PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC

MIDTERM REVIEWER
(S.Y. 2018-2019)

CAPILLARY PUNCTURE  point of care testing

(POCT)
 Method of choice for children under 1 year of
 patients performing tests on themselves
age (heelstick) and for adults whose veins are
 special procedures that require capillary
inaccessible (fingerstick).
blood (e.g. malarial smear)
 Done by puncturing the skin and underlying
capillaries Patients that can produce inadequate capillary
 It is important to remember that the blood sample:
collection of a specimen by dermal puncture
- dehydrated or have poor circulation
may involve the potential exposure to blood
- patients who are extremely cold
borne pathogens as well as other safety
considerations for both phlebotomist and the (Patient’s hand needs to be warmed before the
patient procedure.)

Safety reminders: WARM WET WASHCLOTH

- Gloves are always necessary.
- Wear additional PPE.
 Lab coat or gown when appropriate or
required
 Safety goggles and surgical mask may
be needed if there are potential for
splashes or sprays of blood
- Only have the equipment needed for this
procedure at hand and additional equipment
out of the reach of the patient.
CAPILLARY BLOOD
 Is obtained from capillary beds that consist of
the smallest veins (venules) and arteries
(arterioles) of the circulatory system.
 Venules and arteries join together in capillary
beds forming a mixture of venous blood
along with interstitial and intracellular fluids.
Clinical applications of capillary puncture:
 burnt patients
 cancer patients
 obese patients
 geriatric patients
 more efficient than a dry heat or heat pack
 ideal temperature: 42 degrees Celsius
 wrap around patient’s hands for only 3-5
minutes
(Heat enlarges the capillaries, blood flows faster,
better bleeding.)
(Warming the site can increase the blood flow
sevenfold.)
Puncture sites:
- infant heel (lateral plantar)
- ring finger and great (middle) finger
- earlobe (least preferred site)
 Side or tip of the finger should not be
punctured
 Site must be warm or have been warmed
 Must not be edematous (build up of tissue
fluids)
(Always cut across (perpendicular) the fingerprint
line.)
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
Cleaning the site:
 Use 70% isopropyl alcohol
 Allow to dry thoroughly before any puncture
 Do not use povidone-iodine (betadine) to
clean - ↑ potassium, phosphorus or uric acid
Puncture devices:
 All devices must have the ability to retract the
blade after have been used.
 Devices for glucose monitoring – produce
only 2 to 3 drops, insufficient amount.
 The depth of cut of varies depending in the
device used – toddler device does not
puncture as deeply as adult device.
2 principles used in retractable device:
- Straight down puncture with guillotine-type
action
- Slicing motion that produces half-moon cut.
Collection of sample:
 Hold the patient’s hand downwards – gravity
helps the blood flow into the collector.
 Before the blood is collected, first drop of
blood must be wiped off – interstitial fluid is
released into the first drop.
 Adequate puncture – 0.5 ml can be collected.
 As the drop forms, touch the tip of the
microcollection device.
 Blood flow can be enhanced by gentle,
continuous pressure.
 Excess pressure – hemolysis or contamination
with tissue fluid
 Scraping of the blood – hemolysis
MICROCOLLECTION TUBE
 After blood touches the surface of the
device…
- Tap the device on a hard surface to
facilitate blood flow.
- Rotate the tube after every drop – AC
contact
- Mix by inverting 8-10 times once
capped.
CAPILLARY TUBES OR MICROHEMATOCRIT TUBES
 Are disposable, narrow bore plastic or plastic-
clad glass capillary tubes that fill by capillary
action or typically hold 50-70 ul of blood.
 Are primarily used for hematocrit (packed red
cell volume determinations)
- RED BAND – ammonium-heparin-
coated tube
- BLUE BAND – plain tube
 These tubes are very delicate and must be
used with great caution.
 As soon as the tube is two thirds to three
fourths filled, one end is sealed to prevent
blood from leaking out.
 Plastic or clay sealant are commonly used to
seal one end of microhematocrit tubes.
GLASS MICROSCOPIC SLIDES
 A drop of blood is placed directly on a glass
slide and spread to create an area of cell
examination.
Puncture site:
 Plantar surface
- Medial to a line drawn posteriorly
from the middle of great toe to the
heel
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)

- Lateral to a line drawn posteriorly 1) Blood gases

from between fourth and fifth toes to 2) Lavender-stoppered (EDTA)
the heel. (Primary area of choice to 3) Green-stoppered (sodium heparin)
avoid damage to posterior tibial 4) Other additive microcollection containers
artery.) 5) Red-stoppered (nonadditive)

(Puncture should not be done on the previous

puncture site.) BLOOD COLLECTION EQUIPMENT ADDITIVES and
ORDER OF DRAW
(Do not puncture in the central arch area of the foot –
damage to nerves, tendons, cartilage) Parts of syringe:

Puncture depth:

 Optimal depth:
- 0.85mm (premature infants) to 2mm
(full-term infants)
- Capillary bed of a preterm full-infant
on 0.35 to 1.6mm beneath the skin
surface.
- Puncture to a depth of 2mm on full-
term infant punctures majority of the
capillary bed and does not injure the
bones or nerves.

