Module 12: Phlebotomy

Question 1

Phlebotomy definition

Answer 1

Withdrawing blood from a vein for laboratory testing. Performed according to laboratory guidelines, adhering to OSHA blood-borne pathogen standards and sharps safety protocols.

Question 2

What order details require verification phlebotomy?

Answer 2

Ordering provider
Test and test code
Diagnosis code
Specimen requirements - ex: fasting
Patient demographics
Insurance or other billing information

Question 3

What are special testing samples?

Answer 3

Blood tests that require specific timing, patient preparation, or particular handling of blood samples

Blood cultures require specific preparation of the skin, multiple tubes, and specific specimen labeling

Consult the facility laboratory reference manual

Question 4

What are some factors to consider before blood collection?

Answer 4

Basal state (early morning), fasting status

Condition of venipuncture site - if veins are sclerotic or if skin is scarred, evaluate an alternate location.

Stress- can cause elevation in white blood cells, decrease in iron levels, and abnormal hormone levels

Menstrual cycle, edema, current medications, infections, vomiting, pregnancy.

Hemoconcentration can occur if tourniquet is left on the patient longer than recommended 60 seconds

Question 5

What four pieces of information needs verification against requisition form prior to blood draw?

Answer 5

Provider’s order
Patient’s identity
Labeling of the specimens
Identification number of the specimens

Question 6

Procedure for introductions, identification of patient before blood draw

Answer 6

Introduce yourself to patient and confirm purpose for blood collection; give a concise explanation of the procedure

Confirm patients name, DOB< any other needed demographic information.

Present a calm, professional demeanor

If test requires fasting, ask the patient when the last time they ate or drank anything
If testing for drug levels, ask patient when they last took any medication- names and dosages

Question 7

Vasovagal response; precautions

Answer 7

AKA vasovagal syncope - body overreacts to certain triggers such as the sight of blood or extreme emotional distress

Always question patients about previous blood draws and what their reactions have been; check patient’s response throughout the blood collection procedure either casually or specifically

Question 8

Purpose of standard phlebotomy supplies:

Gloves
Tourniquet
Isopropyl alcohol wipes

Answer 8

• Gloves: Ask patients about the possibility of latex allergies as part of the screening questions prior to assembling phlebotomy supplies.
• Tourniquet: Some facilities use latex tourniquets; screening questions about latex allergies with gloves will provide information regarding this issue.
• Isopropyl alcohol wipes: Standard for skin preparation for all draws except blood cultures.

Question 9

Purpose of standard phlebotomy supplies:

Nonalcohol prep kits or swabs
Nonsterile gauze
Cohesive wrap or paper tape

Answer 9

• Nonalcohol prep kits or swabs: Used for blood cultures; can include povidone-iodine or chlorhexidine gluconate swabs.
• Nonsterile gauze: Typically 2 × 2 size; avoid cotton balls.
• Cohesive wrap or paper tape: Applied postprocedure to aid in hemostasis.

Question 10

Purpose of standard phlebotomy supplies:

Double-pointed needle
Butterfly needle
Blood collection tube

Answer 10

• Double-pointed needle: Typically 21- to 22-gauge; requires connection to plastic needle holder or sleeve.
• Butterfly needle: Also called a winged infusion; used for weak or fragile veins prone to collapse, such as in hand draws.
• Blood collection tube: Also called vacuum tube; sterile glass or plastic tube with a vacuum inside and a rubber, color-coded top to indicate chemical additive.

Question 11

Purpose of standard phlebotomy supplies:

Plastic or glass capillary tube; clay sealant tray
Sterile syringe, needle, and syrine transfer device
Laboratory requisition and labels
Ice or chemical cold packs

Answer 11

• Plastic or glass capillary tubes with clay sealant tray: Used for capillary blood testing; clay creates a seal at one end of the tube to avoid loss of the specimen.
• Sterile syringe, needle, and syringe transfer device: Used for syringe draws when a butterfly needle is not available.
• Laboratory requisition and labels
• Ice or chemical cold packs: Used for post procedure care as needed

Question 12

Vacuum tube with yellow stopper

Answer 12

Contains SPS - Sodium polyanethol sulfonate

SPS for blood culture specimen collections in microbiology

Question 13

Vacuum tube with light blue stopper

Answer 13

Sodium citrate (anticoagulant)

