Phlebotomy
Chapter 53
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives







Define, spell, and pronounce the terms listed in the
vocabulary.
List the equipment needed for venipuncture.
Explain the purpose of a tourniquet.
Explain how to apply a tourniquet and three
consequences of improper application.
Explain why the stopper colors on evacuated tubes
differ.
State the correct order in which various types of
tubes should be collected.
Explain why a syringe is used for blood collection
rather than an evacuated tube.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives





Detail patient preparation for venipuncture that
displays sensitivity to patient rights and feelings.
Describe and name the veins that may be used
for blood collection.
List, in order, the steps of a routine
venipuncture.
Collect a venous blood sample using the
evacuated tube method.
Explain the reasoning behind choosing a winged
infusion set (butterfly) over an evacuated tube.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Learning Objectives





Summarize typical problems that may be
associated with venipuncture.
Identify the major causes of hemolysis during
a venous blood collection.
List situations in which capillary puncture
would be preferred over venipuncture.
Discuss proper dermal puncture sites.
Describe containers that may be used to
collect capillary blood.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
Phlebotomy



The practice of drawing blood.
Phleb-vein
The most common method of obtaining blood is
by venipuncture.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
5
Vocabulary






Hemoconcentration-increase in the concentration of
red blood cells in the circulating blood in proportion to
the plasma.
Hemolysis- the destruction or dissolution of RBC’s
with subsequent release of hemoglobin.
Plasma- the liquid portion of whole blood that
contains active clotting agents.
Serum- the liquid portion of whole blood that remains
after the blood has clotted.
Thixotropic gel- a material that appears to be a solid
until subjected to a disturbance, such as a
centrifugation, whereupon it becomes a liquid.
Centrifugation- This process is used to separate two
immiscible (difficult to separate) liquids.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Basic Venipuncture Equipment


Venipuncture chair – adjustable locking armrest
to protect fainting patient
Gloves:



Glove use during venipuncture is mandated by
OSHA.
Caution with latex products
Tourniquet

Tied 3 to 4 inches above elbow immediately before
venipuncture; a tourniquet on for longer than
1 minute may alter test results
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Venipuncture Equipment
From Flynn JC Jr: Procedures in phlebotomy, ed 3, Philadelphia, 2005,
Saunders.

Tourniquet


Prevents venous flow out of the site, causing veins to
bulge.
Makes veins easier to locate and puncture.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Venipuncture Equipment

Alcohol Pads-Antiseptics

70% isopropyl alcohol most commonly used
 Alcohol does not sterilize skin; inhibits reproduction
of bacteria that might contaminate the sample.
 To be most effective alcohol should remain on skin
30 to 60 seconds.
 Should not be used when drawing blood alcohol test.
Sterile soap pads, benzalkonium chloride, or
povidone-iodine (Betadine) can be used.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
9
Equipment Used in Venipuncture






Double-pointed
safety needles
Evacuated stopper
tubes
Needle holder
Sharps container
Syringes
Winged infusion sets
(butterfly needles)






Tourniquet
Pen
Alcohol swabs
Gauze
Bandages
Gloves
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Venipuncture Equipment
From Stepp CA, Woods MA: Laboratory procedures for medical office personnel, Philadelphia, 1998, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
11
Needles



The venipuncture needle has a shaft with one end cut at
an angle (bevel).
The other end attaches to the syringe or to an adaptor
(hub).
Gauge is designated by a numeric value.
 The higher the number, the smaller the lumen.
 Example: 18 gauge has a large lumen while a 24
gauge has a small lumen.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
12
Needle Safety





Never recap a needle.
Never recap a contaminated needle.
Dispose of used needles and needle holders promptly in
appropriate sharps disposal containers.
Report all needle stick and other sharps-related injuries
promptly to ensure that you receive appropriate followup care.
Use safety needles and shields.
 Self-sheathing safety devices
Modified from Garrels M, Oatis C: Laboratory testing for ambulatory settings, ed 2, St Louis, 2011, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
13
Syringes