Collection of the sample: SYRINGE AND NEEDLE METHOD

 Excessive crying: ↑ WBC count
 WBC count does not return to normal up to
60 minutes.
 HEMOLYSIS – greatest concern with
microcollection samples: ↑ potassium
 Causes:
- Alcohol used was not allowed to dry
- Finger was squeezed too vigorously
- Newborns have increased RBC fragility
- Blood was scraped off
 One of the oldest methods known that DOES
NOT DESTROY THE INTEGRITY OF THE VEIN.
 Purpose of this system then was possibly used
as PUS EXTRACTOR or a MINIATURE FLAME
THROWER.
 Made of either glass or plastic (with majority
of being plastic).
 BARREL and PLUNGER varies in volume from
1ml up to 60ml.
 Barrel: graduated into milliliters

Order of draw:

 If the collection of blood occurs too slowly →

platelets clump → incorrect plt ct. PLUNGER
Microcollection order of draw
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)

 Sometimes may stick and hard to pull. Gauge 22 Used for small veins and
 BREATHING THE SYRINGE is needed before pediatric patients
use of syringe by pulling the back of the Gauge 23 Can be used in
plunger to about halfway up to the barrel and combination with
push it back. butterfly collection set
 Pulling the plunger creates a vacuum with the Gauge 25 Can’t be used in
barrel. venipuncture (RBC’s
 By breathing the syringe, it makes the plunger may be destroyed)
pull more smoothly and not have tendency to Used for intermuscular
JERK when first pulled. infections
Gauge 27 Used for administration
(The larger the size of a syringe = greater amount of
of a purified protein
vacuum obtained.)
derivative (PPD)
(Larger amount of vacuum has the tendency to pull tuberculosis skin test
TOO HARD and COLLAPSE the vein.) Gauge 18 and 16 Used for intravenous
infusion or blood
 Syringe are used for the difficult-to-draw
donation
patients who have veins that are:
1. Fragile
2. Thin NEEDLE
3. Rolly
 Needle bevel is the angle of the needle on the
(Tend to collapse when using ETS esp. pediatric and tip.
geriatric patients.)  The sharper the bevel: less pain
 Silicon-coated for easy insertion
 Surface veins on the FEET and BACK OF THE
 Walls of needle are thinner = outside
HANDS may also require the syringe
diameter is thinner = smaller hole as it enters
technique.
the patient’s arm
 Use of this method is limited to the capacity
of the syringe. EVACUATED TUBE SYSTEM
 Syringe with 10-15ml is not recommended,
 Often called “vacutainer” system.
instead, use BUTTERFLY COLLECTION SET.
 Vacutainer – brand name for evacuated tube
 Recommended length of needle: 1 inch to 1 ½
system manufactured by Becton Dickinson
inch.
Company.
 Gauge is determined by the DIAMETER OF
 A tube with a vacuum already in it attaches to
THE LUMEN or the opening of the bevel end.
the needle and the tube’s vacuum is replaced
by blood.

Two configurations of evacuated tube system:

GAUGE SIZE FUNCTION
Gauge 20-22 Used for venipuncture
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)

1) Basic straight needle with no safety device BUTTERFLY (WINGED-INFUSION

attached SET) COLLECTION METHOD
2) Needle with safety device attached to the
 Used for small veins that are difficult to draw
holder
with the other systems.
 Combines the benefits of the evacuated tube
 Gauges available: 20, 21, and 22.
system and syringe system.
 Gauge 21 and 22 are the MOST COMMON.
 21 or 23 gauge needle with attached plastic
 Needles have thinner walls = smaller outside
wings on one end.
diameter = less pain
 3 to 12 inch tubing leads from the needle
 Silicon-coated needles so they slide into the
where a hub at the ending is used to be
skin with LESS RESISTANCE.
attached to a syringe.
 The tube is the method by which the blood is
 Other alternative: to have the butterfly
pumped from the patient.
attached to an evacuated needle holder and
 The blood fills the tube because of the
Luer adapter.
vacuum of the tube.
 Entire butterfly device with tubing and holder
 When performing venipuncture, bevel of the
is discarded in sharps container.
needle must always be facing UPWARD when
inserted in to the vein. Best way to dispose:
 The angle of the needle should be inserted at
Treat it as a snake, whereby the needle end is
a 15 to 30 degree angle to the surface of the
the head of the snake. Hold the butterfly by the plastic
skin.
wing and drop the head into the sharps container first,
 The deeper the vein = greater angle you will
the remainder of the device to drop next and the holder
need to use.
being the last part to enter the container.
 Shallow vein = 15 degree angle
 Deep vein = 30 degree angle Advantages:

