Lesson 26 — Phlebotomy and Blood Collection

1. Check the provider's order and/or requisition form to determine the tests ordered. Gather the appropriate tubes and supplies.

   Purpose

   Each test requires a specific tube color that is indicated on the requisition.

2. Sanitize your hands and put on the fluid-impermeable lab coat and disposable gloves.

   Purpose

   To ensure infection control.

3. Verify the patient's identity using two identifiers (e.g., have the person spell his or her last name, state the birth date, and/or show a picture ID). Explain the procedure and obtain permission for the venipuncture.

   Purpose

   To make sure you have the right patient; explanations help gain the patient's cooperation.

4. Assist the patient to sit with his or her arm well supported in a slightly downward position.

   Purpose

   The veins of the antecubital fossa are more easily located when the elbow is straight.

5. Assemble the equipment. The choice of needle size depends on your inspection of the patient's veins. Attach the needle firmly to the vacuum tube holder. Keep the cover on the needle.

   Purpose

   If the needle is loose, it may turn during the procedure, causing the bevel of the needle to turn away from its upward position.

6. Apply the tourniquet around the patient's arm 3 to 4 inches above the elbow. The tourniquet should never be tied so tightly that it restricts blood flow in the artery. Tourniquets should remain in place no longer than 60 seconds.

   Purpose

   The tourniquet is used to make the veins more prominent. A quick check of the radial pulse ensures that the tourniquet has not been applied too tightly.

7. Ask the patient to make a fist.

   Purpose

   Clenching a fist produces engorgement of the vein. Do not ask the patient to pump the fist, because this may disrupt the blood's electrolyte balance.

8. Select the venipuncture site by palpating the antecubital space. Use your index finger to trace the path of the vein and to judge its depth. The vein most often used is the median cephalic vein, which lies in the middle of the elbow.

   Purpose

   The index finger is most sensitive for palpating. Do not use the thumb because it has a pulse of its own, which may confuse you.

9. Cleanse the site, starting in the center of the area and working outward in a circular pattern with the alcohol pad.

   Purpose

   The circular pattern helps prevent recontamination of the area.

10. It is recommended to take the tourniquet off while you assemble your equipment and supplies on the nondominant side of the arm. Then reapply it when the alcohol is dry. Alternatively, dry the site with a sterile gauze pad.

    Purpose

    Puncturing an area that is still wet with alcohol stings and can cause hemolysis of the sample.

11. Hold the vacuum tube assembly in your dominant hand. Your thumb should be on top and your fingers underneath. You may want to position the first tube to be drawn in the needle holder, but do not push it onto the double-pointed needle past the marking on the holder. Remove the needle sheath.

    Purpose

    Positioning the hand in this manner provides the best visibility of the needle entering the site and accessibility to insert and withdraw tubes with the nondominant hand. Pushing the tube into the double-pointed needle before it is in the arm causes air to rush into the tube, destroying the vacuum.

12. Grasp the patient's arm with the nondominant hand and anchor the vein by stretching the skin downward below the collection site with the thumb of the nondominant hand.

    Purpose

    Failure to anchor the vein may cause the vein to move away from the needle as it enters the arm, resulting in a missed vein.

13. With the bevel up and the needle aligned parallel to the vein, insert the needle at a 15-degree angle through the skin and into the vein quickly and smoothly.

    Purpose

    The sharpest point of the needle is inserted first. Inserting the needle quickly minimizes pain.

14. Place two fingers on the flanges of the needle holder and use the thumb to push the tube onto the double-pointed needle. Make sure you do not change the needle's position in the vein. When blood begins to flow into the tube, ask the patient to release the fist.

    Purpose

    The thumb has the strength to push the needle swiftly through the stopper. However, if you are not careful, the needle can easily be pushed farther into the site when the tube is pushed.

15. Allow the tube to fill to its maximum capacity. Remove the tube by curling the fingers underneath and pushing on the needle holder with the thumb. Take care not to move the needle when removing the tube. Immediately after removing it from the needle holder, gently invert the tube to mix the additives and the blood.

    Purpose

    Tubes must be full to ensure the proper anticoagulant-to-blood ratio. Moving the needle may result in inadvertent penetration of the other side of the vein or slipping of the needle out of the vein. Gentle inversion prevents clotting of blood, whereas vigorous mixing may cause hemolysis.

16. Insert the second tube into the needle holder, following the instructions in the previous steps. Continue filling tubes until the order on the requisition has been filled. Gently invert each tube after removing it from the needle holder. As the last tube is filling, release the tourniquet.

    Purpose

    The tourniquet should remain in place for no longer than 1 minute to prevent hemoconcentration.

