also known as Capillary or Skin puncture
hospital or clinic and may vary by laboratory tests. • Blood collected by dermal puncture comes from the capillaries,
• STAT SAMPLES - sample is to be collected, analyzed, and arterioles, and venule
results reported immediately. • The method of choice for collecting blood from infants and
• FASTING SAMPLE - NPO (nothing per orem); “nothing by children younger than 2 years.
mouth” Dermal puncture may be required in many adult patients, including:
o FBS ✓ Burned or scarred patients
o Lipid Profile ✓ Patients receiving chemotherapy who require frequent tests and
• TIMED SAMPLES whose veins must be reserved for therapy
o Glucose Tolerance Tests ✓ Patients with thrombotic tendencies
o 2-Hour Oral Glucose Tolerance Test -Lactose Tolerance Test ✓ Geriatric or other patients with very fragile veins
• BLOOD CULTURE ✓ Patients with inaccessible veins
✓ Obese patients
ARTERIAL PUNCTURE ✓ Patients requiring home glucose monitoring and point-of-care
• Generally used for the determination of blood oxygen, carbon tests
dioxide tension and blood pH (Blood Gas Analysis). LANCETS
• Blood collected is called arterial blood or oxygenated blood • Sterile, disposable, sharp-pointed or bladed instrument
• Special training is required for this procedure • Punctures or cuts skin to obtain capillary blood specimen
• Tourniquet is not required • Designed for either finger or heel puncture
• After removing the needle, apply moderate pressure with 2 x 2
sterile gauze until bleeding ceases Regular Feather
• Insert needle (still attached to syringe) in stopper to prevent air Lancet Lancet
from entering needle
 PHLEBOTOMIST PREPARATION
Tenderlett Quick Heel • Phlebotomists should carefully examine the information on the
Lancets Lancet requisition form to ensure that they have the appropriate equipment to
collect all required samples as well as the skin puncture device that
corresponds to the age of the patient
PATIENT IDENTIFICATION AND PREPARATION
Tenderfoot
Unistik 2 • Patients for dermal puncture must be identified using Requisition form,
Lancet
Verbal identification, and ID band
PATIENT POSITION
• For fingerstick: Patient must be seated or lying down with the hand
BD Microtainer Contact-
supported on a firm surface, palm up, and fingers pointed downward
Activated Lancet
• For heelstick: infants should be lying on the back with the heel in a
downward position
DERMAL PUNCTURE DEVICES
SITE SELECTION
• Primary danger in dermal puncture: Accidental contact with the
The primary dermal puncture sites:
bone, followed by infection or inflammation (osteomyelitis or
• Plantar surface of the heel
osteochondritis) o infants younger than 1 year old
• To prevent contact with bone, the depth of the puncture is o heel contains more tissue than
critical. the fingers and has not yet
• The Clinical and Laboratory Standards Institute (CLSI) become callused from walking
recommends that the incision depth should not exceed 2.0 mm • 3rd and 4th fingers on the palmar side of the nondominant hand
in a device used to perform heel sticks. o performed on adults and children over 1 year of age.
MICROSAMPLE CONTAINERS Areas not to be punctured:
• Callused, scarred, bruised, edematous, cold or cyanotic, or infected
CAPILLARY TUBES
areas.
• Also known as microhematocrit tubes
WARMING THE SITE
• small tubes used to collect approximately 50 to 75 µL of blood for
Primarily required for:
the primary purpose of performing a microhematocrit test.
• Patients with very cold or cyanotic fingers
• One end of tube is sealed with • For heelsticks to collect multiple samples
plastic or clay sealants. • For the collection of capillary blood gases
• Heparinized tube (Red) with Moistening a towel with warm water (42°C) or activating a commercial heel
heparin additive warmer and covering the site for 3 to 5 minutes
• Plain Tube (Blue) no anti- CLEANSING THE SITE
coagulant Using 70% isopropyl alcohol in a circular motion.
MICROTAINER TUBES *Use of povidone-iodine is NOT RECOMMENDED for cleaning sites of dermal
• Small plastic tubes designed to hold punctures because sample contamination may elevate some test results,
including bilirubin, phosphorus, uric acid, and potassium.
approximately 600 µL of blood.
PERFORMING THE PUNCTURE
• Color coded in the same way as
While the puncture is performed, the heel or finger should be well supported
evacuated tubes.
and held firmly, without squeezing the puncture area. Massaging the area
• Some have stoppers & markings for min/max fill levels. before the puncture may increase blood flow to the area.
WARMING EQUIPMENT PUNCTURE DEVICE DISPOSAL
• Warming the site increases blood flow as much as 7 times Puncture device should be placed in an appropriate sharps container.
• Commercial Heel Warmer - A packet containing sodium SAMPLE COLLECTION
thiosulfate and glycerin that produces heat when the chemicals • First drop of blood must be wiped away with a clean gauze
are mixed together by gentle squeezing of the packet. • Alternately applying pressure to the area and releasing it will produce
• Warm washcloths or towels the most satisfactory blood flow.
ORDER OF COLLECTION
DERMAL PUNCTURE PROCEDURE 1. Capillary Blood Gases
1. Phlebotomist Preparation 2. Blood Smear
2. Patient Identification and Preparation 3. EDTA Tubes
3. Patient Position 4. Other anticoagulated tubes
4. Site Selection 5. Serum Tubes
5. Warming the Site BANDAGING THE PATIENT
6. Cleansing the Site Pressure is applied to the puncture site with sterile gauze.
7. Performing the Puncture LABELING THE SAMPLE
8. Puncture Device Disposal Microsamples must be labeled with the same information required for
9. Sample Collection venipuncture samples.
10. Order of Collection COMPLETION OF THE PROCEDURE
11. Bandaging the Patient • Proper waste disposal of all used materials
12. Labeling the Sample • Proper Handwashing
13. Completion of the Procedure • Thanking the patient and/or the parents for their cooperation
 SPECIAL DERMAL PUNCTURE Step 12. Hold the finger between the nondominant thumb and index finger,
• Collection of Newborn Bilirubin with the palmar surface facing up and the finger pointing downward.
• Bilirubin is a very light-sensitive chemical and is rapidly destroyed Step 13. Place the lancet firmly on the fleshy area of the finger perpendicular
to the fingerprint and depress the lancet trigger.
when exposed to light.
Step 14. Discard lancet in the approved sharps container.
• Samples must be collected quickly and protected from excess
Step 15. Gently squeeze the finger and wipe away the first drop of blood that
light during and after the collection. may contain alcohol residue and tissue fluid.
Step 16. Collect rounded drops into micro-collection containers in the correct
Amber-colored Microtainer for the collection order of draw without scraping the skin. Do not milk the site. Collect the
of neonatal bilirubin sample within 2 minutes to prevent clotting.
Step 17. Cap the micro-collection container when the correct amount of blood
NEWBORN SCREENING has been collected.
• Require testing for as many as 29 metabolic disorders. Step 18. Mix tubes 5 to 10 times by gentle inversion as recommended by the
• because many of these disorders cause the buildup of manufacturer. They may have to be gently tapped throughout the procedure
unmetabolized toxic food ingredients, it is important that the to mix the blood with the anticoagulant.
Step 19. Place gauze on the site and ask the patient or parent to apply pressure
defects be detected early in life.
until bleeding stops
• The testing of newborn babies for genetic, metabolic, hormonal,
Step 20. Label the tubes before leaving the patient and verify identification
and functional disorders that can cause physical disabilities, with the patient ID band or verbally with an outpatient. Observe any special
mental retardation, or even death, if not detected and treated handling procedures.
early. Step 21. Examine the site for stoppage of bleeding and apply bandage if the
• Levels of these substances are elevated more rapidly in blood patient is older than 2 years.
than urine. Step 22. Dispose of used supplies in biohazard containers.
• Testing for many substances is now performed using tandem Step 23. Thank the patient.
mass spectrophotometry (MS/MS). MS/MS is capable of Step 24. Remove gloves and wash hands.
Step 25. Complete paperwork.
screening the infant blood sample for specific substances
Step 26. Deliver sample to the laboratory
associated with particular IEMs.
• Performed from blood collected by heelstick and placed on
specially designed filter paper.