HOLDER/ADAPTER  It anchors the needle in the center of even a

 Makes the task of collecting the blood sample
easier.
 Gives something more substantial to hold on
to and a way to center the needle into the
stopper of the evacuated tube.
Holders come in two sizes:
- 1 for adult
- 1 for size for small-diameter tubes used in
pediatrics
small vein.
 Tubing is flexible so the needle stays
anchored and does not pull out of the vein.
 Large evacuated tube or large syringe can be
attached to the tubing and the vein will not
collapse as would normally occur.
Disadvantage:
 More expensive than the needle system.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
TOURNIQUET
 Constricts blood flow in the arm and makes the
veins more prominent.
 Most commonly used tourniquet is a soft,
pliable, flat strip.
 Approximately 1 inch wide by 15 to 18 inches
long.
 Velcro strips and round rubber tubing are no
longer accepted.
 Flat strip: most widely used because it can
easily be released with one hand.
 Obese patients: there is a tendency that the
flat strip tourniquet will roll into a tube and cut
into the patient’s arm.
(Remedy: Place the tourniquet over the patient’s
sleeve or use a blood pressure cuff.)
 Tourniquet should be of non-latex material to
avoid latex exposure to both the patient and
the phlebotomist.
 Latex items should not be stored with non-
latex tourniquets because the latex particles
will be transferred to the non-latex
tourniquets.
 It is applied 3-4 inches above the puncture
site.
 It is applied tight enough to slow the flow of
blood in the veins but not prevent the flow of
blood in the arteries.
 Patient should then close his/her hand to
make the veins more prominent.
 Pumping the hand should be AVOIDED
because this can alter some test results (e.g.
potassium – pumping of the hand releases
potassium into the bloodstream from the
tissue and RBCs therefore elevating the
potassium in the blood sample.
 With the tourniquet
applied the arteries fill the veins with blood,
pooling the blood in the veins making the
veins more prominent which lets the
phlebotomist palpate the veins to determine
their DIRECTION, DEPTH, and SIZE.
 Palpating is one of the more difficult skills a
phlebotomist learns. Phlebotomists use the
same finger of the NONDOMINANT HAND to
feel for the vein – finger of choice is INDEX
FINGER.
 By using the same finger all the time,
phlebotomist builds sensitivity in that finger
which allows the phlebotomist to be able to
palpate if he/she misses the needs to redirect
the needle.
 Tourniquet should be on the arm NO LONGER
THAN 1 MINUTE.
 Prolonged tourniquet application leads to
HEMOCONCENTRATION – increased
concentration of constituents in the blood
sample and will disrupt the balance of fluid in
the tissue and cause potassium to be
released.
Major Veins for Venipuncture:
1) Median cubital vein
- Preferred vein
- Typically large, closer to the surface
- Most stationary
2) Cephalic vein
- Often the only vein felt in obese
patients
- Second choice vein
3) Basilic vein
- Last choice; not recommended unless
no other vein in either arm is more
prominent.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)

Special Site-selection Situations Order of Draw

1) Intravenous lines 1) Sterile tubes – yellow

- a limb with an IV line running should 2) Light blue – citrate
not be used for venipuncture because 3) Red top – serum tube
of contamination to the specimen. 4) Separator tubes (Serum and Plasma)
The patient’s other arm or an 5) Green – heparin
alternate site should be selected. 6) Lavender – EDTA
2) Edema 7) Gray – oxalate/iodoacetate
- Edema is the abnormal accumulation
Order of Dispensing
of fluid in the intracellular spaces of
tissue. 1) EDTA
3) Scarring or Burn patients 2) Heparin
- Veins are very difficult to palpate in 3) Non-anticoagulated tube
areas with extensive scarring or burns.
Filling of Microtubes
Alternate sites or capillary blood
collection should be used. 1) Blood gas
4) Dialysis patients 2) EDTA
- Blood should never be drawn from a 3) Other additive tubes
vein in an arm with a cannula 4) Serum tubes
(temporary dialysis access device) or
Phlebotomy problems:
fistula (a permanent surgical fusion of
a vein and an artery). A trained staff Occasionally, a venipuncture is unsuccessful. Do not
member can draw blood from a attempt to perform the venipuncture more than two
cannula. The preferred venipuncture times. If two attempts are unsuccessful, notify the
site is a hand vein or a vein away from phlebotomy supervisor. Problems encountered in
the fistula on the underside of the phlebotomy can include:
arm.
 Refusal by the patient to have blood drawn.
5) Mastectomy patients
 Difficulty obtaining a specimen because the
- If a mastectomy patient has had
bore of the needle is against the wall of the
lymph nodes adjacent to the breast
vein or going through the vein.
removed, venipuncture should not be
 Movement of the vein.
performed on the SAME side as the
 Sudden movement by the patient of
mastectomy.
phlebotomist that causes the needle to come
out of the arm prematurely.
 Improper anticoagulant
 Inadequate amount of blood in an evacuated
tube
 Fainting or illness subsequent to venipuncture
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)