17. Remove the last tube from the holder. Place gauze over the puncture site and quickly remove the needle, engaging the safety device. Dispose of the entire unit in the sharps container.

    Purpose

    The gauze over the puncture site and activation of the safety needle ensure infection control.

18. Apply pressure to the gauze or instruct the patient to do so. The patient may elevate the arm but should not bend it.

    Purpose

    Applying direct pressure is the best method to stop bleeding. Elevating the arm above the heart also stops bleeding.

19. Label the tubes with the patient's name, the date, and the time, or affix the preprinted tube labels while the patient is applying pressure.
20. Check the puncture site for bleeding and hematoma formation.
21. Apply a hypoallergenic pressure bandage using a clean, folded gauze pad under the bandage.
22. Disinfect the work area. Dispose of blood-contaminated materials (e.g., gauze and gloves) in the biohazard waste container. Remove your lab coat and sanitize your hands.

    Purpose

    To ensure infection control.

23. Complete the laboratory requisition form and route the specimen to the proper place.
24. Record the procedure in the patient's record.

    Purpose

    A procedure is considered not done until it is recorded.

1. Check the provider's order and/or requisition form to determine the tests ordered. Gather the appropriate tubes and supplies.

   Purpose

   To collect the specimen properly based on the tube requirements on the requisition.

2. Sanitize your hands and put on the fluid-impermeable lab coat and disposable gloves.

   Purpose

   To ensure infection control.

3. Verify the patient's identity using two identifiers (e.g., have the person spell his or her last name, state the birth date, and/or show a picture ID). Explain the procedure and obtain permission for the venipuncture.

   Purpose

   To make sure you have the right patient; explanations help gain the patient's cooperation.

4. Assist the patient to sit with his or her arm well supported and straight in a slightly downward position.

   Purpose

   The veins of the antecubital fossa are more easily located when the elbow is straight.

5. Assemble the equipment. The choice of syringe barrel size and needle size depends on the amount of blood required for the ordered tests and your inspection of the patient's veins. Attach the needle firmly to the syringe. Pull and depress the plunger several times to loosen it in the barrel while keeping the cover on the needle. The plunger must be pushed in completely after it has been loosened in the barrel.

   Purpose

   Using the smallest syringe possible minimizes the chance of hemolysis. Engaging the plunger ensures that you will not have to use as much force to pull the blood into the barrel, thereby minimizing the chance of hemolysis.

6. Apply the tourniquet around the patient's arm 3 to 4 inches above the elbow. The tourniquet should never be tied so tightly that it restricts blood flow in the artery. The tourniquet should remain in place no longer than 1 minute.

   Purpose

   The tourniquet is used to make the veins more prominent. A quick check of the radial pulse ensures that the tourniquet has not been applied too tightly.

7. Ask the patient to make a fist.

   Purpose

   Clenching a fist produces engorgement of the vein.

8. Select the venipuncture site by palpating the antecubital space. If you have difficulty palpating the vein with gloves, you can remove the gloves, palpate the vein and visibly mark its location, then put on new gloves before continuing. Use your index finger to trace the path of the vein and to judge its depth. The vein most often used is the median cephalic vein, which lies in the middle of the elbow.

   Purpose

   The index finger is most sensitive for palpating. Do not use the thumb because it has a pulse of its own, which may confuse you.

9. Cleanse the site, starting in the center of the area and working outward in a circular pattern with the alcohol pad. Allow the area to dry before proceeding.

   Purpose

   The circular pattern helps prevent recontamination of the area. Puncturing an area that is still wet with alcohol stings and can cause hemolysis of the sample.

10. Hold the syringe in your dominant hand. Your thumb should be on top and your fingers underneath, the same as in the vacuum tube method. Remove the needle sheath. Grasp the patient's arm with the nondominant hand and anchor the vein by stretching the skin downward below the collection site with the thumb of the nondominant hand.

    Purpose

    Failure to anchor the vein may cause the vein to move away from the needle when it is inserted, resulting in a missed vein.

11. With the bevel up and the needle aligned parallel to the vein, insert the needle at a 15-degree angle through the skin and into the vein rapidly and smoothly. Observe for a "flash" of blood in the hub of the syringe. Ask the patient to release the fist.

    Purpose

    The sharpest point of the needle is inserted first. The angle ensures that the needle does not penetrate through the vein. The appearance (flash) of blood in the hub ensures that the needle is in the vein.

12. Slowly pull back the plunger of the syringe with the nondominant hand. Do not allow more than 1 mL of head space between the blood and the top of the plunger. Make sure you do not move the needle after entering the vein. Fill the barrel to the needed volume.
13. Release the tourniquet when the proper volume is reached. The tourniquet must be released before the needle is removed from the arm.

