Phlebotomy Part 3

Review based on GDoc named "Phlebotomy 7/23/25"

Syringe and non-vacuum blood collection

Better control of suction

Vacutainer

Not suited for small veins because the strength of the vacuum can collapse the vein closed

Butterfly needle

• better control as compared to a straight needle

• useful in infants and children

• useful in difficult sticks, small, and fragile veins

What is the angle for a butterfly needle?

10 to 15 degrees

What is the angle for a straight needle?

15 to 30 degrees

What is the lancet standardized to?

2 mm

What are some factors causing hemolysis?

• sampling error

  • inject forcefully into the tube

• inappropriately stored due to temperature

• vigorously shaking of blood instead of inversion

• puncturing the vein before alcohol dries (the alcohol mixes into the sample)

• frothing of the blood when the needle end is partially inserted into the lumen of the vein

• old sample

  • collecting the sample “just in case” and not sending it to the lab immediately

Do you ever draw an extra tube of blood from the pateint?

NOOO

Icteric

yellow discoloration of serum due to high bilirubin

If you are drawing a bilirubin level on a patient, what do you do to prevent a reaction to light?

The sample must be in an amber colored tube

Lipemic

Milky or turbid appearance of serum due to high triglyceride levels

How long can you leave a tourniquet on?

1 minute

If you reach the 1-minute mark with a tourniquet, what do you do?

You leave it off for 2 minutes before you can put it back on for 1 minute

Where do you place a tourniquet?

3 to 4 inches above the injection site

As a phlebotomist, do you stick someone in the feet or legs?

NOOOO

What are some areas to avoid sticking?

• contains thrombi/clot

• feels hard (sclerosed veins)

• hematoma

• edema

• burns

• scars

• mastectomy

  • in the hospital, they will be wearing a pink band

• through the IV site

  • instead, stick below the IV site

What could potentially damage your blood sample?

Edema

Drawing blood from what kind of pateint can cause injury?

Mastectomy patients

What do you do if you have to draw blood above the IV site?

Ask the nurse to turn off the IV pump for 2 MINUTES

Heparin or saline lock

• venous access devices

• cannula inserted into the vein

• must be flushed periodically to prevent clotting

How long can a saline lock/heparin/IV remain in place?

48 to 72 hours

How do you get a sample from a patient on dialysis?

• DO NOT USE THE FISTULA ARM

• fistula = grapht = shunt

What are some causes of failure to obtain blood?

• resting against the wall of the vein

• going through the vein because the angle is too high

• the needle rests on top of the vein because the angle is too low

• a vein rolls if it is not anchored

• the vein collapses because the vacutainer is too big (too much pressure)

How to course correct if the lancet it leaning against the wall the vein and you cannot draw blood?

Rotate the needle, pull back, advance some, and change the angle of the needle

How many attempts do you have to draw blood?

2 attempts only! After that, request another phlebotomist to do it!

What is the smallest gauge needle for an adult and why?

23 gauge (any smaller, it will damage RBCs)

What is the standard gauge needle on an adult?

21 gauge

What are some causes of hemolyzed specimens (damaged RBCs)

• using a needle smaller than 23

• the needle is not attached to the syringe, causing frothing

• pulling the plunger back too fast, causing frothing

• drawing blood from a hematoma

• vigorously mixing tubes

• forcing blood into the tube

• collecting blood from IV lines

• applying a tourniquet too close to the entrance site

What are some causes of hematomas?

• failure to take off the tourniquet prior to needle removal

• inadequate pressure on the site after needle removal

• bending the arm while applying pressure

• excessive probing

• failure to insert the needle far enough into a vein

• going through the vein

• elderly patients have decreased vein elasticity

How long do you tell a healthy patient to hold pressure at the site for?

2 minutes

How long do you tell a patient taking an anticoagulant to hold pressure at the site for?

5 minutes

How long do you tell a patient to hold pressure at the site for if you hit an artery?

10 minutes

How do you treat a hematoma?

• remove the tourniquet and needle, apply pressure and ice

  • USE A COLD PACK, don’t put ice on bare skin

• Find a new site

Do you pre-label tubes?

If there is no preprinted label, yes. Do NOT label after drawing blood

What should you do if the patient has allergies to the adhesive?

Use gauze

What are some reasons of rejection of the specimen by the lab?

• unlabeled/mislabeled

• QNS (quantity not sufficient)

• wrong tube

• hemolysis

• lipemia (too much fat in blood)

• clot in a coagulation tube because the tube wasn’t inverted enough

• no requisition (no doctor’s note for the purpose of the lab)

• contaminated specimen container

What is the issue with an QNS or a short draw?

• many collection tubes contain additives (anticoagulants)

  • underfilled tubes will have higher concentrations of additives, which can cause erroneous results

Describe blood culture bottles

• come in pairs

• blood was tested for the presence of an infection

• sterile technique is critical to avoid contamination

Which blood culture do you fill first?

Aerobic bottle

Which blood culture do you fill second?

Anaerobic bottle

What is the minimum alcohol level for a prep pad to be considered an effective antiseptic?

70%

What antiseptic do you use when doing a blood alcohol test?

Chlorhexidine gluconate because it won’t skew the results

What cleansing mediums can you use to clean a site for blood cultures?

• at least 70% alcohol

• chlorhexidine gluconate

• iodine/betadine

• benzalkonium chloride

Describe peripheral (fingertip) blood smears

• a thin film of blood smears onto a glass slide

• used for microscopic examination of blood

  • hematological disorders

  • screen for malaria parasites

• on the slide, label it with a universal acronym in pen on the bottom right corner

  • CSF = cerebrospinal fluid

  • BM = bone marrow

What are some reasons that blood would be drawn?