Unacceptable specimens: - Use of lipemic

serum may interfere with triglyceride
1) Clotted specimens
assay.
- Not suitable for cell counts because
the cells are trapped in the clot and Venipuncture procedures:
are therefore not counted.
1. Describe the test request process,
- A cell count on a clotted sample will
types of requisitions used, and
be falsely low.
requisition information.
2. Discuss the test status designations,
2) Hemolyzed specimens
status priorities, and the procedure to
- Hemolyzed serum/plasma is
follow for each status designation.
unsuitable for several chemistry
3. Describe proper “bedside manner”
determinations because substances
and how to handle special situations
usually present within cells (e.g.
associated with patient contact.
potassium) can be released into the
4. Discuss how to prepare patients for
serum is left on the cells for a
testing, answer inquiries and what to
prolonged period.
do if a patient objects to a test.
- In addition, several other constituents
5. Describe how to verify fasting and
including ACP, LDH, AST are present in
other diet requirements.
large amounts in RBCs, so hemolysis
6. Describe each step in the different
of red cells will significantly elevate
venipuncture procedures.
the value obtained for these
7. List necessary information found on
substances in serum.
specimen tube labels and acceptable
reasons for inability to collect
3) Icteric specimens
specimen.
- When serum/plasma takes on an
8. Perform the different venipuncture
abnormal brownish yellow color,
procedures and the proper way to
there has most likely been an increase
safely dispense blood into tubes
in bile pigments, namely bilirubin.
following a syringe collection.
Those performing clinical laboratory
9. Describe unique requirements
determinations should note any
associated with drawing blood from
abnormal appearance of the serum or
special populations including
plasma because it can interfere with
pediatric, geriatric, and long-term care
photometric measurements.
patients.