Coagulation studies

Question 14

Vacuum tube with red stopper

Answer 14

Plastic: clot activator, Glass: no additive

Question 15

Vacuum tube with gold/tiger top (red-grey) stopper

Answer 15

SST - Serum separator tube
Clot activator
Thixotropic gel

Question 16

Vacuum tube with green stopper

Answer 16

Sodium heparin, Lithium heparin

Plasma determinations in chemistry

Question 17

Vacuum tube with lavender stopper

Answer 17

EDTA (anticoagulant)

White blood hematology

Question 18

Vacuum tube with gray stopper

Answer 18

Potassium oxalate, sodium fluoride

Glucose testing

Question 19

“Order of the draw”

Answer 19

Adhering to the accepted order of the draw ensures collected specimens produce accurate results

Yellow -> Light Blue -> Red -> Gold/Red-gray -> Green -> Lavender -> Gray

Question 20

Methods of allowing easier selection for veins

Answer 20

Warming the site to increase blood flow, tourniquet, palpation, infrared vein scanner

Question 21

Infants 6 months of age site selection venipuncture

Answer 21

Most often only heel stick and capillary blood specimen

Question 22

6 months to 2 years site selection venipuncture

Answer 22

Typically finger stick, but traditional venipuncture occasionally if more extensive testing

Question 23

2 years and older site selection venipuncture

Answer 23

Traditional venipuncture is routine

Question 24

Medical restrictions for site selection venipuncture

Answer 24

Fistulas - abnormal connection between vessels (or organs)
Ports - small medical appliance beneath the skin
Mastectomy - surgery to remove breast (generally no usable veins left on that side)

Be cautious, use guidance from provider and lab

Question 25

Preferred area for venipuncture: general area and three specific veins; backup areas

Answer 25

Antecubital space - interior forearm by elbow

Lateral to Medial:
Cephalic vein
Median cubital vein
Basilic vein

If those veins are inaccessible, the hand, wrist, and foot are also options

Question 26

Risk of blood draws from the foot

Answer 26

Deep vein thrombosis - should only be performed under the supervision of a physician

Question 27

Difficulties with venipuncture on older patients (Skin integrity and venous sufficiency with age)

Answer 27

As we age our muscles atrophy, veins lose their elasticity and venous insufficiency occurs. Veins are prone to roll, they are fragile and easily damaged by venipuncture

Veinous insufficiency is when our veins cannot properly function to pump blood back to our hearts

Question 27

Preparing for venipuncture: positioning, handling of supplies, cleansing

Answer 27

POSITIONING: seat the patient in comfortable, well-lit area. For patients who have a fainting history, position in semi-Fowlers (back of table lowered to 45*) or laying down.
Patient with arm extended to form a straight line from the shoulder to the wrist, and the palm of the hand facing upward.
Can have patient make a fist with opposite hand and place behind elbow of arm being used for the procedure.
Fleet flat on floor with good posture.

SUPPLIES: All necessary supplies within reach. Hold the needle in dominant hand, avoid switching hands once skin has been penetrated. Engage needle safety devices when disposing of a needle in the sharps container

CLEANSING: Disinfect with 70% alcohol, concentric circles of increasing diameter. Allow skin to air dry. Do not blow or wave hands - this contaminates the site.

Question 28

Evacuated tube method for venipuncture
1. Before
2. Tourniquet
3. Venipuncture
4. Post draw care

Answer 28

Most common method. Straight double-ended needle with color-coded vacuum tubes. Discard tube if top is removed or compromised.

1. Verify order and patient identity, ask necessary questions (fasting, allergy to latex, blood thinners, etc), wash hands and apply nonsterile gloves prior to handling supplies/selecting a vein. Appropriate needle gauge usually 21 to 22. Needles must be sterile and have locking safety device.
2. Place tourniquet under arm, 3 to 4 inches above the site. Never leave longer than 1 MINUTE. Wait 2 minutes before reapplying if necessary.
3. Anchor vein by grasping firmly with the thumb 1 in below the draw site, holding skin taut. Hold the needle/sleeve unit in the dominant hand and insert the needle with the bevel facing upward at angle of 15 TO 30 DEGREES. Use nondominant hand to place tube, take caution needle is not pushed further into the arm or pulled out from the skin. Use correct ORDER OF THE DRAW. Release tourniquet with nondominant hand
4. Place gauze over the draw site. Remove the needle and apply pressure. Dispose of needle sleeve unit in sharps container. Have patient apply pressure to gauze and elevate the arm for 2 minutes, keeping it straight. Gently invert vacuum tubes, label immediately following the procedure

Question 29

Syringe method for venipuncture

Answer 29

Needle selection same for vacuum tube procedures, syringe size depends on amount of blood required.
Same rules for tourniquet (3 to 4 in above, no more than a minute)
Same rules for needle insertion (Hold skin taut, angle of 15 to 30 degrees)

Pull the plunger slowly. Syringe draws are typically used if vein is fragile - be careful.

