PHLEBOTOMY

1. REQUISITION FORM
o The FIRST STEP in performing any blood collection procedures is
to SECURE that there is a provided or requested requisition form
o PURPOSE: To provide...
- Legal protection that we are permitted to perform the phlebotomy
- Information to correctly identify the px
- Information of necessary equipment to use
- Information of appropriate samples
o NEVER COLLECT A SAMPLE WITHOT REQUISITION FORMS
o WHERE DO WE GET REQUISITION FORMS?
- If OUTpatient: may be hand carried by the patient, or requests from
other healthcare providers by telephone or fax
- If INpatient: may be delivered to the lab by pneumatic tube system, OR
entered into the hospital computer and printed out by the lab computer.
2. GREET THE PATIENT

INPATIENT OUTPATIENT
SLEEPING PATIENTS o Introduce yourself
o Gently wake the patient and wait for the px
o Explain that you will be the one
to be oriented before proceeding to
introductions collecting blood and how you will
o After the px becomes well-awake, introduce perform it
yourself
o REASSURE the patient
o Explain that you will be the one collecting
blood and how you will perform it o Carefully listen to the patient OR the
o REASSURE the patient nearby guardians with them IF they
o Carefully listen to the patient OR the nearby
guardians with them IF they have something
have something to say that you must
to say that you must know beforehand that know beforehand that would aid a
would aid a successful blood collection (such successful blood collection (such as
as allergies, pain sensitivity, phobia or fear
of needles etc.)
allergies, pain sensitivity, phobia or
fear of needles etc.)
UNCONSCIOUS PATIENTS
o Should be greeted in the SAME WAY as
conscious px because some unconscious px
may actually be conscious but is unable to
respond
 3. PATIENT IDENTIFICATION

INPATIENT OUTPATIENT
o ASK the patient to STATE his full name o ASK the patient to STATE his full name,
**DO NOT ask the name itself such as, address, and birth date
“Are you Izzie Stevens?” because some o COMPARE the stated information by
patients are medically groggy, or has hearing
the px with px requisition form
problems and has tendency to automatically
answer “yes” to anything.
o EXAMINE the patient’s ID wristband to UNIDENTIFIED EMERGENCY DEPT PX
confirm px name, hospital ID number, o Some px comes to ER disoriented and
birth date, and physician. unable to identify themselves
**It should MATCH the information on o Hospitals usually generate ID bands for
patient’s requisition form these px with ID number and
**DO NOT RELY on wristbands lying on temporary names as:
bedside table or the sign over the patient’s John Doe (Male) or Jane Doe (Female)
bed because a different patient might be or sometimes as Patient X
seated on the wrong bed. o Refer to the given ID numbers
o WHAT IF THE ID BAND IS MISSING? generated by the hospital in the ID
→ Contact a nurse and request for bands of unidentified patients
another ID band for the patient

4. PATIENT PREPARATION
o Patient must be seated properly **DO NOT COLLECT BLOOD in a STANDING POSITION
with arm openly and straightly positioned on armrest
**DO NOT HYPEREXTEND THE ELBOW as this makes the vein palpation difficult
**SLIGHTLY BENDING THE ELBOW may help in vein palpation
o Ask the patient to make a fist with their hand
o Make sure there are no obstructive objects on the patient’s mouth such as food,
drink, gum etc. as this could cause choking
5. EQUIPMENT SELECTION
o Re-read the requisition form to correctly identify the equipment to be used
such as: - blood collection system: ETS, Syringe, or Winged collection set
- number and type of collection tubes

o TYPES OF COLLECTION TUBES:

CLASS’N ITEMS ADDITIVES TUBE INDICATED USAGE TUBE
MATERIALS INVERSION
NO ADDITIVE TUBE N/A GLASS Determinations in serum for: 0x