4) Lipemic specimens
- The presence of lipid or fats in serum
or plasma can cause this abnormal
appearance.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
TEST REQUEST FORM
 Sometimes used instead of labels only.
 Lists the information needed for the
phlebotomist to complete the task and collect
the correct samples.
 Following information should be included on
the form:
1. Patient’s complete name and age or date
of birth
2. Patient identification number
3. Date and time the sample is to be
obtained
4. Type of test to be collected
5. Accessioning number
6. Physician’s name
7. Department/Location where the work is
to be done (printed on computer
requests)
8. Other information that is necessary to
accurately collect the sample, such as a
specific time of collection, whether the
patient should be fasting, and so on.
9. ICD 10 diagnosis coded for outpatients
 Identification numbers on the patient’s
identification bracelet are compared to the
name and numbers on the request form used
in the health care institution.
ORDER FORMS
 Manual requisition that is usually a multipart
carbon form that lists many of the tests
available.
 Manual requisition that is IMPRINTED from an
imprinting plate that prints the patient’s
name, identification numbers, physician, and
room number. Tests are
either typed on the form or hand written.
 These manual requisitions can be used in an
OP setting or in patient. Manual requisition
patient information and tests requested are
handwritten on the requisition by the
physician or nurse.
 This requisition is then given to the
phlebotomist for the patient if he/she is an
outpatient.
 The patient then takes the requisition to an
outpatient laboratory service center.
 Billing information in obtained from the
patient, and the requisition, along with the
sample, is sent to the testing laboratory for
entry into the computer system.
PRIORITIZING SAMPLE COLLECTION
STAT
 Indicates that the sample collection is critical
to the immediate treatment of the patient.
 Should always be collected first.
 After collection, it must not be carried on the
phlebotomist’s tray while other low-priority
samples are collected.
 Should be taken immediately to the
appropriate laboratory.
 STAT testing on average takes the laboratory
45 minutes to 1 hour to complete after the
sample is received.
 Even if the patient does not look critical, the
sample must be handled as ordered.
(All phlebotomy must be completed with all the
proper steps.)
(Never take shortcuts to speed the processing.)
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
 TRUE STAT – ex. A patient comes into the
hospital emergency department with massive
injuries.
 TIMING REASONS – ex. The physician may
need the results before the patient is sent
home, or someone forgot to order the test
and the physician needs those test results
before the next dose of medicine can be
given.
ASAP
 Is sometimes used to indicate that the sample
needs to be collected generally within an
hour of the order time.
 Results of ASAP requests are typically
available within 2 to 4 hours.
AM/PM or TODAY
 Lesser priorities.
(Certain types of tests determine when the
phlebotomists collects the sample.
Ex. Blood test for Ammonia, sample must be placed
on ice and then delivered to the laboratory within 20
minutes of collection.)
 If the phlebotomist has several patients to
draw and one of those patients has an
ammonia test ordered, the ammonia test
must be drawn last and then delivered
IMMEDIATELY to the laboratory.
IMPORTANCE OF PATIENT IDENTIFICATION
GREET THE PATIENT
 BEFORE any attempt is made to collect a
sample from the patient, you must gain the
patient’s trust.
 Gaining the patient’s trust is done through
properly greeting the patient. It will decrease
the patient’s anxiety and
improve patient compliance.
(Always greet the patient in a positive manner.
Establish eye contact.)
 Introduce yourself to the patient, giving
your name and your immediate role in his
or her care. This is a way to create a
personal connection with the patient.
 Explain how long will the procedure take
and explain what you are going to do.
 Listen closely to the patient with your
eyes and ears.
 Always be attentive to the patient’s tone
of voice and body language.
 After a positive greeting, start verifying
you have the correct patient.
 DO NOT TRUST that he/she is the patient
when he/she allowed you to come.
 Verifying the identification bracelet
confirms the patient’s full name and that
is acceptable identification.
 Hospital patients have a hospital
identification bracelet that includes their
FIRST and LAST names, hospital numbers
(often two sets of numbers), birth date,
and physician.
 Patient will often have been asleep or not
paying attention and will answer yes.
 Ask the conscious patient to STATE his her
FULL NAME and SPELL THE LAST NAME.
This helps patients realize that someone is
in the room and it gets them thinking so
they will be awake when their blood is
collected. However, the phlebotomist still
needs to check the identification bracelet
with the others or labels to verigy that the
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
correct patient is being drawn even after
the patient has stated his/her name.
 In addition, check the patient’s
identification numbers. If the patient does
not have an ID bracelet, DO NOT DRAW
THE BLOOD. Request the nurse to attach
PATIENT ON ANTICOAGULANT THERAPY
an identification bracelet before
collection. If this is impossible, nurse
needs to identify the patient and sign the
requisition or tube label indicating that
he/she positively identified the patient.
 Once the patient is identified, a
permanent ID number is assigned and the
temporary number is cross-referenced to
the permanent number.
 Traditionally, phlebotomist would print
BAR CODE LABELS in the laboratory and
take them to the nursing units. The
phlebotomist would take the label to the
patient’s room, identify the patient, and
match it to the patient’s armband
information. Sample would then be
collected and labeled with the bas code
label.
 Systems have now been developed
whereby the phlebotomist has a handheld
device. Orders are wirelessly transmitted
to the handheld device and the
phlebotomist can determine the next
patient who needs blood drawn.
 When the phlebotomist enters the room,
the armband is scanned with the
handheld device and labels are printed for
tubes needing collection on that patient.
Once the blood is collected, the samples
are sent to the laboratory by the
PNEUMATIC TUBE SYSTEM.
 The phlebotomist does not have to return
to the laboratory to receive orders from
more patients. The
handheld device is checked and any new
orders will be displayed on it.
/Table 6.1/
 Patient who has been receiving