Question 30

Butterfly method for venipuncture

Answer 30

Same as vacuum tube draw - only difference is needle

Takes more time that traditional straight-needle due to smaller gauge/length of tubing. Pay more attention to tourniquet time.
Use locking safety device following procedure prior to sharps disposal.

Question 31

Tube inversions: purpose and procedure

Answer 31

Vacuum tubes additives should be gently inverted for mixing. Completely turn the tube upside down and return it to its upright position. Invert three to 10 times according to manufacturer instructions. Do not shake or forecfully invert due to risk of hemolysis.

Question 32

Capillary puncture definition and purpose/limitations

Answer 32

AKA finger sticks, used when only a small amount of blood is needed or when immediate results are required. Capillary blood is a mixture of blood from arterioles, venules, capillaries, and intracellular/interstitial fluids - not all testing should use capillary blood.

Question 33

Capillary puncture supplies

Answer 33

• Nonsterile gloves
• Automatic retractable lancets
• Disinfectant pads, such as 70% isopropyl alcohol
• Clean gauze pads
• Bandage wraps
• Micropipette
• Blood collection device appropriate for the test
  o Small glass tube (capillary tube)
• Microcollection tube
• Glass microscope slide
• Reagent strip
• Screening card or paper
• Plastic testing cartridge or cassette
• Capillary tube sealer (when capillary tubes are used)
• Biohazard sharps container

Question 34

Location of capillary puncture

Answer 34

Preferred site is middle or ring finger of nondominant hand. Perform the puncture slightly off center.
Perform infant capillary puncture on outer edge of underside of the heel.

Question 35

Preparing site for capillary puncture

Answer 35

Warm the patient’s hand prior to the procedure . Prep the skin with 70% isopropyl alcohol, allow to air dry completely.

Question 36

Performing capillary puncture

Answer 36

Hold the patient’s finger between your thumb and forefinger firmly but gently. Hold the lancet device in the dominant hand and at a right angle to the puncture site. Discard used lancet into sharps container.

Always wipe away the first drop of blood - it’s contaminated with tissue fluids.
If blood is slow to flow a gentle pressure may be applied, but avoid milking the finger.

Place a clean gauze pad over the puncture site, ask the patient to apply pressure to the area. Properly handle container specimen.
Once blood flow has slowed or stopped, a bandage may be applied - elevate the arm over the level of the heart if necessary to aid in hemostasis

Question 37

Order of draw for microcapillary tubes

Answer 37

Blood gases -> EDTA tubes -> Other additive tubes -> Serum tubes

Question 38

Discharge instructions post-phelbotomy

Answer 38

Leave bandaging in place for at least 15 minutes (longer in some cases ex: donating blood). If the patient has a reoccurrence of bleeding, radiating pain, or dizziness, the clinic should be notified

Question 39

Handling of phlebotomy specimen

Answer 39

PPE must be applied to prevent injury and avoid exposure. Change PPE between each patient.
Each specimen has specific handling instructions.

Time management is crucial in processing of specimens

Allow serum specimens to clot prior to centrifugation, typically 30 minutes. Balance tubes in centrifuge by inserting across from each other

Question 40

Aliquot samples; procedure

Answer 40

When a single specimen must be divided into multiple tubes for testing on different equipment

Use a single-use pipette for transfer of the serum from one tube to another. When transferring blood in the physicians office laboratory (POL) between containers, wear face and eye protection and use a tube rack. Never pour blood specimens from one container to another. Always use a disposable pipette.

Question 41

Most laboratory errors occur due to:

Answer 41

Mislabeling of specimens: continually match specimen to completed lab requisition

Question 42

Storage of blood specimens

Answer 42

All specimens should be placed into a clearly marked biohazard bag.

Some must be stored at 37C (98.6F). Some must be wrapped in foil for light sensitivity, or in slurry of ice

Use a separate biohazard bag for each patient’s specimens

Question 43

Lab procedure abnormal test results

Answer 43

Authorized lab supervisor should repeat and verify abnormal or critical results. Some require immediate notification of physician, but not all abnormal results are critical. Provider should review all lab reports before being uploaded to a patient’s chart

Forward laboratory results to ordering physician. Medical assistant is responsible for notifying patients of their results or scheduling follow-up appts for patients to review results with the provider