    Purpose

    Removal of the tourniquet releases pressure on the vein and helps prevent blood from getting into adjacent tissues, causing a hematoma.

14. Place sterile gauze over the puncture site at the time of needle withdrawal. Then, immediately activate the needle safety device using the syringe hand and apply pressure to the site with the nondominant hand. Instruct the patient to apply direct pressure on the puncture site with sterile gauze. The patient may elevate the arm but should not bend it.

    Purpose

    Direct pressure is the best method to stop bleeding. Elevating the arm above the heart also stops bleeding.

15. Remove the syringe safety needle and transfer the blood immediately to the required tube or tubes using a safety transfer device. Do not push on the syringe plunger during transfer. Discard the entire unit in the sharps container when transfer is complete. Invert the tubes after the addition of blood and label them with the necessary patient information.

    Purpose

    The safety transfer device protects against accidental needlesticks and allows the correct amount of blood to be delivered into the tube by vacuum. Pushing the plunger hemolyzes the blood and may alter the amount of blood intended in each tube. Blood begins to clot shortly after collection, so it must be transferred into the vacuum tube and mixed with anticoagulant immediately after collection. Inverting the tubes ensures anticoagulation.

16. Inspect the puncture site for bleeding or a hematoma. Apply a hypoallergenic pressure bandage. Disinfect the work area. Dispose of blood-contaminated materials (e.g., gauze and gloves) in the biohazard waste container. Remove your lab coat and sanitize your hands.

    Purpose

    To ensure infection control.

17. Complete the laboratory requisition form and route it and the specimen to the proper place. Record the procedure in the patient's record.

    Purpose

    A procedure is not considered complete until it is recorded.

1. Check the provider's order and/or requisition form to determine the tests ordered. Gather the appropriate tubes and supplies.

   Purpose

   For efficiency in preparation

2. Sanitize your hands and put on the fluid-impermeable lab coat and disposable gloves.

   Purpose

   To ensure infection control.

3. Verify the patient's identity using two identifiers (e.g., have the person spell his or her last name, state the birth date, and/or show a picture ID). Explain the procedure and obtain permission for the venipuncture.

   Purpose

   To make sure you have the right patient; explanations help gain the patient's cooperation.

4. Remove the butterfly device from the package and stretch the tubing slightly. Take care not to activate the needle-retracting safety device accidentally. Attach the butterfly device firmly to the vacuum tube holder using the sheathed needle at the end of the tubing. Make sure the two are seated firmly together to prevent air from leaking into the vacuum tube when the sheathed needle makes contact with the vacuum.

   Purpose

   To keep the tube from recoiling.

5. Seat the first tube in the vacuum tube holder and place the unit carefully where it will not roll away. Apply a tourniquet to the patient's arm or wrist just proximal to the wrist bone. Do not apply the tourniquet so tightly that blood flow in the arteries is impeded. Have the patient place the venipuncture hand over his or her other, fisted hand (or around your nondominant hand) with the fingers lower than the wrist. Or place the patient's arm in the same position as for the previous venipuncture procedures with the arm straight and slightly downward.

   Purpose

   These positions help blood fill the veins in the hand; this makes it easier for you to identify the veins and choose the draw site.

6. Select a vein and cleanse the site at the bifurcation (forking) of the veins. Using your thumb, pull the patient's skin taut over the knuckles. With the needle bevel up and at a 10- to 15-degree angle, align it with the vein. Insert the needle by holding the wings or the rear of the set. After insertion the wings are never touched again. Make sure the safety device is not activated.

   Purpose

   Stretching the skin prevents the veins from rolling underneath. Inserting the needle by holding the wings gives a greater sense of control. If the sides are held, the safety shield slides forward over the needle when the point of the needle makes contact with the skin.

7. Push the blood collecting tube into the end of the holder. Note the position of the hands while drawing the blood. When drawing blood into a syringe, make sure the vacuum you create is slow and steady and that no more than 1 mL of head space exists between the blood and the plunger. Release the tourniquet when the blood appears in the tubing or a "flash" of blood is seen in the hub of the syringe.

   Purpose

   Drawing blood too forcefully into the syringe may collapse the vein or hemolyze the blood. To prevent hemoconcentration, the tourniquet should remain in place no longer than 1 minute.

8. Always keep the tube and the holder in a downward position so that the tube fills from the bottom up. Place a gauze pad over the puncture site and gently remove the needle, engaging the safety device. Dispose of the entire unit in the sharps container. Label the tubes with the patient's name, the date, and the time, or affix the preprinted tube labels while the patient is applying pressure.
9. Check the puncture site for bleeding and hematoma formation. Apply a hypoallergenic pressure bandage using a clean, folded gauze pad under the bandage. Disinfect the work area. Dispose of blood-contaminated materials (e.g., gauze and gloves) in the biohazard waste container. Remove your lab coat and sanitize your hands.