anticoagulants to thin the blood is susceptible
to continued bleeding and hematomas.
 The continued bleeding tendency should be
treated after venipuncture by holding
pressure on the site for at least 5 minutes.
After 5 minutes, a 2-by-2 inch gauze pad
should be folded down the middle and then
folded down the middle again to make a thick
1-inch square and a non-latex elastic wrap is
then wrapped around the arm to provide
additional continuous pressure to the site.
 After this is done, the nurse should be asked
to check the arm in 15 minutes to check for
any bleeding through the gauze.
 Do not allow an outpatient to leave until
waiting 15 minutes to determine if the
bleeding has stopped.
 A patient who immediately bleeds through
the gauze square should have several layers
of fresh gauze placed over the site and
pressure held on the site until you are sure
the bleeding has stopped.
 Do not release the patient until you are sure
there is no problem.
 Once the bleeding has stopped, the arm must
be wrapped with a nonlatex elastic bandage
over several layers of gauze.
 For inpatients, the nurse must be asked to
monitor the patient further.
 Outpatients should be asked to wait in the
waiting room for an additional 15 to 30
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
minutes until you are certain the bleeding
does not return.
 Anticoagulant therapy also causes patients to
develop hematomas from the venipuncture.
Bleeding can often be stopped, but a
hematoma still forms.
A PATIENT WHO IS RESISTANT
 Patient who is resistant can be aware of his or
her behavior and simply not want blood
drawn.
 A patient who is semiconscious or comatose
is sometimes resistant and can be UNAWARE
of his or her actions.
 Patient who is aware does HAVE THE RIGHT
to refuse to have a sample drawn. In this
case, the doctor must be notified so he/she
can try to convince the patient that the blood
work is essential to the patient’s recovery.
 Patient who is unaware can have blood
drawn, but the phlebotomist will sometimes
need assistance in holding the patient still –
have the nurse present so it can be
documented in the patient’s chart that the
patient was held to draw the requested blood
sample but was not injusred in the process.
 Even an unconscious patient will often move
during a venipuncture – must take special
care to anticipate the patient’s jerks or other
types of moves while the needle is in the arm.
GAUZE SHOULD BE READILY AVAILABLE and
you should be ready to release the tourniquet
of the patient moves and the needle pulls out
the arm.
 IF THE NEEDLE ACCIDENTALLY GOES MUCH
DEPPER, the patient’s physician may need to
examine the area for possible damage. If the
patient is too aggressive to hold, then the
physician may prescribe a sedative.
(ALWAYS REMEMBER:
Patient’s wishes and legal rights must be
honored. Drawing blood from a patient without
patient’s consent or legal caregiver can result in
charges of assault and battery.)
PATIENT WITH PSYCHIATRIC DISORDERS
 Often, they do not understand what is
being done to him or her in a clinical
setting.
 When drawing blood from patients in a
psychiatric health care area, nurse needs
to be informed.
 Nurse often accompanies the
phlebotomist to the patient’s room to
help explain the procedure to the patient
or to help hold the patient for optimal
care.
 Patient’s caregiver or relative may be the
only person a psychiatric patient trusts.
 Phlebotomist may need to enlist the help
of the patient’s caregiver to explain what
is going to be done.
 The situation this patient has been placed
in is intimidating and the patient feels
insecure. (ex. You may have a 35-year-old
patient but mentally working with a 5-
year-old.
 They can be unpredictable, as with the
patient who exhibits resistance, be ready
for movement or jerks.
 Some patients may be suicidal – watch
your equipment. Take only the minimum
amount of equipment with you into the
room. It is best to leave your tray or cart
outside the room.
PATIENT WHO IS OBESE
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
 Weins of a patient who is obese are often
difficult to feel through the layers of tissue.
 Tourniquet has to be rather tight to exert
pressure deep enough to slow the flow of
venous blood.
 Median cubital vein is usually the most
prominent vein to feel. If not found, veins in
the hands and wrists should be more readily
accessible.
PATIENT IN ISOLATION
/procedure 2-3 and 2-4/
PATIENT WITH DAMAGED OR COLLAPSING VEINS
 Condition of patient’s veins can be a
challenge to obtaining blood.
 Veins can be damaged or have healed
improperly usually the result of the:
1. Patient having been burned
2. Scars on the veins from drug abuse or
accidents
3. Chemotherapy
4. Surgical procedures in the areas of the
veins
(Such damage makes the veins inaccessible because
the scar tissue is too thick or the vein no longer carries
blood.)
 A collapsing vein is weak, and the vacuum of
the syringe or evacuated tube sucks the walls
of the vein together so no blood can flow –
the vein refills the instant the vacuum is
discontinued.
 Using a syringe is the best way to obtain
blood from a vein that has the tendency to
collapse – the syringe plunger is pulled gently,
a small pull at a time – the timing between
the pulls allows the vein to refill. (DO NOT
WORK SO SLOWLY THAT
THE BLOOD STARTS TO CLOT IN THE
SYRINGE.)
 Complete the filling of the syringewithin 30
seconds from the time it starts filling then
IMMEDIATELY transfer the blood to the
appropriate tubes with a transfer device.
 An evacuated tube system WORKS to draw
from a collapsing vein, but only small tubes
can be used. The larger the evacuated tube,
the more vacuum in the tube. If a 10-ml tube
collapses the vein, next choose 3-ml tubes to
obtain 9-ml of blood to provide
approximately the same volume.
VERIFYING FASTING AND OTHER DIET
REQUIREMENTS
FASTING SAMPLE
- Collected from a patient in the morning
before the patient has had breakfast and
before any activities. There will often be a
sign on the patient’s door stating “NPO” –
Nothing per Orem.
- NPO indicates that the patient should not be
given anything to eat or drink.
- In addition to a patient fasting to ensure
accurate test results, some tests require DIET
RESTRICTIONS – no alcohol for a number of
hours before the test or a limitation on
certain foods and medicines are some of the
restriction – some foods or drinks can mask
the results that the physician is looking for.
- After the blood is drawn on a patient with
restrictions, the patient may be released from
the restrictions. The patient’s nurse needs to
be informed that you have just drawn a
sample from the patient for the fasting blood
work so the nurse can release the restrictions.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
