PHLEBOTOMY

LECTURE 7

Presenter: Melanie Sinclair

 Procedure for drawing blood
Steps
1 – Assemble equipment

2 – Identify and prepare the patient

3 – Select the site

4 – Perform hand hygiene and put on gloves

5 – Disinfect the entry site

6 – Take blood
7 – Fill the laboratory sample tubes

8 – Draw samples in the correct order

9 – Clean contaminated surfaces and complete patient procedure

10 – Prepare samples for transportation

11 – Clean up spills of blood or body fluids

 Step 1 – Assemble equipment
Collect all the equipment needed for the procedure and place it within safe and easy reach
on a tray or trolley, ensuring that all the items are clearly visible. The equipment required
includes:

• a supply of laboratory sample tubes, which

should be stored dry and upright in a rack;

• well-fitting, non-sterile gloves;

• an assortment of blood-sampling devices (safety-engineered devices or needles
and syringes), of different sizes;

Lancet
• a tourniquet;

• 70% alcohol swabs for skin disinfection;

• gauze to be applied over puncture site;

• writing equipment;

• laboratory forms;
• leak-proof transportation bags and containers;

• a puncture-resistant sharps container.

Ensure that the rack containing the sample tubes is close to you, the health worker,
but away from the patient, to avoid it being accidentally tipped over.
 Step 2 – Identify and prepare the patient
Where the patient is adult and conscious:
• Introduce yourself to the patient and ask the patient to state their full name.

• Check that the laboratory requisition form matches the patient’s identity (i.e., match
the patient’s details with the laboratory form, to ensure accurate identification).

• Ask whether the patient has allergies, phobias or has ever fainted during previous
injections or blood draws.

• If the patient is anxious or afraid, reassure the person and ask what would make them
more comfortable.
• Make the patient comfortable in a supine position (if possible).

• Discuss the test to be performed and obtain verbal consent. The patient has a right to
refuse a test at any time before the blood sampling, so it is important to ensure that the
patient has understood the procedure.

For pediatric and neonatal patients, use the method described below to ensure that
patients are correctly identified before taking blood.

• If a parent or legal guardian or nurse is present, ask that person for the child’s first and
last names.
Step 3 – Select the site
The choice of site and procedure (venous site, finger-prick or heel-prick – also referred
to as “capillary sampling” or “skin puncture”) will depend on the volume of blood needed
for the procedure and the type of laboratory test to be done.

Hospitalized patients
• In hospitalized patients, do not take blood from an existing peripheral venous access
site because this may give false results.

• Hemolysis, contamination and presence of intravenous fluid and medication can all
alter the results.
• Nursing staff and physicians may access central venous lines for specimens following
protocols. However, specimens from central lines carry a risk of contamination or
erroneous laboratory test results.

• It is acceptable, but not ideal, to draw blood specimens when first introducing an in-
dwelling venous device, before connecting the cannula to the intravenous fluids.
 Step 4 – Perform hand hygiene and put on
gloves

• Perform hand hygiene:

– wash hands with soap and water, and dry with single-use towels; or

– if hands are not visibly contaminated, clean with alcohol rub – use 3 ml of alcohol rub on
the palm of the hand, and rub it into fingertips, back of hands and all over the hands until
dry.

• After performing hand hygiene, put on well-fitting, non-sterile gloves.

 Step 5 – Disinfect the entry site
• Unless drawing blood cultures, or prepping for a blood collection, clean the site with a 70%
alcohol swab for 30 seconds and allow to dry completely (30 seconds).

Note: Alcohol is preferable to povidone iodine, because blood contaminated with povidone iodine
may falsely increase levels of potassium, phosphorus or uric acid in laboratory test results.

• Apply firm but gentle pressure. Start from the center of the venipuncture site and work downward
and outwards to cover an area of 2 cm or more.

• Allow the area to dry. Failure to allow enough contact time increases the risk of contamination.

• DO NOT touch the cleaned site; in particular, DO NOT place a finger over the vein to guide the
shaft of the exposed needle. If the site is touched, repeat the disinfection.
 Step 6 – Take blood
Venipuncture
• Anchor the vein by holding the patient’s arm and placing a thumb BELOW the venipuncture
site.

• Ask the patient to form a fist so the veins are more prominent.

