Principles of Medical Laboratory Science Practice 2 (LAB) 1

EXERCISE NO. 1: Proper Hand washing EXERCISE NO. 2: Donning and Doffing of PPE

Hand washing Personal Protective Equipment

 single most important way to prevent the spread of  Used by the Phlebotomist, may include:
infection o Gloves
 the best choice or method of choice for the removal of o Gowns
any bacteria and viruses from the skin o Masks
Alcohol-based cleaners o Respirators
o Goggles or Face shields
 acceptable in place of hand washing when hands are not
 These equipment serves as a barrier of protection for the
visibly soiled
skin, mucous membrane and clothing of the phlebotomist
from infectious materials
Both hand washing and the use of alcohol based cleaners reduce the
Proper Donning and Doffing of these PPE are both necessary to
number of microorganisms but do not totally eliminate them
AVOID contaminations of the health of the health care provider, as
well as to PREVENT spread of infections from one patient to another
When should hand washing be performed?
(or to protect the patients as well)
 Upon arrival at the work area
 Before & after patient contact
Nosocomial Infection— or also known as Hospital-acquired
 Before touching the eyes, nose and mouth
infection/ Health care related infection is an infection that develops
 Before leaving the work area
in a patient 48 hours or more after admission to a hospital or health
 Before & after using bathroom facilities
facility
 After touching garbage
 After touching public installations (e.g. door knobs) Resources
 At any time when they have been knowingly contaminated
 Disposable gown/ Laboratory gown
Direct contact— common way of infection  Disposable mask/ goggles/ face shields
Resources:  Disposable cap
 Sink with running water  Gloves
 Liquid hand washing soap  Disposable shoe covers
 Disposable paper towel  Biohazard waste container
 Nailstick and/or brush— used for the first wash of the day Donning PPE Sequence
or when hands become excessively soiled  Gown
 Waste container  Mask
 Goggle/Face shield
Procedure:  Cap
1. Remove all watches, rings and other jewelry – to avoid  Shoe cover
contamination Doffing PPE Sequence
2. Have disposable towels ready or use automatic towel dispenser
 Gloves
3. Stand back from the sink so that you and your clothing do not
 Goggles/Face shield
touch the sink
 Gown
4. Turn on the water with the foot pedal or with a disposable
towel if not foot controlled  Mask
5. Wet hands and wrists under running water. Be careful not to  Cap and Shoe cover
touch the sides of the sink
6. Apply soap and lather whole hands and wrists well Procedure A: Donning of PPE
7. Sequence of scrubbing: Scrub for at least 15-20 seconds 1. Determine the extent of necessary isolation. Not the type of
a) Right palm over left, finger interlaced; vice versa isolation from wither the isolation signage or by consulting the
b) Palm to palm, fingers interlaced patient’s nurse
c) Back fingers to opposing fingers interlocked 2. Remove rings, watches and jewelry unnecessary for patient
d) Rotational rubbing of right thumb clasped in left palm; vice care
versa 3. Place any items that you will need for patient care outside of
e) Rotational rubbing backwards and forwards with tops of the patient’s rooms. Do not take the phlebotomy tray or cart
fingers and thumb of right hand on left; vice versa into the room
f) Scrubbing of wrists 4. Wash hands. If you have been wearing a laboratory coat,
8. Rinse hands with water flowing downward off the fingertips – remove first and leave it outside your room
so that contaminants will be washed off directly to the sink 5. Wearing of the gown.
9. Dry hands and wrists with disposable towels a) Place the gown to cover outer garments completely
10. Turn off water with disposable towels if sink is not foot b) Place the gown in front you your body and place your arms
controlled through the sleeves
The purpose of lathering and scrubbing— to remove dirt and c) Tie the top strings on the gown behind the neck, then tie
bacteria especially on the areas of our hands with crease the lower strings behind your back
Note: Procedure 5-8 should be done twice for the first hand wash of 6. Apply the mask by placing the top of the mask over the bridge
the day of the nose and pinch the metal strip to fit the nose

“Yes, it's going to be hard but it's going to be worth it.”

Simran Misha
 Principles of Medical Laboratory Science Practice 2 (LAB) 2

a) For masks with ties: tie the top strings of the mask so the o Vein that is used to majority of the time
strings are positioned above the ears, then tie the lower o Easiest to palpate and has less tendency to roll
strings behind the neck and adjusted to cover nose and than other veins
mouth 2. Cephalic veins – second choice for venipuncture
b) For masks with straps: mask is held in place with one hand
o Follows along the thumb side of the arm
while the other hand places the straps behind the ears and
adjusted to cover nose and mouth o Not prone to rolling, but it slightly more difficult
7. If necessary, wear goggle or face shield to feel
8. If necessary, apply the cap to cover hair and ears. Pull long hair 3. Basilic veins – third choice for venipuncture
up under the cap o More difficult to feel and has tendency to roll
9. If necessary, wear shoe covers o Underlying is the brachial artery and median
10. Put on the gloves without touching the external surface cutaneous nerve (major nerves)
Procedure B: Doffing of PPE
You should not just look for the vein, you should feel the vein
1. Removal of the gloves
a) Hold hands out away from the body Resources
b) Grasp the palm of one hand, and pull down the glove to  70% Alcohol
pull the glove inside out. Do not touch the bare skin with  Tourniquet
contaminated gloves  Cotton (wet and dry)
c)  Gloves
d) Contain the inverted glove completely in the gloved hand
e) Insert two fingers of the ungloved hand under the cuff of Procedure
the glove of the other hand 1. Wear appropriate PPE
f) Pull down the glove and contain the other glove inside out. 2. Select the best puncture site
This will invert the glove and contain the other glove inside
Notes: Avoid sites with:
the second glove
g) Dispose the gloves into a biohazard container  Edematous arms
h) Wash hands with running water  Arms in casts
2. If applicable, remove goggles or face shield and place it on the  Arms with IVs – stop the IV for at least 2 minutes; first
are for contaminated goggles
barrel drawn should be discarded
3. Removal of the gown
a) Untie the lower strings of the gown first, then top strings  Arms with Cannulas, Fistulas,
b) Slip the finger of one hand inside the cuff of the gown and  Arms with Extensive Scaring such as burns (dehydrated
pull the gown over the hand area) or hematomas
c) Using the hand covered by the gown, pull the gown down  Arms on the side of mastectomy (lymph fluids moves in
over the other hand faster resulting to the WBC to increase in number)
d) Pull the gown of your arms. Hold the gown away from you
 Birthmarks/moles
and roll it into a ball with the contaminated side inside the
ball. Dispose the gown in biohazard container  Arms with tattoos
4. Removal of the mask: 3. Position the patient’s arm slightly bent in a downward position
a) For masks with ties: untie the lower strings, then the top 4. Tourniquet application
strings. Touch the ties of the mask only. Dispose into a Place Tourniquet 3 to 4 inches above the selected puncture site
biohazard container (this is to prevent hemolysis and if it’s near the venepuncture
b) For masks with straps: Remove the mask by pulling the
site, the blood flow might stop/ slow down)
straps only
5. If applicable, remove cap and shoe cover without touching their a) Cross the tourniquet over the patient’s arm
external surface b) Tuck the portion of the left side under the right side to
6. Wash hands and retrieve the items that were left outside the make partial loop facing the puncture site.
room The free end should be away from the puncture area.
EXERCISE NO. 3: Selecting and Disinfecting the Proper Make sure there are no folds when applying the
Venipuncture Site tourniquet
Veins that the phlebotomist will use are located in the: Note: Tourniquet should only be applied not more than 1 minute—
 Antecubital fossa (bend of the arm) the specimen might hemolize or hemoconcentrated (decrease in
 Back of the hand fluids, increase of solutes)
 Wrist 5. Ask the patient to make a fist. This makes the vein more
 Ankle or foot palpable
Antecubital fossa – Preferred venipuncture site 6. Palpate the vein using the tip of the index finger or middle
fingers in a vertical and horizontal direction to determine the
Veins—are near the surface and large enough to give access to the depth, direction, and size of the vein
blood; frequently form M- or H-shaped pattern Note: The basilic vein should be avoided if possible
1. Median cubital vein – center of the antecubital fossa 7. Release the tourniquet and have the patient open his/her fist
o Forms a bridged pathway between cephalic and 8. Cleanse the area with 70% alcohol in a circular motion from the
basilic veins center to the outside
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
 Principles of Medical Laboratory Science Practice 2 (LAB) 3