• type and cross-match/type and screen

  • blood typing

• antibody screening

• blood donation

• therapeutic phlebotomy

Therapeutic phlebotomy

• removal of blood for the patient’s benefit

• treatment for medical conditions such as polycythemia vera (too many RBCs and hemoglobin) and hemochromatosis

• patients require close monitoring

How much blood removed can cause anemia?

3% of total blood volume

How much blood removed can cause cardiac arrest?

10% of total blood volume

What is the first choice of venipuncture site selection in the anticubital (AC) region?

Median cubital vein

Why is the median cubital vein the first choice for venipuncture?

It is large, well-anchored, least painful, least likely to bruise, and is in the middle of the arm

What is the second choice of venipuncture site selection in the anticubital (AC) region?

Cephalic vein

Why is the cephalic vein the second choice for venipuncture?

It is not well anchored, it is more painful when punctured, and it is located on the thumb side of the arm

If you have an obese patient, which of the 3 anticubital veins is the easiest to palpate?

Cephalic vein

What is the third choice of venipuncture site selection in the anticubital (AC) region?

Basilic vein

Why is the basilic vein the third choice for venipuncture?

It rides the brachial artery and on the pinky side of the arm

When would you choose a venipuncture site on the wrist or hand?

When the median cubital or cephalic veins are unsuitable or unavaliable

Should you use a straight or butterfly needle on the wrist or hand?

Butterfly needle and small evacuation tube

If the tubes contain an additive, how should you mix the sample?

Invert them gently 0 to 8 times after blood removal to mix the sample and additive

When do you mix a sample?

Immediately after drawing the specimen

Why do you mix a sample?

Most tubes contain an additive to be mixed with the blood sample

How do you mix a sample?

Holding the tube upright. GENTLY invert 180 degrees and back 0 to 8 times

What are some consequences if a sample is mixed improperly?

• the blood can clot and the specimen may need to be redrawn

• if it mixed too vigorously, hemolysis can occur

Pre-analytical phase

The doctor has ordered the lab work, you are aware that you are drawing blood, but you are not with the patient yet

Analytical phase

When you are with the patient and actively drawing their bloodword

Post-analytical phase

When you are done drawing the blood, it is sent to the lab, and the results are available for review by the doctor/patient

What are the most common causes of needle stick injuries?

• safety device not activated

• hand-off (exchange) of needle device after use

• improper disposal

• manipulating the needle within the patient

• patient moves during the procedure

What are some safety tips to avoid needle stick injuries?

• pre-plan for the disposal of the needle prior to the procedure

• ALWAYS activate the safety device on the needle

• work in good lighting

• immediately dispose of used needles

• do one thing at a time

• explain the procedure to the patient

What should you ALWAYS do when labeling samples?

• verify that the information on the tube labels matches the information on the order slip and patient ID band

• label tubes BEFORE they are drawn in the presence of the patient to reduce the risk of specimen misidentification

• if additional information must be added to the label (e.g., fasting, time of draw), write with ink, never in pencil

What should you NEVER do when labeling samples?

• label tubes after the venipuncture

• leave a patient room before labeling the tubes

How should you send a sample to the lab?

• place the labeled tube in a biohazardous specimen collection bag

• status specimen as “collected” in the computer

  • make sure the time of collection is accurate and print the requisition

• to ensure accurate result times in the computer, NEVER status a specimen as “collected” until the specimen is in your hand

• securely attach the paper requisition in the pocket of the collection bag with the tube

• immediately transport the specimen to the lab

What fingers do you stick for capillary punctures?

Middle and ring finger

For a capillary puncture, do you stick the whorls?

NEVER; avoid the apex of the fingerprint

For a capillary puncture, do you stick the side of the finger?

YES

How do you prep a finger for a capillary puncture?

• massage to warm the finger and increase blood flow by gently squeezing from the hand to the fingertip 5 to 6 times

• cleanse fingertips with 70% isopropyl alcohol and always allow to completely air dry

• using a sterile retractable lancet, make a skin puncture just off the center of the finger pad

• NEVER use the first drop of blood

Is the first or second drop for a finger stick the test drop?

• NEVER use the first drop of blood

  • wipe away the first drop of gauze because it is too saturated with alcohol, which can impact the accuracy of the result

• The second drop of blood is the test drop

What is the age limit for a heel stick?

2 years old

What is the maximum depth a lancet can puncture?

2.0 mm

Do you stick a heel in the center? Why or why not?

DO NOT stick in the center of the heel because you can puncture the calcaneus bone, potentially causing osteomyelitis

Do you use the first or second drop of blood for a heel stick?

The second drop is the test drop

How do you do an ink blot card?

• only applies to kids

• SATURATE each circle on the ink blot card with capillary blood

How do you dry the ink blot card?

Lie the card on a flat, dry surface and let it air dry

Arterial blood gas (ABG)

• Drawn from the radial artery (typically)

• measures gas exchange of oxygen and carbon dioxide

Where is an ABG drawn from?

An artery

What does an ABG get drawn into?

A syringe

How many times do you invert an ABG?

You DON’T. You roll it between your palms

How is an ABG transported to the lab?

On ice

Allen test

A test on the hand that analyzes circulation

What are the parts of a needle?

The bevel (includes the lumen), shaft, and hub