   Purpose

   To ensure infection control.

10. Complete the laboratory requisition form and route the specimen to the proper place. Record the procedure in the patient's record.

    Purpose

    A procedure is considered not done until it is recorded.

1. Check the provider's order and/or requisition form to determine the tests ordered. Gather the appropriate tubes and supplies.

   Purpose

   To perform the procedure efficiently. Once the skin has been punctured, the collection must proceed as rapidly as possible so that the blood does not clot before the entire specimen has been collected.

2. Sanitize your hands and put on the fluid-impermeable lab coat and disposable gloves.

   Purpose

   To ensure infection control.

3. Verify the patient's identity using two identifiers (e.g., have the person spell his or her last name, state the birth date, and/or show a picture ID). Explain the procedure and obtain permission for the venipuncture.

   Purpose

   To make sure you have the right patient; explanations help gain the patient's cooperation.

4. Select a puncture site, depending on the patient's age and the sample to be obtained (e.g. side of middle or ring finger of nondominant hand; medial or lateral curved surface of the heal for an infant)

   Purpose

   The nondominant hand may have fewer calluses. The side of the finger is less sensitive, and the skin is usually not as thick. Use great caution when performing capillary puncture on infants.

5. Gently rub the finger along the sides.

   Purpose

   To promote circulation. If the finger is very cold, you may immerse it in warm water or moisten it with warm towels.

6. Clean the site with alcohol, allow to air dry, it with a sterile gauze.

   Purpose

   Puncturing skin that is wet with alcohol is painful and can hemolyze the specimen

7. Grasp the patient's finger on the sides near the puncture site with your nondominant forefinger and thumb.

   Purpose

   Firmly holding the site allows control of the puncture

8. Hold the safety lancet against the patient's finger and press down on the button that activates the needle or blade to penetrate the skin and then automatically retract.

   Purpose

   Lancets are designed to puncture at specific depths that permit the free flow of blood.

9. Dispose of the lancet in the sharps container. Wipe away the first drop of blood with a clean, sterile gauze.

   Purpose

   The first drop of blood contains tissue fluid, which may alter the test results.

10. Apply gentle intermittent pressure to cause the blood to flow freely.

    Purpose

    Forceful squeezing liberates fluid that dilutes the blood and causes inaccurate results.

11. Collect the blood sample using one of the applicable steps (1 or 2) below: (1) Express a large drop of blood. Touch the end of the tube to the drop of blood (not the finger) and fill the capillary tube to approximately three-fourths full or to the indicated line. Then tip the tube with the pre-sealed end down. When the blood flows down and touches the sealant, hold it for 30 seconds to allow it to seal automatically Alternatively, place your finger over the blood-free end of the tube and seal the other end of the tube by inserting it into sealing clay. In both cases, the tube should be approximately three-fourths full before sealed

    Purpose

    The specimen needs to be without air bubbles and then sealed in preparation for centrifuging. Placing your finger over the capillary tube presents blood from dripping onto the sealing clay.

12. (2) Wipe the patient's finger with a clean, sterile gauze pad. Express another large drop of blood and fill the microtainer. Do not touch the container to the patient's finger. If more blood is needed, wipe the puncture with sterile gauze and gently squeeze another drop. Cap the microtainer tube when the collection is complete.

    Purpose

    Touching the container to the finger irritates the puncture site and may cause infection.

13. When collection is complete, apply pressure to the site with clean, sterile gauze. The patient may be able to assist with this step.
14. Select an appropriate means of labeling the containers. Sealed capillary tubes can be placed in a red-topped tube, which is then labeled. Microtainers can be placed in zipper-lock biohazard bags that are subsequently labeled.
15. Check the patient for bleeding and clean the site if traces of blood are still visible. Apply a nonallergenic bandage indicated.
16. Disinfect the work area. Dispose of blood-contaminated materials (e.g. gauze, gloves) in the biohazard waste container. Remove your lab coat and sanitize your hands.

    Purpose

    To ensure infection control.

17. Complete the laboratory requisition form and route the specimen to the proper place. Record the procedure in the patient's record.

    Purpose

    A procedure is considered not done if it is not recorded.

Knowledge-check items

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L26-01 · Venipuncture with Vacuum Tube

L26-02 · Venipuncture with Syringe

L26-03 · Venipuncture with Butterfly

L26-04 · Capillary Puncture