9. Allow the area to dry  Chemistry Test& Serology

 Serum
EXERCISE NO. 4: Blood Collection Tubes and Order of Draw Serum Tube
 Red top
 Has clot activators
Evacuated Tubes  No anti-coagulant
 most frequently used for blood collection because they  Chemistry Test& Serology
contain a premeasured amount of vacuum  Serum
 amount of blood in an evacuated tube is dependent on Rapid Serum Tube
the size of the tube and the amount of vacuum present  Orange top
 a wide variety of sizes is available to accommodate adult,  Has clot activators
 STAT request
pediatric, and geriatric patients
 Thrombin— Anti-coagulant
 Available in glass and plastic
 Chemistry Test& Serology
Color coding— indicates the type of sample that will be  Serum
obtained when a particular tube is used
Plasma Separator Tube
Test may be run on: Plasma, Serum or Whole Blood  Light Green & Tiger top
Test may also require the presence of: Preservatives,  Heparin – Anti-coagulant
Inhibitors, clot activators, or barrier gel  Plasma Chemistry Test (Routine Chemistry)
Clotting time— if you need to centrifuge the blood  Plasma
Inversions— figure of 8, prevents hemolysis Heparin Tube
 Green
 Plasma Chemistry Test (Routine Chemistry)
 Plasma
Ethylenediaminetetracetic Acid (EDTA) tube
 Purple/Lavender Top
 Hematology
 HbA1C
Plasma Preparation Tube (PPT)Separator Tube
 Anti-coagulant: EDTA
 Molecular Diagnostics
Fluoride Tube
 Also known as Glycolytic Inhibitor Tube
 Fluoride inhibits Glycolysis (not an Anti-coagulant)
 Glycolysis affects alcohol level
 Glucose Testing, Alcohol Testing
 Anti-coagulant: Potassium Oxalate sometimes EDTA
 Plasma
Tan Top
 Serum Lead determinations
 Less than 0/01 μg of Lead
Royal Blue Top
Blood Culture Tube (Sodium polyanethol sulfonate)
 Toxicology
 Yellow Top Bacteriology
Black Top
 First to in order of draw
 Requires specimen to be completely sterile  Westergren Sedimentation rate
 Bacteriology  4:1
 Whole Blood  3.8% Sodium Citrate
Pink Top
Citrate Tube
 Light Blue top  K2EDTA
 Sodium Citrate 3.2%  Immunohematology
 Very sensitive to the proportion of anti-coagulant to blood
ratio (AC 1:9 B) Anti-coagulants
 Coagulation Test— associated with clotting (e.g. Potassium Oxalate/ Sodium Fluoride
Prothrombin Time (PT); Activated Partial Thromboplastin  Works by precipitating out the calcium in the blood and
(APTT); Partial Thromboplastin Time (PTT)) therefore stopping the coagulation cascade
 Plasma  Primary function: Glycolytic inhibitor
Serum Separator Tube Sodium Citrate
 Gold and Tiger top  Prevents the coagulation by binding calcium in a non-
 Has clot activators ionized form
 Glucose, protein, lipids, enzymes  3.8% Sodium Citrate or 3.2% Sodium Citrate
concentrations (most widely used)
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
 Principles of Medical Laboratory Science Practice 2 (LAB) 4