Correct and incorrect blood

collection with filter paper

CAPILLARY BLOOD GASES

• Arterial blood is the preferred sample for blood gases (oxygen
and carbon dioxide content) and pH levels in adults
• Samples are collected in heparinized blood gas pipettes
• The pipette should fill in less than 30 seconds.
COLLECTION OF BLOOD FROM A FINGERSTICK
PROCEDURE:
Step 1. Obtain and examine the requisition form.
Step 2. Greet the patient and explain the procedure to be performed.
Step 3. Identify the patient verbally by having him or her state both the first
name and last name and compare the information on the patient’s ID band
with the requisition form. A parent or guardian may do this for a child.
Step 4. Prepare the patient and/or parents and verify diet restrictions, as
appropriate, allergies to latex, or previous problems with blood collection.
Step 5. Position the patient’s arm on a firm surface with the hand palm up. The
child may have to be held in either the vertical or horizontal restraint.
Step 6. Select equipment according to the age of patient, the type of test
ordered, and the amount of blood to be collected.
Step 7. Wash hands and put on gloves.
Step 8. Select the puncture site in the fleshy areas located off the center of the
third or fourth fingers on the palmar side of the nondominant hand. Do not
use the side or tip of the finger.
Step 9. Warm the puncture site if necessary.
Step 10. Cleanse and dry the puncture site with 70% isopropyl alcohol in
concentric circles and allow to air dry.
Step 11. Prepare the lancet by removing the lancet locking device and open
the cap to the microcollection container.