- Do not give hospital patients food or tell them
they can eat without first checking with the
nurse.
- The fasting test just drawn may be only one of
several tests for which the patient must
remain fasting.
- The patient may be going to surgery or
radiology and may be fasting for those areas.
- The outpatient who has come in only for
blood tests may be released from restrictions
once the phlebotomist obtains the sample.
TIMED SAMPLES
 These samples should be collected at the
precise time intervals required.
 Phlebotomist must have specific directions on
how the sample should be collected and at
what intervals.
 Tests that exhibit a DIURNAL effect, where
values in the patient vary throughout the day,
are serum iron, corticosteroids, and other
hormones – these are often drawn 12 hours
apart in the early morning and evening.
 Monitoring of a patient’s drug therapy also
requires a timed sample. Aminoglycosides,
coagulation therapy monitoring, digoxin, and
other types of drugs are monitored at a
particular time of day or a time interval after
the dose of drug.
 All these are tracked through THERAPEUTIC
DRUG MONITORING (TDM), the goal of TDM
is to provide information that will allow the
dose given to the patient to be effective but
not toxic.
 Every patient has a different metabolic rate
for each drug given. The method of
administration of the drug also affects the
metabolism, of the drug.
 Drug may be given
ORALLY or injected INTRAMUSCULARLY or
INTRAVENOUSLY.
 Timing of collection of the samples is critical
to the proper determination of the level of
drug in the patient.
Many variables influence the effectiveness of the
drug:
1. Drug half-life
2. Concentration of medication
3. Form of drug administration
4. Age of the patient
5. Weight of the patient
6. Liver function
7. Kidney function
8. Disease state
9. Interacting drug therapy
10. Patients metabolism
 Patient is tested for a presample before the
drug is given and then for a postsample after
the drug has been administered.
TROUGH LEVEL (PREDOSE)
 Pre-sample collected when drug is at LOWEST
LEVEL in the patient. It is usually drawn 30
minutes BEFORE the next dose of drug is
administered – drug is usually administered
through an INTRAVENOUS (IV) injection.
PEAK LEVEL (POSTDOSE)
 Collected once the drug has been
COMPLETELY administered for a specific
period. Should be collected when the drug is
at its HIGHEST level in the patient. This peak
level SHOULD fall somewhere in the
therapeutic range.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
 Patient’s response time to the therapy
depends on the method of administration.
 ORAL MEDICATION – peak will not occur for a
time. Level will then drop rapidly until
another dose is given.
 INTRAVENOUS – impact is almost immediate
and then also diminishes rather quickly.
First site to check:
UPPER BEND OF THE ARM (Antecubital area).
Order for checking for the best available site:
1. Upper arm
2. Hand
3. Wrist
4. Ankle or foot
PATIENT REACTIONS
PAIN
 Most common patient reaction to
venipuncture
 The patient may indicate that the
venipuncture is painful = try repositioning the
needle slightly and releasing the tourniquet
 Releasing tourniquet often helps because the
tourniquet may be pinching the arm and
causing pain rather than the needle.
 AVOID deep, probing venipunctures, esp. in
the area of basilica vein (because this vein is
close to a major nerve).
NERVE DAMAGE
 Damage will be first felt
by the patient as a tingling or numbing of the
arm or hand on which the venipuncture was
performed.
 Sensation usually goes away in a few hours to
days if the nerve was only TOUCHED and NOT
DAMAGED.
 If nerves was damaged, this numbness could
be PERMANENT.
Best method to avoid nerve damage:
- Avoid probing venipunctures and attempt to
puncture only veins that can be felt.
(Deep punctures can not only cause nerve damage
but can also result in puncture of an artery.)
SYNCOPE (FAINTING)
1. Pale
2. Perspiring
3. Starting to breathe shallowly
4. Followed by drooping eyelids
5. Weak, rapid pulse
6. Unconscious
 If a patient does faint, IMMEDIATELY remove
the needle and stop the patient from getting
hurt.
 Patient in a chair must be held there to keep
from sliding out onto the floor.
 Lower the head and arms.
 Wipe patient’s forehead and back of the neck
with a cold compress if necessary.
(If the patient still does not respond, a physician
must be notified.)
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
 It is best to ask the patient PRIOR to drawing
the blood if he/she has had any reactions to
having blood drawn.
 If the patient states that he/she has fainted in
the past, have the patient lie down before
drawing the blood.
 NEVER draw blood with a patient standing or
sitting on a stool or on a chair with wheels.
NAUSEA
 Patient may indicate that he/she feels sick.
 Make the patient as comfortable as possible,
and instruct him/her to breathe deeply and
slowly.
 Apply cold compresses to the patient’s
forehead.
 Give the patient an emesis basin,
wastebasket, or container, and have facial
tissues ready if the nausea does not diminish.
 Give patient water to rinse out his/her mouth
if vomiting does occur
DIABETIC SHOCK
 Patients can go into DS or experience
hypoglycemia because they have fasted.
 Patients with diabetes need to regulate their
diet and eat at specific times of the day.
 The patient is 1 to 2 hours late eating
breakfast and can go into diabetic shock from
low blood sugar.
 Usually the result of too much insulin in their
blood stream.
First signs:
 Cold sweat and pale face similar to the signs
of syncope.
 Patient becomes weak
and shaky, followed by sudden mental
confusion that appears as an instant
personality change – at this point, patient
may indicate what is happening or lapse into
unconsciousness.
 If the patient is conscious enough to swallow,
a glass of orange juice or cola will help
TEMPORARILY.
 Call a physician if the patient remains
unconscious.
COVULSIONS
 Patient who goes into convulsions becomes
unconscious and exhibits violent or mild
convulsive motions.
 DO NOT TRY TO RESTRAIN THE PATIENT, but
MOVE objects or furniture out of the way to
prevent injury.
 Call the physician or nurse to help with the
situation.
 Patient will usually recover within a view
minutes and will be able to leave after a few
minutes of rest.
CARDIAC ARREST
 Patient falls into unconsciousness and has no
pulse or respiration, dilated eyes and a blue
or gray skin tone.
 IMMEDIATE cardiopulmonary resuscitation
(CPR) is necessary to avoid patient’s death.
 ONLY persons CERTIFIED to do CPR can
perform this procedure.
 Most health care institutions call this
occurrence a code or code blue.
/ CONTINUED BLEEDING /
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)