 1 anti-coagulants:9 parts of blood Procedure 1: Syringe Method

Sodium Polyanethol Sulfonate (SPS) 1. Examine the requisition form upon receiving
 Main function: allow bacteria to grow so they can be 2. Greet the patient. Identify patient by having the patient
cultured verbally state his/her full name and confirm with the patient’s
 (a) Inhibits the phagocytosis of the bacteria by the white requisition form (outpatient and in-patient) and/or hospital
blood cells; (b) Inhibits serum complement, which would identification number (in-patient).
destroy the bacteria; and, (c) Inhibits certain antibiotics in 3. Verify diet restrictions, latex allergy, and if the patient had
case a patient is already on an antibiotic previous problems during any phlebotomy procedure
Ethylenediaminetetraacetic Acid (EDTA) 4. Explain the procedure. Position and reassure the patient
 Binds Calcium to prevent Coagulation 5. Perform hand hygiene
 K3EDTA – used in glass tubes and is in liquid form 6. Prepare all the equipment
 K2EDTA – used in plastic tubes and is in spray-dried a) Prepare the appropriate tubes and place them in the
powder form; anticoagulant in Hematology; preserved cell correct order for aliquoting
morphology for CBC and differential blood smears; b) Ensure that other materials are complete: syringes and
provides stable haematocrit results needle, tourniquet, wet and dry cotton, and adhesive tape
Heparin 7. Choose the best puncture site
 Stops the coagulation by inhibiting the conversion of 8. Apply the tourniquet
prothrombin to thrombin and thus the following stages 9. Ask the patient to make a fist
that lead to a clot 10. Select the most suitable vein for puncture
 Naturally occurring substance that is present in most of Note: Palpate using the tip of the index finger or middle finger. Even
our tissues but at low levels if the vein is visible, palpate to determine the vein location and path
 Produces least stress on erythrocytes and minimizes 11. Release tourniquet then cleanse the area with 70% alcohol in
hemolysis concentric circles, working from the center to outside. Allow
 For pH determinations, electrolytes studies, and arterial area to dry
blood gases 12. While allowing the puncture site to dry, put on the gloves.
 Not acceptable for blood sample that may be stored for Open the sterile syringe packages, attaching the needle if
more than 48 hours before testing necessary. Pull the plunger away halfway and push it all the
way in
EXERCISE NO. 5: Venipuncture 13. Reapply the tourniquet. Ask the patient to make a fist again
14. Hold the syringe with the dominant hand. Uncap and inspect
Phlebotomy
needle. Align the needle in the same direction as the vein. The
 Process of collecting blood sample for laboratory analysis needle should be in the bevel up position (needle opening
to diagnose and monitor medical conditions facing upward)
Venipuncture 15. Using the thumb of the non-dominant hand, pull the patient’s
 Most common procedure in phlebotomy skin tightly 1 to 2 inches below the puncture site
 16. Using one deliberate, smooth motion, insert the needle in the
 Done by penetrating the vein with a needle to draw blood same direction as the vein at approximately 150 -300 angle with
Three Methods used in Venipuncture the skin until there is a lessening of resistance. Blood back flow
 Syringe method— most commonly used in the Philippines will be seen if the vein was penetrated properly
and developing countries 17. Brace the fingers in the patient’s arm. Pull the plunger gently
 Evacuated Tube System (ETS) / Method— most with the non-dominant hand and establish blood flow
commonly used method in the US and other developing 18. Draw the desired volume of blood for the examination
countries Note: If more blood is needed, replace the barrel with another
 Butterfly (Winged Infusion Set) System/ Method – used barrel. The needle should remain in the vein. Place clean
for people with thin veins cotton/gauze under the needle during this procedure to catch blood
a) Using ETS while making the change
b) Using a syringe 19. Ask the patient to open fist. Release the tourniquet
Mortal Sin— Mislabeling of Medtechs 20. Apply the dry cotton lightly over the punctured site and
withdraw the needle smoothly
Avoid misidentification to avoid misdiagnosis 21. Instruct the patient to apply pressure on the punctured site for
Resources 3-5minutes. Do this procedure for the patient after aliquoting
 ETS Tube holder w/ multi-sample needle (20, 21, 22) the blood if unable to
 Syringe with multi-sample needle (21,23) 22. Aliquoting the blood:
 Butterfly needle a) Follow the correct order of draw
 70% alcohol b) Aliquot the blood into the tubes by puncturing the rubber
 Evacuated Tubes stopper using the needle of the syringe
 Tourniquet c) The tube and the syringe must be in a vertical position
 Micropore tape d) Invert the tubes as necessary as possible right after filling
 Cotton balls (wet and dry) them
 Yellow bag Note: Do not push the plunger while filling the tubes
 Sharps Container 23. Dispose the puncture equipment and other bio hazardous
wastes.
24. Recheck the patient’s identification
25. Label all the tubes correctly
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
 Principles of Medical Laboratory Science Practice 2 (LAB) 5

26. Examine the puncture site and apply adhesive bandage until there is a lessening of resistance. Blood will fill the tube if the
27. Remove the gloves. Perform hand hygiene vein was penetrated properly.
28. Thank the patient 17. Hold the butterfly needle in place.
Note: For multiple draws that require both hands to manipulate
NOTE: The phlebotomist should converse appropriately with the tubes, the butterfly needle may be temporarily taped down to left in
patient through the procedure place
18. Pull the plunger gently with the non-dominant hand and
Procedure 2: Evacuated Tube System (ETS) establish blood flow
1-12 same as syringe method 19. Draw desired blood flow for the examination
13. While allowing puncture site to dry, put on the gloves. Prepare Note: If more blood is needed, replace the barrel with another
the materials needed. ETS Preparation: barrel. The needle should remain in the vein. Place clean
a) Break the needle seal and thread the appropriate needle cotton/gauze under the needle during this procedure to catch blood
into the holder while making the change
b) Tap all tubes that contain additives to ensure that all the 20. Ask patient to open fist. Release tourniquet
additive is dislodged from the stopper and wall of the tube 21. Apply dry cotton lightly over the punctured site and withdraw
c) Insert the tube into the holder until the needle slightly the needle smoothly
enters the stopper 22. Instruct patient to apply pressure on the punctured site for 3-5
14. Reapply the tourniquet. Ask the patient to make a fist again minutes. Do this procedure for the patient after aliquoting the blood
15. Hold the ETS with the dominant hand. Uncap and inspect needle. if unable to
Uncap and inspect needle. Align the needle in the same direction as 23. Aliquoting the blood:
the vein. The needle should be in the bevel up position (needle a) Follow the correct order of draw
opening facing upward) b) Aliquot the blood into the tubes by puncturing the rubber
16. Using one deliberate, smooth motion, insert the needle in the stopper using the needle of the syringe
same direction as the vein at approximately 150 -300 angle with the c) The tube and the syringe must be in a vertical position
skin until there is a lessening of resistance. Blood will fill the tube if d) Invert the tubes as necessary as possible right after filling
the vein was penetrated properly. Release the tourniquet once them
blood start filling the tube Note: Do not push the plunger while filling them
17. Brace the fingers in the patient’s arm while the non-dominant 24. Dispose the puncture equipment and other bio hazardous
hand manipulates the removal and insertion of tubes wastes
18. Fill the tubes until vacuum is exhausted. The after filling the first 25. Recheck the patient’s Identification
tube, remove tube gently and invert the tube as necessary right 26. Label all the tubes correctly
after filling it. Do these procedure until the last tube needed 27. Examine the puncture site and apply adhesive bandage
19. Apply the dry cotton lightly over the punctured site 28. Remove the gloves. Perform hand hygiene
and withdraw the needle smoothly. Instruct the patient to 29. Thank the patient
applypressure on the punctured site for 3-5 minutes
Note: The phlebotomist should converse appropriately with the
20. Dispose the puncture equipment and other bio hazardous
patient through the procedure
wastes
21. Recheck the patient’s Identification
Requisition form details:
22. Label all the tubes correctly
23. Examine the puncture site and apply adhesive bandage  Name
 Birthday Main
24. Remove the gloves. Perform hand hygiene
25. Thank the patient  Hospital Identification Number
 Gender
Note: The phlebotomist should converse appropriately with the  Time requested
patient through the procedure  Diagnosis (as well as the test that the patient should
undergo to know the type of tube to use
Procedure 2: Evacuated Tube System (ETS) NOTE: Any discrepancy noticed, requisition form should be returned
to the nurse
1-12 same as syringe method
13. While allowing puncture site to dry, put on the gloves. Prepare
Diet Restrictions:
the materials needed. Preparation:
a) Open the sterile syringe packages, remove the needle if  Fasting Blood Sugar – 6-8hrs
necessary  Lipid Profile— 12-16hrs
b) Pull the plunger away halfway out and push it all the way
in Proper labelling should include:
c) Open the butterfly needle system package, attaching the  Name
syringe to the needle system  Age
14. Reapply the tourniquet. Ask the patient to make a fist again  Time of Collection
15. Hold the butterfly needle system with the dominant hand.  Gender
Uncap and inspect needle. Uncap and inspect needle. Align the  Date
needle in the same direction as the vein. The needle should be in the  Initials of Phlebotomists
bevel up position (needle opening facing upward) One-hand technique— to avoid accidental prick
16. Using the dominant hand, insert the needle in the same Do not bend arm to apply pressure – can cause hematoma
direction as the vein at approximately 150 -300 angle with the skin