Clot Activator PLASTIC 5x

SERUM PRO-COAGULATION Clot Activator GLASS ▪ Clinical biochemistry 8-10x
TUBE TUBE /PLASTIC ▪ Immunology
GEL & CLOT Gel & Clot GLASS ▪ Serology 8-10x
ACTIVATOR Activator /PLASTIC
TUBE
GLUCOSE Potassium oxalate GLASS Determinations in 8-10x
TUBE + Sodium fluoride /PLASTIC stabilized anti-coagulated
or whole blood or plasma for:
K2EDTA
+ Sodium fluoride ▪ Glucose testing
▪ Lactate testing
PT Sodium citrate GLASS Determinations in 3-4x
PLASMA (Prothrombin) (1:9) /PLASTIC citrated plasma for:
TUBE TUBE
▪ Coagulation testing
HEPARIN GLASS Determinations in 8-10x
TUBE /PLASTIC heparinized plasma for:

Lithium Heparin ▪ Routine Clinical chemistry

▪ Electrolytes
▪ Special Chemistry tests
Sodium Heparin (Troponin assays)
▪ Karyotyping
EDTA Determinations in
TUBE EDTA whole blood for: 8-10x

GLASS ▪ Hematology
4mL /PLASTIC (CBC/ Differential/ Retic/ Sed
rate, FK506, Cyclosporin,
Platelet Ab, Coombs, Flow
WHOLE Cytometry)
BLOOD ▪ Immunohematology
TUBE 6mL (Blood typing, Blood Screening,
Compatibility study, Direct
Coombs, HIV viral load)
ESR Sodium citrate GLASS Determinations in 5x
TUBE (1:4) /PLASTIC EDTA whole blood for:

▪ Erythrocyte Sedimentation Rate

ACD Trisodium citrate, GLASS Determinations in ACD tube for: 8-10x
TUBE Citric acid, /PLASTIC
and Dextrose ▪ HLA Tissue typing
▪ DNA studies
▪ HIV cultures
6. HAND SANITATION AND GLOVES APPLICATION in front of the patient
o This reassures the patient that proper safety measures are being followed
7. TOURNIQUET 1st APPLICATION
o WHY DO WE NEED TOURNIQUET?
IMPEDES veins but NOT arterial blood flow causing blood accumulation
→ to easily locate veins
→ and provides larger amount of blood for collection

o WHAT COMPLICATION OR ISSUE ENCOUNTERED IN USE OF TOURNIQUET?

ALTERS some test results
→ by INCREASING the ratio of cellular elements to plasma
(or also called HEMOCONCENTRATION)
→ by causing HEMOLYSIS

o Tourniquet should remain in place ONLY FOR 1 MINUTE to prevent complication

o To avoid longer tourniquet application, apply the tourniquet TWICE instead
→ ONE for vein palpation and selection
→ SECOND ONE for immediate venous puncture
**There should be 2 minutes interval before reapplication of tourniquet
o APPLY tourniquet 3-4 inches above venipuncture site
**Tourniquet should NOT BE ROLLED or TWISTED
**Tourniquet SHOULD BE FLATTENED

**Tourniquet should NOT BE TOO TIGHT or TOO LOOSE

Signs of undesirable tightness:
- Petechiae
- Blanching of skin (pamumutla) around tourniquet
- Inability to feel radial pulse
What could RESULT from application of undesirable tightness?
- Blood flow OBSTRUCTION
**Tourniquet should be at COMFORTABLE TIGHTNESS