Used when there is concern that the strong vacuum in a
stoppered tube will collapse the vein.
The syringe needle fits on the end of the barrel and
comes in different gauges.
It must be transferred immediately to another tube
because the blood will clot in the syringe barrel.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
14
BD Vacutainer Blood Transfer Device
Courtesy Becton, Dickinson & Company, Franklin Lakes, NJ.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
15
Needle Holders



Translucent cylinders.
Cylinders have a ring that indicates how far the
tube can be pushed onto the needle without
losing the vacuum.
Needles are not removed from the needle
holder, and the safety feature must be activated
before disposal.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
16
Vacutainer System and Holder
(Evacuated tube)
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
17
Evacuated Collection Tube (Vacutainer)





Tubes of various sizes with color-coded tops indicating
tube contents
Volumes range from 2 to 15 ml
Each test requires a specific amount of blood
For a test requiring 3 ml of serum 6 ml of blood must be
collected
Match needle gauge to tube size; the larger the tube,
the greater the vacuum and more likely blood will
hemolyze if a high-gauge, small-lumen-sized needle is
used.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
18
Order of Collection and Additives and
Inversion Mixing (page 1135-1136)
The National Committee for Clinical Laboratory Standards
developed a set of standards outlining the order of draw
for a multi-tube draw.
1. Yellow topped tube-Used for blood cultures.
2. Red topped-contain no additives.
USES: chemistries, immunology, serology,
blood bank (glass tube only)
For plastic tubes they must be inverted at least
5-6 times. If glass, no inversion is needed.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
19
Order of Collection and Additives
3. Light blue topped tubesADDITIVE: Sodium Citrate
USES: Coagulation tests
ACTION: Forms calcium salts to remove
coagulation and prevent clotting.
REQUIREMENTS: FULL DRAW, invert 3-4 times
4. Green topped tubes.
ADDITIVE: Heparin
USES: Chemistries
ACTION: Anti-coagulant and gel seperates via
centrifuge
REQUIREMENTS: Invert 8-10 times.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
20
Order of Collection and Additives
5. Lavender topped tubes.
Additive: EDTA
(ethylenediaminetetraacetic acid)
Uses:Hematology, blood bank.
Action:Forms calcium salts to remove coagulants and
prevent clotting
Requirements: Full draw. Invert 8-10 times
6. Red/gray marble topped tubes.
Additive: Serum seperator tube (SST gel) and clot
activator.
Uses: chemistries, immunology and Serology
Action: Gel seperates blood by centrifuge
Requirements: Invert 5-6 times.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
21
Order of Collection and Additives
7. Gray-topped tube.
Additives: Sodium floride/potassium
oxalate
Uses: Glucose, alcohol and lactate levels
Actions: Antiglycolytic preserves glucose
for 5 days
Requirements: Full draw .
Invert 8-10 times.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
22
Tube Additives


Ethylenediaminetetraacetic acid (EDTA)
 Lavender-topped tube
 Prevents platelet clumping and preserves
appearance of blood cells for microscopic
examination
Clot activators promote clotting of blood
 Silica particles
 Thrombin quickly promotes clotting; used in tubes
drawn for stat chemistry testing or for patients taking
anticoagulants
 Without a clot activator, blood will clot in 30 to 60
minutes, after which it must be centrifuged .
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
23
Tube Additives


Anticoagulants prevent blood from clotting
 Whole blood sample – CBC and blood
typing
 Centrifuge sample to separate plasma from
blood cells – plasma used for stat
chemistry testing and coagulation studies
Thixotropic gel- a material that appears to be
a solid until subjected to a disturbance such
as a centrifugation where upon it becomes a
liquid.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
24
Winged Infusion Sets
(Butterfly Needles)



Designed for use on small veins such as those
in the hand or in pediatric patients.
Needle size is 23 gauge.
Needle is ½ to ¾ inch long with a plastic,
flexible butterfly-shaped grip attached to a short
length of tubing.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
25
Routine Venipuncture
Refer to the Steps to Performing a
Venipuncture Handout
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
26
Choice of Veins