“Yes, it's going to be hard but it's going to be worth it.”

Simran Misha

EXERCISE NO. 6: Collection for Blood Culture
In blood culture, strict aseptic technique—removing all the
microorganisms in the area; removal of microorganisms— is
required because skin is covered with microorganisms. Improper
aseptic technique would cause a false positive culture—
microorganisms from the skin and not from the blood; and sepsis—
bacterial infection in the blood
An anticoagulant—either SPS is used or SAS (does not inhibit
bacterial growth and may infact, enhance it by inhibiting the action
of phagocytes, complement and some antibiotics) — must be
present in the tube or blood culture bottle to prevent
microorganisms from being trapped within a clot, where they might
be undetected; therefore, blood culture bottles must be mixed after
the blood is added.
Sodium PolyanetholSulfonate
 Inhibits complement; part of the immune system; makes the
bacteria explode (bacteriolysis)
 Prevents bacteria from being trapped in the clot, might not
grow
 Promotes the growth of bacteria through preventing
phagocytosis
Best Time for Blood Collection:
(1) During the height of fever— bacteria has the most number
during this time in the blood stream; fast growth of bacteria
(2) Before the Administration of Antibiotics— antibiotics kills
bacteria
Should collect at least two (2) bottles from different puncture sites
Procedure
1. Obtain and examine the requisition form
2. Greet the patient.
3. Identify the patient by having that patient verbally state
his/her full name and confirm with the patient’s
requisition form (outpatient and in-patient) and/or
hospital identification number (in-patient)
4. Verify diet restrictions, latex allergy and if the patient had
previous problems during any phlebotomy procedure
5. Explain the procedure. Position and reassure the patient
6. Perform hand hygiene
7. Select equipment
a) Prepare the appropriate bottle/tubes (blood culture
bottles).
b) Ensure that other materials are complete: (syringes
and needles tourniquet, wet and dry cotton, and
adhesive tape)
8. Choose two puncture sites: one from the left (L) and one
from the right (R) – as long as it’s the opposite side e.g left
arm (right arm not available) right foot/ankle
9. Apply the tourniquet to the first puncture side. Ask the
patient to make a fist
10. Select the most suitable vein for puncture
Note: Palpate using the tip of the index finger or middle fingers.
Even if the vein is visible, palpate to determine the vein location
11. Release the tourniquet then sterilize the area using
Alcohol first then Chlorhexidine Gluconate/Iodine
tincture (Alcohol + Iodine; 2%)/Benzalkonium Chloride.
Creating a friction, rub for 30 to 60 seconds. Allow the
area to dry at least 30 seconds for antisepsis. (Iodine is
such effective when dry)
Note: When re-palpating the site after disinfection is done, cleanse
the palpating finger in the same manner as the puncture site.
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
Principles of Medical Laboratory Science Practice 2 (LAB) 6
12. While allowing the puncture site to dry, put on the gloves.
Prepare the materials.
Preparation:
a) Open the sterile syringe packages, attaching the
needle if necessary
b) Pull the plunger halfway out. And push it all the way
in.
c) Confirm the volume of blood required from the label
for the blood culture bottles (more blood, inhibits
bacterial growth)
d) Cleanse the top of the blood culture bottles with a
70% alcohol and allow to dry (do not use iodine
because iodine can enter the blood culture bottle and
might cause deterioration of the stopper/rubber
making bottle exposed)
13. Reapply the tourniquet. Ask the patient to make a fist
again
14. Hold the syringe with the dominant hand. Uncap and
inspect needle. Align the needle in the same direction as
the vein. The needle should be in the bevel up position
15. Using the thumb of the non-dominant hand, pull the
patient’s skin tightly 1 to 2 inches below the puncture site
16. Using one deliberate, smooth motion, insert the needle in
the same direction as the vein at approximately 15o to 30o
angle with the skin until there is a lessening of resistance.
Blood back flow will be seen if the vein was penetrated
properly
17. Brace the fingers on the patient’s arm. Pull the plunger
gently with the non-dominant hand and establish blood
flow
18. Draw the desired volume of blood for the examination
19. Ask the patient to open fist. Release tourniquet
20. Apply the dry cotton lightly over the punctured site and
withdraw the needle smoothly
21. Instruct the patient to apply pressure on the punctured
site for 3-5 minutes
NOTE: if the patient is unable to apply pressure, simply put a
micropore tape on the cotton to secure the cotton
22. Specimen preparation:
a) Attach safety transfer device
b) Inoculate the anaerobic blood culture bottle first
when using a syringe or second when using a winged
blood collection set
c) Dispense the correct amount of blood into the blood
culture bottles
Note: Some institutions require documenting the
amount of blood dispensed
d) The bottle and the syringe must be in a vertical
position
Note: Fill other collection tubes after the blood
culture tubes if more than one test is required.
e) Invert the bottles as necessary right after filling them
Note: Do not push the plunger while filling the bottles
f) Dispose the puncture equipment and other bio
hazardous wastes
g) Label all the tubes correctly (write site of collection:
ex. (R) Arm or (L) leg)
23. Do procedure #9-23 with the next opposite site (if
possible)
24. Dispose the puncture equipment and other bio hazardous
wastes
25. Examine the puncture site and apply adhesive bandage
26. Remove the gloves. Perform hand hygiene
27. Thank the patient