o WHY DO WE NEED TO MAINTAIN CERTAIN DISTANCE BETWEEN

TOURNIQUET AND VENIPUNCTURE SITE?
Application of tourniquet TOO CLOSE to venipuncture site → causes vein to
COLLAPSE
o Other methods than tourniquet to locate difficult veins:
→ USE of BLOOD PRESSURE CUFFS inflated to 40mm Hg
8. SITE SELECTION
o Preferred site is antecubital fossa located anterior and below the bend of elbow
o 1st Choice – MEDIAN CUBITAL VEIN
WHY?
→ Large
→ Does not move when needle is inserted (well-anchored)
→ More isolated from underlying structures
→ Least painful
→ Less likely to bruise
nd
o 2 Choice – CEPHALIC VEIN
WHY?
→ also Large but more difficult to locate
→ Has tendency to move (not as well-anchored as median cubital)
→ More painful than median cubital
rd
o 3 Choice – BASILIC VEIN
WHY?
→ also Large and easy to Locate
→ But most often not well anchored (slippery) and lies NEAR brachial artery
and median nerve (either of which could be accidentally punctured)
o We locate the veins by palpation method
**DO NOT USE THUMB for palpation because it has a pulse beat
**USE INDEX FINGER for palpation
o Veins are differentiated from arteries from their spongy, bouncy, and resilient
characteristics when palpated
o If NO palpable veins are found in the antecubital area,
WRIST and HAND can be an option
o Wrist and/or Hand veins are SMALLER, it is necessary to prepare smaller needle
or winged blood collection set
**NEVER USE VEINS ON WRIST UNDERSIDE as nerves, ulnar and radial arteries
lies close to the veins in this location and could cause nerve or arterial damage.
**NERVE INJURY due to blood collection in the underside of wrist
MAY CAUSE LOSS OF HAND POTENCY or FLEXIBLE MOBILITY
9. CLEAN THE SITE
o RELEASE the tourniquet after palpation and clean the selected site
o Use 70% Isopropyl alcohol
o Circular motion starting from inside to outward away from selected site
to PREVENT bacterial contamination of either patient or sample
o Allow alcohol to air dry
WHY?
→ to PREVENT stinging sensation to px’s arm
→ to PREVENT sample hemolysis caused by alcohol
**DO NOT HUFF AND PUFF
**DO NOT FAN
**DO NOT WIPE WITH NONSTERILE GAUZE
as these would cause more contamination to the site
10. RE-APPLY TOURNIQUET

11.PERFORM THE VENIPUNCTURE

o Use 21 gauze needle (for routine CBC but also depends on what is on requisition)
o Before needle insertion, make sure to loosen the plunge so that you can easily
pull it and avoid getting stuck mid collection
o Position the needle bevel up and at 15-30 degree angle
o Lightly hold the back of patient’s arm with your other arm’s four fingers while its
thumb supports near the puncture site
WHY?
→ To PREVENT rolling veins
12. REMOVAL OF NEEDLE
o Before removing the needle, make sure that tourniquet has been removed FIRST
WHY?
→ Failure to remove the tourniquet before the needle
may produce HEMATOMA in patient’s arm
o RECAP the needle
o PLACE gauze to the punctured site as soon as the needle is removed and
APPLY PRESSURE to the site until the bleeding stops, so at least 2-3 minutes
**DO NOT IMMEDIATELY BANDAGE or TAPE GAUZE IN PUNCTURED SITE
as this would only produce HEMATOMA in patient’s arm
o EXAMINE after few minutes if bleeding has stopped
then thereafter APPLY the bandage
13. DISPOSE THE NEEDLE
o IMMEDIATELY DISPOSE the needle after use in its proper sharp container

14. TRANSFER COLLECTED BLOOD TO TUBE

o OPEN the cap of tube
o STICK the needle adapter to the walls of tube and push plunge SLOWLY
to PREVENT hemolysis during transfer
o CLOSE then INVERSION X
(refer to table depending what collection tube is used on inversion count)

15.LABEL THE TUBES

o IMMEDIATELY LABEL THE TUBE as soon as the collection procedure is done
to prevent confusion and mislabeling
o WHAT SHOULD BE INDICATED IN THE LABEL?
→ Patient’s NAME
→ Patient’s ID NUMBER
→ DATE and TIME OF COLLECTION
→ Phlebotomist’s NAME