• Enter the vein swiftly at a 30-degree angle or less and continue to introduce the needle
along the vein at the easiest angle of entry.

• Once sufficient blood has been collected, release the tourniquet BEFORE withdrawing the
needle.
• Withdraw the needle gently and apply gentle pressure to the site with a clean gauze. Ask the
patient to hold the gauze in place, with the arm extended and raised. Ask the patient NOT to
bend the arm, because doing so causes a hematoma.
Capillary Puncture
• Apply alcohol to the entry site and allow to air dry.

• Puncture the skin with one quick, continuous and deliberate stroke, to achieve a good flow
of blood and to prevent the need to repeat the puncture.

• Wipe away the first drop of blood because it may be contaminated with tissue fluid or
debris (sloughing skin).

• Avoid squeezing the finger or heel too tightly because this dilutes the specimen with tissue
fluid (plasma) and increases the probability of hemolysis.

• When the blood collection procedure is complete, apply firm pressure to the site to stop the
bleeding.
 Step 7 – Fill the sample tubes
Venipuncture
• When obtaining multiple tubes of blood, use evacuated tubes with a needle and tube
holder. This system allows the tubes to be filled directly. If this system is not available, use
a syringe or winged needle set instead.

• If a syringe or winged needle set is used, best practice is to place the tube into a rack
before filling the tube. To prevent needle-sticks, use one hand to fill the tube or use a
needle shield between the needle and the hand holding the tube.
• Pierce the stopper on the tube with the needle directly above the tube using slow, steady
pressure. Do not press the syringe plunger because additional pressure increases the risk of
hemolysis.

• Where possible, keep the tubes in a rack and move the rack towards you. Inject downwards
into the appropriate coloured stopper. DO NOT remove the stopper because it will release the
vacuum.

• If the sample tube does not have a rubber stopper, inject extremely slowly into the tube as
minimizing the pressure and velocity used to transfer the specimen reduces the risk of
hemolysis. DO NOT recap and remove the needle.

• Before dispatch, invert the tubes containing additives for the required number of times.
Step 8 – Draw samples in the correct
order
Draw blood collection tubes in the correct order, to avoid cross-contamination of additives
between tubes.

With venipuncture, collect the specimens in the order below:

• Chemistry/Serology specimens;
• Hematology specimens;

With skin punctures, collect the specimens in the order below:

• Hematology specimens;
• Chemistry/Serology specimens;
 Step 9 – Clean contaminated surfaces and
complete patient procedure
• Discard the used needle and syringe or blood sampling device into a puncture-resistant
sharps container.

• Check the label and forms for accuracy. The label should be clearly written with the
information required by the laboratory, which is typically the patient’s first and last names,
identification number and the date and time when the blood was taken.

• Discard used items into the appropriate category of waste. Items used for phlebotomy that
would not release a drop of blood if squeezed (e.g., gloves) may be discarded in the general
waste.
• Perform hand hygiene again, as described above.

• Recheck the labels on the tubes and the forms before dispatch.

• Inform the patient when the procedure is over.

• Ask the patient how they are feeling.

• Check the insertion site to verify that it is not bleeding and place a band-aid over the
site.

• Thank the patient and say something reassuring and encouraging before the person
leaves.
 Step 10 – Prepare samples for
transportation

• Pack laboratory samples safely in a plastic leak-proof bag with an outside compartment for
the laboratory request form. Placing the requisition on the outside helps avoid contamination.

• If there are multiple tubes, place them in a rack or padded holder to avoid breakage during
transportation.
 Step 11 – Clean up spills of blood or body
fluids
• If blood spillage has occurred (e.g., because of a laboratory sample breaking in the
phlebotomy area or during transportation, or excessive bleeding during the procedure),
clean it up.

•Put on gloves and a gown or apron if contamination or bleaching of a uniform is likely in a

large spill.

• Mop up liquid from large spills using paper towels and place them into the infectious waste.

• Remove as much blood as possible with wet cloths before disinfecting.

• Flood the area with 10% sodium hypochlorite (1:10 dilution of a 5.25% chlorine bleach to
water). This is the preferred concentration for large spills. Leave the area wet for 10 minutes.

• Prepare bleach solution fresh daily and keep it in a closed container because it degrades over
time and in contact with the sun.