NOTE: The phlebotomist should converse appropriately with
the patient through the procedure
Aerobic – lives in the presence of oxygen— 1st to fill in winged set m
Anaerobic – die sin the presence of oxygen—1st to fill in syringe m
Four (4) Blood Culture Bottles are used; two (2) for each puncture
site
8-10mL – Adults; 1-5mL— pediatrics
Gelatin— Blood: Broth ratio (1:10 – 1:20)
EXERCISE NO. 7: Centrifugation and Transfer of Serum/Plasma for
Laboratory Testing
Blood from skin puncturecomes from the capillary area of the
circulatory system which is predominantly arterial blood and
acceptable as substitute for venous blood.
Skin puncture—is the method of choice in children under 1 year of
age and for adults whose veins are inaccessible. Capillary puncture is
done by puncturing the skin and underlying capillaries.
Adult capillary puncture—palmar surface of the distal phalanx of
either the middle or ring finger
Child capillary puncture— medial or lateral side of the plantar
surface of the heel
Note: Capillary puncture in earlobe is NOT recommended because
the blood flow is not adequate
Capillary punctures in adults are done in the following situations:
 Patients who are severely burned
 Patients with cancer whose veins are reserved for
therapeutic purposes
 Patients who are obese and whose veins are too deep to
locate
 Geriatric patients or whose veins are inaccessible and very
fragile
 POCT in a health care facility
 Patients performing tests on themselves (Glucose
monitoring)
 Special procedures that requires capillary blood (Malarial
Procedure: Infant Heelstick Capillary Puncture
Smear)
Order of Draw for Capillary puncture procedure:
1. Blood Gases
2. Slide/Smear
3. Microtainer
a. Lavender-stoppered (EDTA) container
b. Green-stoppered (Heparin) container
c. Other additive microcollection container
d. Red-stoppered container
Procedure: Fingerstick Capillary Puncture
1. Identify the patient
 In-patient –Ask her/his name; tell them to spell
his/her last name; verify identification bracelet name
and hospital number with hospital label or requisition
 Out-patient—Ask her/his name; tell them to spell
his/her last name; verify with the computer label or
requisition information
2. Verify the collection orders
3. Perform hand hygiene before patient contact
4. Choose a finger that is not cold or edematous. The dorsal
end of the third or fourth finger is the most commonly
used site
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
Principles of Medical Laboratory Science Practice 2 (LAB) 7
5. If all fingers are cold, warm the hand 3 min with a warm
washcloth or heel warmer
6. Select the appropriate contaienrs for blood collection
7. Clean the puncture site with alcohol, and let the area clean
8. Put on gloves if you have not already done so
9. Prepare the puncture device for use
10. Massage the lower portion of the fingers while avoiding
the puncture side to stimulate blood flow
11. Hold the finger between the non-dominant thumb and
index finger, with the palmar surface facing up and the
finger pointing down
12. Place the lancet firmly on the fleshy area of the finger
perpendicular to the fingerprint and depress the lancet
trigger to puncture the skin and then dispose the device
into a sharps container
13. Wipe away the first drop of blood with sterile dry cotton
14. Gently squeeze the finger and collect rounded drops into
microcollection containers in the correct order of draw
without scraping the skin. Do not milk the site
15. Hold the cotton or have the patient hold it until the
bleeding stopped
16. Seal the microcollection container when the correct
amount of blood has been collected
17. Anticoagulant samples should be inverted 8 to 10 times
18. Label the tubes before leaving the patient and verify
identification with the patient ID band or verbally with an
out-patient. Observe any special handling procedures
19. Examine the site for stoppage of bleeding and apply
bandage if the patient is older than 2 years
20. Dispose of used supplies in biohazard containers
21. Perform hand hygiene after patient contact
22. Thank the patient
23. Remove gloves and wash hands
Note: If an insufficient sample has been obtained, the
puncture may be repeated at a different site. A new sterile
lancet must be used and the steps 4 to 23 must be
prepared
1. Perform hand hygiene and apply gloves before any contact
with the patient
2. Identify the patient:
 In-patient— check with the nurse to identify the
patient and verify the ID bracelet name and hospital
number with the computer label or requisition form
Note: Never use the name on the bassinet to identify the
infant. The information must be attached to the infant
which is usually seen to the ankle of the infant
 Out-patient— ask the person bringing the infant in to
identify the infant. Ask to spell the infant’s last name
and verify with the computer label or requisition
information
3. Verify collection orders
4. Choose the heel for the puncture site that is not cold or
edematous
5. Position the baby lying on his or her back with the foot
lower than the body
6. Warm the foot for 3 min with warm washcloth or heel
warmer
7. Select the appropriate containers for blood collection
8. Select the puncture side on the medial or lateral plantar
surface of the heel. Do not use the arch or back of the
heel. Clean the puncture site with 70% isopropyl alcohol,
and let the area dry

