LESSON 6: PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY PMLS 2

PRE-ANALYTICAL TESTING PHASE Variable Blood Composition Affected

-includes laboratory handling and identification, and AGE RBC, WBC, CC (creatinine clearance)

proper control measures to avoid subsequent issues. ALTITUDE RBC

-starts when the doctor’s order is given and ends DEHYDRATION Hc (hemoconcentration), RBC, E
when laboratory testing has officially commenced. (enzymes), Fe (iron), Ca (calcium), Na

- phlebotomist must identify factors that affect the (sodium)

DIET Glucose, Lipids, Electrolytes
process and address it when it’s needed.
DIURNAL TSH (thyroid-stimulating hormone),
- Reference range or Reference Interval- it shows
VARIATION Cortisol, Iron (Fe)
the high and low limits of result values as compared
to healthy individuals. DRUG Enzymes, Hormones

-Basal state- represents the condition of the THERAPY

EXERCISE/IM pH (Potential of Hydrogen), PCO 2
metabolism of the body early in the morning or after
(carbon dioxide partial pressure), CK
approximately 12 hours of fasting. Can influenced by INJECTION (creatine kinase), LDH (lactic acid
dehydrogenase), Glucose
age, gender, and conditions of the body. FEVER Hormones, Cortisol

GENDER RBC, HgB, HcT

JAUNDICE Yellow color interfaces due to

increased bilirubin.
INTRAMUSCULA CK (creatine kinase) and the skeletal
R INJECTION muscle fraction of LDH
POSITION Protein, K (potassium)

PREGNANCY RBC

SMOKING Cholesterol, Cortisol, Glucose, GH

(growth hormones), Triglyceride,
WBC
STRESS WBC, Fe, ACTH (adrenocorticotropic
hormone), Catecholamine, Cortisol
TEMPERATURE Hc (hemoconcentration)
AND HUMIDITY