Survey the arm thoroughly.
Veins bounce lightly when palpated.
The cephalic veins run lateral or to the outside of
the antecubital area.
Median cubital (cephalic) vein is first choice of
draw.
The basilic vein lies in the inside part of the
antecubital area and is close to brachial artery
and median nerves. Because it lies close to
these areas, it is the last choice of draw.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
27
Veins of the Forearm
(page 1140)
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
28
Phlebotomy Requisitions
Must have the following information:
 Patient name
 Date of birth
 Identification number
 Name of physician making the request
 Type of test requested
 Test status (timed, fasting, stat, and so forth)
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
29
Problems Associated
with Venipuncture (page 1149)







Failure/unable to
obtain blood
Burned area
Convulsions
Scarred veins
Edema
Hematoma
Syncope




IV Therapy
Mastectomy
Nausea
Petechiae
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
30
Specimen Recollection







Unlabeled or mislabeled specimen
Quantity not sufficient
Defective tube
Incorrect tube used for test ordered
Hemolysis
Clotted blood in an anticoagulated specimen
Improper handling
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
31
Capillary Puncture




Capillaries are small blood vessels that
connect arterioles to small venules.
A capillary (or dermal) puncture is an efficient
means of collecting a blood specimen.
Only a small amount of blood is required.
Capp puncture is used when a patient’s
condition makes venipuncture difficult.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
32
Capillary Puncture
Examples:
 Older patients
 Pediatric patients (especially
under the age of 2 years)
 Patients who require
frequent glucose monitoring
 Patients with burns or scars
in venipuncture sites
 Obese patients
 Patients receiving
intravenous therapy
 Patients who have had a
mastectomy




Patients at risk for venous
thrombosis
Patients who are severely
dehydrated
Tests that require a small
volume of blood
When venous blood and
capillary blood are not
identical
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
33
Capillary Puncture Equipment


Collection containers
Skin puncture device

Lancet
Courtesy Becton, Dickinson & Company, Franklin Lakes, NJ.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
34
Equipment

Manufacturers also provide various collection
devices designed to obtain small quantities of blood
for “point-of-care” testing for analytes such as
glucose, hemoglobin A1c, and cholesterol
 Paper cards (Guthrie Cards)-used to test neonates
for metabolic disorders such as PKU
(phenylketonuria).
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
35
Capillary Puncture

Site selection

Usually ring finger
 Middle finger preferred
 Heel stick for infants under age of 1
 Thumb is too callused
 Index finger has extra nerve endings thus makes it
too painful.
 Pinky has too little tissue for a successful puncture.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
36
Capillary Puncture


Preparation-follow all aseptic procedure and
gather all equipment necessary.
Collecting Specimen

Puncture is made at the tip and slightly to the side
of the finger.
 Puncture a fleshy area closer to the center of the
finger to prevent damage to underlying bone.
 Avoid areas that are scarred, burned, infected,
cyanotic, or edematous.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
37
Capillary Puncture
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
38
Pediatric Phlebotomy




Performed only by personnel trained in the
techniques for pediatric phlebotomy.
Tactfully determine if the parent is
comfortable with assisting in restraining an
uncooperative child.
Refer to Table 53-7 page 1156.
Collect blood by dermal puncture for those
under 2 years of age; may use dorsal hand
vein with 23-gauge winged infusion set.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
39
Handling Specimens



Most samples are centrifuged
Should be refrigerated and tested within
72 hours
Blood may be drawn for drug and alcohol
testing, DNA analysis, or parentage testing


Samples must be handled according to special
procedures to prevent tampering, misidentification,
or interference with the test results
Follow chain of custody procedures
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
40
Patient Education


The medical assistant must maintain a
professional attitude and still be
sympathetic to the fears and
apprehensions of the patient.
Use the patient’s suggestion in choosing
the site for the removal of a blood
specimen.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
41