9. Prepare the puncture device for use. Turn off any lights
that might be over the infant
10. Hold the feel firmly by wrapping the heel with the non-
dominant hand
11. Place the lancet perpendicular to the heel print and
depress the lancet trigger to puncture the heel and
dispose the device into a sharps container
12. Wipe away the first drop of blood with a sterile dry cotton
13. Collect rounded drops of blood into micro-collection
containers without scraping the skin. Do not mil puncture
site. Touch only the top of the collection tubes to the drop
of blood.
Note: Blood flow is encourage of the puncture site is held in a
downward angle and a gentle pressure applied to the foot
14. Seal the micro-collection container when the correct
amount of blood has been collected
15. Anticoagulant samples should be inverted 8 to 10 times
16. Label the tubes before leaving the patient and verify
identification with the patient’s ID band or verbally with an
out-patient. Observe any special handling procedures
17. Examine the site for stoppage of bleeding and apply
bandage of the patient is older than 2 years
18. Dispose of used supplies in biohazard containers
19. Perform hand hygiene after patient contact
Note: if an insufficient sample has been obtained, the puncture
may be repeated at a different site. A new sterile lancet must
be used and the steps 4 to 20 must be prepared
EXERCISE NO. 8: Centrifugation and Transfer of Serum/Plasma for
Laboratory Testing
Centrifugation and aliquoting of blood sample is primarily
associated with laboratory tests performed on plasma (anti-
coagulated blood) and serum (clotted blood)
Centrifuge— instrument that spins blood tubes at a high Relative
Centrifugal Force (RCF) to separate serum/plasma from the blood
cells. It is recommended to separate blood samples within 2 hours
to prevent contamination by cellular constituents (A lot will change,
specially, beyond two hours)
Aliquoting—consists or removing the serum/plasma in small
amounts by pipette and placing it into the appropriate color-coded
tubes.
Aliquot— a portion of the sample that is placed in a separate tube.
 Care must also be taken to prevent the formation of
aerosols when stoppers are removed from the
evacuated tubes.
 Specimens must never be poured from one tube to
another, because this will produce aerosols. A
disposable transfer pipette may be useful in
transferring the plasma or serum form the
centrifuged blood collection
Whole blood— no need to centrifuge (sometimes aliquot)
Blood cells are still alive outside of the body, however, it is not
moving; higher chances of diffusion; can cause false or erroneous
results; metabolism is still continuous.
Changes that occur once analytes diffuse:
 LDH and K
  Glucose and Na
Layers of Centrifuged Blood:
 Fatty/Foamy Layer
 Plasma/Serum Layer (50%)
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
Principles of Medical Laboratory Science Practice 2 (LAB) 8
 Buffy Coat (1mm)
 Pact RBC
 glass to glass – plastic to plastic
Procedure 1: Centrifugation of Serum
1. After the venipuncture, do not centrifuge immediately.
Allow the blood to clot in an upright position for at least 30
min to 1 hour
2. Every tube placed in cups of the rotor head must be
equally balanced. This is accomplished by placing tubes fo
equal size and volume directly across from each other. A
final check for balancing should be made just before
closing the centrifuge lid
3. A centrifuge should never be operated until the top has
been firmly fastened down, and the top should never be
opened until the rotor head fully stopped from rotating.
Blood tubes must remain closed before, during and after
centrifugation (only if you need to aliquot)
Note: Specimen pH increases when the cap is removed and
may cause erroneous pH, ionized calcium, and acid
phosphatase results. Fibrin strands in a sample that has not
completely clotted can interfere with chemistry analyzers and
lead to erroneous results. Loosening clots from the side of the
tube (rimming) before centrifugation is not recommended
because it may cause hemolysis
4. Do not walk away from a centrifuge until it has reached its
designated rotational speed and no evidence of excessive
vibration is observed (not balanced)
Note: When a tube breaks in the centrifuge, immediately stop
the centrifuge and unplug it befor4e opening the cover. The
inside of the centrifuge must be cleaned of broken glass and
disinfected
5. Centrifuge the sample for 15 minutes at 2200 – 2500 RPM
Serum: 10-15min gf: 800-1000g (usually)
6. Re-centrifugation of samples must be avoided. This can
cause hemolysis and erroneous tests results.
Note: When the serum or plasma has been removed from the
tube, the volume ratio of plasma to the blood clotting, will then
be centrifuged into the serum and alter test results
7. Transfer the serum to a plastic *screw-cup
RCF is computed from RPM &gf and radius of rotor head
ETS— when stoppers are removed it should not pop; aerosols
and liquids
Note: turn the stoppers and cover it with gauze/ tissue to
present aerosols from spreading.
Procedure 2: Centrifugation of Plasma
1. Samples collected with anticoagulant can be separated
immediately after collection
FOLLOW STEPS 2-7 OF PROCEDURE 1
Primary tube sampling – first tube used for sampling
Measuring/ Graduated
1. Serological— usually for solutions; not usually used for
blood; with graduations up until the tip
2. Mohr— has less graduations
3. Micropipette— either of the two: serological (1mL or less
sample) or Mohr
Transfer
1. Volumetric— bulb-like; exact amount; commonly used for
non-viscous substances (water-like)
2. Ostwald-Folin— bulb-like; exact amount; used for blood
and other viscous fluid