Problems Areas to Avoid and Troubleshooting in

Physiological Variables that Influence Laboratory the Site Selection

Results 1. Burns, Scars, and Tattoos -veins in that area are

Factors that affect blood collection: difficult to examine and blood circulation may
LESSON 6: PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY
be impaired. Burns are too painful to when
touched and tattoos are susceptible to
infections duet to the dyes.
2. Damaged Veins -can produce inaccurate results.
Veins could be sclerosed/ hardened/
thrombosed/ clotted.
3. Edema (oedema) -abnormal swelling caused by
the accumulation of fluid in the tissues. It is due
to medications, pregnancy, infections, and other
medical problems.
4. Hematoma -a solid swelling or mass of blood in
the tissues caused by the leakage of blood from
the vessels. It will obstruct the blood flow and
lead to contamination of blood sample.
5. Mastectomy -the removal of the breast through
surgery (breast cancer). Here, the lymph node is
obstructed and there may be swelling and
infection after surgery. Tourniquet cannot be
applied because it can cause injury and change
the blood composition.
6. Obesity -an individual is grossly overweight
where their veins are deep and difficult to
locate. Should use longer tourniquet and
locating cephalic/cubital vein.
Vascular Access Devices (VADs) for:
 Blood sampling
 Infusing medication
 Central venous pressure readings
 Blood transfusion of a patient
Vascular Access Sites and Devices:
PMLS 2
1. Arterial Line -a thin catheter inserted into an
artery for arterial blood gas and laboratory
studies in critically ill patients. Used also to
monitor blood pressure continuously.
Tourniquet and venipuncture is NOT ALLOWED
in the arm with arterial line.
2. Arteriovenous Shunt or Fistula -a passageway in
the arms created through surgery for connecting
the artery and a vein directly.
3. Blood Sampling Device -collects blood from
arterial or central venous catheter. Used to
avoid the use of needle-sticks, prevent
infections, and reduce wastage from line draws.
4. Heparin or Saline Lock (hep-lock) -an
intravenous (IV) catheter attached to a
stopcock/cap with diaphragm. To provide access
for administering medicine or drawing blood
from a patient. Threaded in the peripheral vein
for 48 hours and usually flushed with
heparin/saline (to prevent clogging).
5. Intravenous (IV) Sites -IV line (thin plastic
tube/catheter inserted into forearm’s vein) to
inject fluids to the bloodstream. Avoid collecting
blood from an IV site because it is contaminated
by IV fluid. collection of blood from a previous IV
site should be avoided for 24-28 hours.
6. Central Vascular Access Devices (CVADs)
(indwelling lines) -tubings inserted to the main
vein or artery for blood collection, monitoring
blood pressure, and inserting fluids.
3 types of CVADs:
LESSON 6: PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY
1) Central Venous Catheter (central line) -large
vein (subclavian) into superior vena cava.
2) Implanted port -implanted disk-shaped
chamber attached to indwelling line. Placed on
upper chest below collarbone.
3) Peripherally inserted central catheter (PICC) -a
flexible tube inserted veins in extremities and
central veins.
Handling Patient Complications Associated with
Blood Collection
1. Allergies to Equipment and Supplies
 Adhesive allergy -place a gauze over the site and
should removed after 15 minutes. Or patient
apply pressure unto it for 5 minutes.
 Antiseptic allergy -use different antiseptic.
 Latex allergy - use non-latex gloves, tourniquet,
and bandages.
2. Excessive Bleeding
Bleeding takes longer time when patient is on aspirin
or anticoagulant. So apply pressure to the site until
bleeding stops. Call authorized personnel if the
bleeding continues after 5 minutes.
3. Fainting
-a temporary loss of consciousness caused by
insufficient flow of blood to the brain. Lie down
patients prone to fainting during venipuncture.
4. Nausea or Vomiting
Phlebotomist has to discontinue the procedure if
patient is nauseous or wants to vomit until the
patient feels better. Emesis basin or wastebasket,
PMLS 2
and a cold damp washcloth (applied on forehead)
should be provided.
5. Pain
Warned patient before inserting needle and avoid
redirection of the needle. Remove the needle if it
causes the patient extreme numbness or pain and
apply ice to the site because it could indicate nerve
involvement.
6. Petechiae
-small red or purple spots that looks like rashes
which appear on the arm when tourniquet is
applied.
7. Seizures or Convulsions
-quickly discontinue blood draw when
seizures/convulsions occur.pressure must be held at
the site; mouth is free from any obstruction;
protected from self-injury; and notify immediately
the first-aid personnel.
Hematoma formation -a phlebotomist must hold
pressure over the site immediately after
discontinuing the draw. Use cold compress or ice
pack to avoid swelling.
Conditions that trigger hematoma:
 There is excessive or blind probing.
 There is inadvertent arterial puncture.
 The size of the vein is too small.
 The needle penetration has gone all through the
vein.
 Needle is not completely inserted.
LESSON 6: PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY
 Tourniquet is still on when the needle was
removed.
 The pressure is not adequate.
Iatrogenic Anemia -blood loss due to blood draw. If
10% of the blood volume is removed at once from
the body, patient could face a threat.
Inadvertent Arterial Puncture -rapid formation of
hematoma on the site due to blood filling up the
tube rapidly.
Infection can be avoided by:
 Tapes and bandages are not opened ahead of
time.
 Needles are not preloaded into the tube
holders.
 Insertion of the needle is not touched after
sterilization.
 Cap is removed just before venipuncture.
 Patients advised to keep the bandage on the site
for at least 15 minutes.
Nerve Injury happens when
 Improper site selection
 Rapid needle insertion
 Blind probing
Redirect needle if initial attempt is unsuccessful
(forward/backward) then remove the needle and
find alternative site.
Vein Damage -follow proper technique and avoid
blind probing to avoid vein damage.
SPECIMEN QUALITY
PMLS 2
1. Hemoconcentration -decrease in the fluid
content or plasma volume caused by tourniquet
that stagnates the normal blood flow and leads
to increase in concentration of RBC and other
non-filterable large molecules.
2. Hemolysis (haemolysis) -rupture of RBC that
makes the hemoglobin released into the
surrounding fluid.
3. Partially filled tube or short draw -happens
when phlebotomist pull a tube before reaching
the required volume that leads to incorrect
blood-to-additive ratio.
4. Specimen Contamination -specimen is
compromised due to incorrect handling which
involves:
 Allowing alcohol, powder, or other materials
into the sample.
 Getting glove powder or perspiration into
films and specimens.
 Using the wrong antiseptic.
 Improper antiseptic procedure.
5. Wrong or expired collection tube -should not be
use due to not warrant quality of the seal and
pressure after after expiration date.
Collapsed Veins -veins being blocked resulting in
insufficient blood flow. This happens when:
 Strong pressure in the vacuum of the tube
or plunger.
 Tourniquet is too close to the site or too
tight.
 Tourniquet has been removed during the
draw.
LESSON 6: PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY PMLS 2

Tube Vacuum -to avoid failure due to loss of

vacuum, make sure that the bevel is not partially out
of skin and tube is not damaged.