3. Pasteur Pipette— does not deliver exact amount;
estimation; used of not required to deliver exact amount
4. Automatic— most commonly used with pipette tips (blue
and yellow)
Micro – 1mL or less (2-20μL, 20-200μL, 100-1000μL)
Macro – more than 1mL
Blue— 1000μL
Yellow— 100-200μL or less
Most accurate at its maximum volume
The maximum value, the  level of accuracy; up to 35%
of its maximum volume
Centrifugation— if it is not balance (prone to breakage), balancers
are present
DO NOT RE – CENTRIFUGE
EXERCISE NO. 9: Bleeding Time and Clotting Time
Bleeding Time (BT) is the time it takes for the standardized incision
to stop bleeding
It tests:
a) The ability of platelets to form a plug strong enough to
stop bleeding from an incision
b) The ability of the capillary blood vessels to contract and
slow blood flow to the area
Test results may also be affected by the type and condition of the
patient’s skin, vascularity, and temperatures well as, the
phlebotomist’s technique.
Bleeding Time is considered a screening test, and abnormal results
are followed by additional testing.
Clotting (Coagulation) Time is the time it takes for blood to solidify
after it has been removed from the body. It is reflective to the
normal function of the coagulation pathway; however, PT and aPTT
has replaced its usefulness for screening coagulopathies (not used in
the US)
Bleeding Time 1O Hemostasis— platelet-plug formation;
vasoconstriction (narrowing of the blood vessels)
Clotting Time 2O Hemostasis— coagulation; clot formation/ Fibrin
strands
Duke Method (Slide or Drop Method) — Oldest; uses a
standardized incision to determine the length of time a patient takes
to stop bleeding. Uses a drop of blood on a slide to determine the
length of time it takes for blood to clot. Both are indicative of
possible bleeding tendencies in the patient; evaluates CTBT; 3mm
deep (standard)
Ivy – more standardized because of pressure (BP); 40mmHg; two (2)
standardized puncture
Standardized template— modified Ivy method; more reproducible
and accurate; 5mm long, 1mm deep
Procedure: Duke Method
1. Identify the patient following routine protocol
2. Explain the procedure to the patient, and, verify the
collection orders and other necessary information
3. Prepare necessary materials. Perform hand hygiene and
wear gloves prior to patient contact
4. Choose puncture site and perform the puncture according
to proper capillary puncture procedure
5. Upon puncture, start timer for both bleeding time and
clotting time
6. Collect the first drop of blood onto the center of the glass
slide
7. For bleeding time, blot the drop at 30second intervals
without letting the filter paper touch the wound. Stop the
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
Principles of Medical Laboratory Science Practice 2 (LAB) 9
timer when the blood no longer stains the paper (round off
to the nearest 30 sec)
8. For clotting time, pass the tip of the lancet through the
drop of blood on the glass slide at 30-second intervals and
note the formation of fibrin strands. Ensure that the glass
slide is within eye level when doing this. Stop the timer
when fibrin strands are seen clinging to the tip of the
lancet
9. Dispose all wastes properly
10. Remove gloves and perform hand hygiene
11. Document the results
Note: (1) the pressure on the lancet affects the bleeding time; thus,
pressure must be consistent in every test performed
(2) Incision may either be parallel or perpendicular to the
fingerprints. Results vary depending on the direction: therefore,
direction must be consistent in every test performed
Increased or Decreased Bleeding Time
1. Thrombocytopenia—  platelet <100,000mm3/ 100x109/L
2. Thrombasthenia/Platelet Dysfunction—even if platelet
count is normal, it will still bleed
3. Von Willebrand’s Disease— CM factor associated with F8;
helps platelet stick to each other in between platelets
4. Blood Vessel Problems—
Anything that is causing the integrity of the specimen;
weak collagen; weak blood vessels
5. Aspirin—Inhibits an enzyme important in the formation of
platelets; affects platelet plug-formations
Exercise No. 10: Point-of-Care Testing
Point-of-Care Testing
 Referred to as alternate site testing, near-patient testing,
or bedside testing
 Is the performance of diagnostic tests at or near the
patient’s location rather than in a central laboratory
 Is essential for the rapid detection of analytes near to the
patient, which facilitates better disease, diagnosis,
monitoring, and management
 Tests are often accomplished through the use of portable
and handheld instruments (e.g., blood glucose meter,
hemoglobin analyzer) and test kits (e.g., pregnancy rest,
dengue NS1) which can be operated by both laboratory
and non-laboratory personnel
Bedside glucose monitoring
 One of the most common tests done by POCT primarily to
monitor persons with diabetes mellitus
Glucose
 Determined with dermal puncture and reagent strips and
the specimen tested is whole blood
Principle
 To determine the blood glucose level of the patient at the
bedside for fast and accurate result
Procedure
1. Greet and identify the patient
2. Examine the requisition form and check the type of
glucose test ordered by the physician

3. Verify the patient’s preparation prior to glucose testing
(depending on type of glucose test ordered) by asking his
or her last meal. Explain the procedure to the patient
4. Prepare all the necessary equipment needed
5. Prepare hand hygiene and wear gloves before patient
contact
6. Position the patient and choose puncture site
7. Clean the puncture site with alcohol, and allow the area to
dry. While allowing the puncture site to dry, remove a
reagent strip from the container and close tightly.
8. Insert the strip in to the glucose meter strip slot towards
the direction of the arrow until it locks in place
9. Perform the puncture and wipe away the first drop of
blood
10. Gently squeeze the fingertip to produce a large drop of
blood
11. Hold the glucometer firmly and gently touch the edge
portion of the glucose strip toward blood drop until it has
absorbed enough volume to begin the test.
Note: do not bend or remove the test strip before or while applying
blood, or while the test is in progress.
12. Wait for a few seconds until the test is complete and the
result will appear on the display window of the glucometer
13. Apple dry cotton over the puncture site and ask patient to
apply pressure
14. Read the result and record it on the requisition form
15. Remove the test trip from the meter and discard all waste
in biohazard container
16. Remove gloves and perform hand hygiene
17. Thank the patient.
Exercise No. 11: Urine Sample Collection
Urine
 Is one of the most common samples the patient needs to
collect
 Frequently collected urine samples include random, first
morning, midstream clean-catch, 24-hour (timed) samples,
catheterized, and suprapubic aspirations
 Random and first morning samples are best collected using
midstream clean-catch urine method
 Proper instructions must be discussed with the patient to
obtain the best possible sample and accurate results
Principle
 The most common urine sample collected is clean-catch
sample taken from the midstream of the urine
Procedure A: Collecting a Clean-Catch Midstream Urine Sample
1. Wash hands using soap and water
2. Cleanse the genital area. Be sure to cleanse well before
collecting the sample
3. Void a small amount of urine into the toilet
4. Bring the urine container into the stream of urine and
collect an adequate amount of urine. Do not touch the
inside of the container or allow the container to touch the
genital area.
5. Finish voiding in to the toilet
6. Cover the sample with the lid. Touch only the outside of
the lid and container
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
Principles of Medical Laboratory Science Practice 2 (LAB) 10
7. Wash hands after collection
8. Label the container with the name and give the urine to
the laboratory staff
Collecting a Bagged Urine Sample from Children
Principle
 A urine bag with an adhesive seal is used to collect urine
from children who do not yet have the control to urinate
in a container
 A bagged urine collection is used to perform urinalysis or a
urine culture on the patient.
 For sample that will be used for culture, the container
must be sterile
Procedure: Collecting a Bagged Urine Sample from Children
1. Remove the urine bag from the packaging.
2. Clean the genital area with an antiseptic wipe where the
bag will attach.
3. Allow the skin surface to dry.
4. Attach the bag to the front of the child with the adhesive.
Check that the adhesive is in contact with the skin. This will
affirm that the urine will collect into the bag and not leak
out around the adhesive area.
5. Do not fold or roll the bag while placing the diaper back on
the child.
6. Wait until the child has urinated.
7. Carefully remove the bag, keeping the urine in the bottom
of the bag.
8. Place the urine bag into another sealing container or bag.
9. Label the container with the name and give the urine to
the laboratory staff.
Principle
A 24-hour urine collection is used to determine the 24-
hour distribution of certain urine chemical output. Certain solutes
exhibit diurnal variations, being higher or lower at different times of
the 24-hour period. A complete 24-hour cycle shows the distribution
of these variations in the total collection. Due to the length of time
the urine must be collected, the urine must be refrigerated or
maintained on ice and a preservative such as hydrophobic acid may
need to be added before collection.
Procedure:
1. Obtain a 24-hour sample container from laboratory. Be
careful not to touch or spill any additive that may have
been placed in the container before collection.
2. Void and discard the first morning urine sample, and
record the time.
3. Collect all the urine voided during the next 24 hours. Urine
should be refrigerated or maintained on iced throughout
the collection period.
4. At exactly the same time the following morning, void
completely and add this sample to the container.
5. Deliver the sample to the laboratory the morning the
collection was stopped. The laboratory staff will ask your
name, height, weight, and the time the test was started
and stopped.
6. An aliquot is saved for testing and additional or repeat
testing. The remaining urine is discarded
Notes: Urine sample should be tested within 1 hour. If this cannot
be done, special precautions must be taken. The urine should be

refrigerated or placed on ice with a small amount of water added so
that cooling is immediate. Other special precautions are using
special preservatives. This is necessary to avoid deterioration of
chemical and cellular elements in the urine or the multiplication of
bacteria. Multiplication of bacteria causes a decrease in the urine
glucose, change the pH, affecting all cellular elements presents.
Exercise No. 12: Urine Drug Sample Collection Procedure
Sample collection
Sample collection is the most vulnerable part of a drug-testing
program. For urine samples to withstand legal scrutiny, it is
necessary to prove that no tampering (e.g., adulteration,
substitution, or dilution) took place. Proper specimen collection is
essential for legally and scientifically defensible drug test result.
o Substitution – no trace of his/her urine
o Dilution – addition of something (liquid) to the urine
o Adulteration – addition of something (solid) to the urine
Principle
Chain of Custody is the chronological documentation or paper trail,
showing the collection, transfer, receipt, analysis, storage, and
disposal of the sample.
o COCs written in the procedure are substituted as CCF. CCF
or Custody and Control Form is the one used in the
Philippines
DT 001 – Donor’s consent
DT 002 – Custody and Control Form (CCF)
DT002 A – Donor’s copy
DT002 B – ASC Copy (Authorized Specimen Collector)
DT 002 C – Drug test analyst
DT002 D – Reference Laboratory
Procedure for Authorized Specimen Collector (ASC):
1. Wash hands and wear gloves.
2. Add bluing agent (dye) to the toilet water reservoir to
prevent an adulterated sample.
Note: Some drug testing toilet facilities have a waterless bowl
fitted for the collection of the specimen.
3. Eliminate any source of water other than toilet by taping
the toilet lid and faucet handles.
4. Ask the donor to provide a photo identification or positive
identification from the employer representative.
5. Complete step 1 of the COC form and have the donor sign
the form.
6. Instruct the donor to remove all unnecessary outer
garments and to empty his pockets. Check items that may
be used to adulterate the specimen through bodily search.
7. Instruct the donor to wash his or her hands before
receiving the sample cup.
8. Observe one collection at a time. Pay close attention to
the collection. When unusual behavior is seen, repeat
procedure under “Direct Observed Collection”.
9. Ask the donor to hand the sample cup.
10. Check the urine for abnormal color and for the required
amount.
11. Check the temperature of the sample cup between 32.5°C
and 37.7°C. Record the in-range temperature on the COC
form (COC step 2). If the sample temperature is out of
range or the sample is suspected to have been diluted or
“Yes, it's going to be hard but it's going to be worth it.”
Simran Misha
Principles of Medical Laboratory Science Practice 2 (LAB) 11
adulterated, a new sample must be collected and a
supervisor notified.
Note: Sample can be adulterated in three categories: (1) Urine
substitution; (2) Ingestion of fluids or compounds for flushing
out the system, diluting the sample, or interfering with the
testing process; (3) Direct addition of adulterants to the urine
specimen itself.
12. Place the sample in your sight with the donor at all times.
13. With the donor watching. Peel off the sample
identification strips from the COC form (COC step 3) and
put them on the capped bottle, covering both sides of the
cap.
14. Ask the donor to sign the sample bottle seals. The date
and time should also be written on the seals.
15. Ask the donor to complete step 4 on the COC form.
16. Complete step 5 on the COC form.
Note: Each time the sample is handled, transferred, or placed in
storage, every individual must be identified and the date and
purpose of the change recorded.
17. Follow the laboratory-specific instructions for packaging
the sample bottles and laboratory copies of the COC form.
18. Distribute the COC copies to the appropriate personnel.
Exercise No. 13: Modified Allen’s Test
Modified Allen’s Test
 Performed to check for the presence of collateral
circulation to determine if the ulnar artery is capable of
providing sufficient circulation to the hand
 Usually done when the radial artery is going to be used for
arterial punctures for drawing blood gases, cannulation for
placement of arterial lines, catheterizations or radial artery
harvest for bypass surgeries
 Lack of available circulation could result in loss of the hand
or its function, and another site should be chosen
Principle
 To determine the adequacy of blood circulation supplied
by the ulnar artery prior to arterial puncture
Procedure
1. Greet and identify the patient
2. Check the requisition form and explain the procedure to
the patient
3. Perform hand hygiene and put on gloves
4. Position the patient’s arm on a flat surface with the wrist
supported on a rolled towel
5. Ask the patient to make a tight fist
6. Locate the pulses of the radial and ulnar arteries on the
palmar surface of the wrist by palpating with the middle
and index fingers
Note: the radial artery is located on the thumb side of the
wrist, while the ulnar artery is located on the little finger side
7. Use the middle and index fingers of both hands to apply
pressure to the patient’s wrist, compressing both the
radial and ulnar arteries at the same time for few seconds
8. While maintaining pressure, have the patient open the
hand slowly. It should appear pale in color/blanched.
 Principles of Medical Laboratory Science Practice 2 (LAB) 12

Note: if this is not the case, you have not completely occluded
the arteries with your fingers.
9. Release pressure on the ulnar artery only while
maintaining pressure over the radial artery
10. Observe if the palm flushes pink or return to its color
11. Interpret the results
 Positive results – if the palm flushes pink or
return to its normal color within 5 to 10 seconds,
there is adequate collateral circulation and you
may proceed with the radial puncture
 Negative results – if the palm does not flush pink
or return to its normal color within 5 to 10
seconds, there is inadequate collateral
circulation and the artery should not be
punctured

“Yes, it's going to be hard but it's going to be worth it.”

Simran Misha