 After completion of venipuncture, a gauze  Some patients are

square or cotton ball is placed on the allergic to tape or iodine (used for blood
puncture site to help stop the bleeding. culture).
 NORMALLY, the bleeding will stop in  Usually the result of the patient having a latex
approximately 2 minutes – the time it takes to sensitivity.
label and initial the tubes that were drawn.  Before leaving the patient, check that all
 Some patients have continuous bleeding at bleeding has stopped and tell the patient to
the venipuncture site for > 5 minutes. hold a cotton ball or gauze square on the
 Continue to apply pressure to the site by puncture site.
wrapping an elastic gauze bandage around
the arm over a pad. ANEMIA
 Tell the patient to leave the bandage on for at
 Caused by 4 factors:
least 15 minutes.
1. Decrease in RBCs
HEMATOMA 2. Decrease in hemoglobin
3. Deficiency of hemoglobin
 At the first sign of hematoma, the 4. Abnormal hemoglobin
phlebotomist should discontinue the
venipuncture and apply heavy pressure to the  As a result of anemia, patient has:
site. - Lack of energy
 Phlebotomist should use the major superficial - Pale skin
veins for venipuncture. - Fatigue
 Only the upper most wall of the vein should - Shortness of breath
be punctured to prevent a hematoma.
 Puncture should not be so deep that the top
and bottom walls of the vein are punctured.
 Puncture should be deep enough to fully
penetrate the the uppermost wall of the vein
(partial penetration allows blood to leak
around the puncture site).
 Petechiae, small red dots that are indications
of small amounts of bleeding under the skin
surface may be present on the skin of some
patients.
 Petechiae are often the result of low platelet
counts or other coagulation problems.

SKIN ALLERGIES
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)
TYPES OF ANEMIA
TYPE DESCRIPTION
SICKLE CELL ANEMIA Hereditary disease
Abnormal sickle shape
RBCs
Abnormal hemoglobin
IRON-DEFICIENCY Excessive iron loss
ANEMIA caused by nutritional
deficiencies that create
lower-than-normal RBCs
production
HEMOLYTIC ANEMIA Hereditary condition
RBCs are destroyed
faster than normal
THALASSEMIA Hereditary disease
Hemoglobin production
is suppressed
IATROGENIC ANEMIA Drawing excessive
quantities of blood from
a patient during the
care of the patient;
usually of most concern
with premature infants
DRAWING FROM VASCULAR ACCESS DEVICES
 Many patients have inserted indwelling lines
or vascular access devices such as:
1. Arterial lines
2. Venous catheters
3. Percutaneous indwelling central catheters
4. Heparin/saline locks
(These devices consist of small plastic tubing that is
placed in the patient for access to give fluids and
medication to draw blood.)
 To keep blood from clotting in the line,
heparin/saline is injected into the line until all
the blood is pushed back to the patient. This
keeps the line clear until
the next blood sample needs to be taken.
 Any samples first taken from the line contain
a mixture of blood and heparin or saline.
 Capacity of the line must be discarded at least
TWICE to clear any fluid from the line.
 For coagulation testing, the capacity must be
discarded at least 5 or 6 times.
 If the line contained heparin and a
coagulation tube needs to be collected, at
least 7ml of blood is usually sufficient as a
discard to clear all the heparin/saline.
 After the discard, the blood can be drawn as if
you are drawing from a vein.
METHOD OF DRAWING:
- Can be with a syringe or with an evacuated
tube system.
 To draw from a line with the evacuated tube
system, a Luer adapter is used.
 A Luer adapter looks like an evacuated needle
without the needle.
 The part that screws into the holder has the
same needle and rubber sleeve.
 Phlebotomists in some situations are drawing
blood from lines, but usually nurses to this
type of collection.
 The same limitations hold for accessing a
cannula, a type of tubing connector used on
patients with kidney transplant or on dialysis.
 Some dialysis patients have fistulas – an
artificial shunt connection done by a surgical
procedure to fuse together a vein and an
artery.
 When encountering a patient with a fistula,
samples should be drawn from the OPPOSITE
arm.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE LAB & LEC
MIDTERM REVIEWER
(S.Y. 2018-2019)

FAILED VENIPUNCTURE  PROBING is not

 When you can’t obtain a blood sample, it may
be necessary to CHANGE the position of the
needle.
 If the needle has penetrated too far into the
vein, pull back a pull out LITTLE – always
SLOWLY.
 If the needle has not penetrated the vein far
enough, advance it farther into the vein.
 Only advance SLIGHTLY – a small change can
make the difference between a failed and a
successful venipuncture.
SEVERAL REASONS FOR FAILURE:
 Tube may have pulled back out of the holder.
 Tubes often will not stay pushed all
the way into the holder while the
blood is being collected.
 A slight pressure holding the tube into
the holder will reseat the tbe and
remedy this problem.
 Tube being used may not have sufficient
vacuum.
 Try another tube before withdrawing.
 Tourniquet could have been on too
tight, stopping the blood flow.
 Reapply the tourniquet loosely
 An alternative to a tourniquet is a BP
cuff inflated to between the patient’s
systolic and diastolic pressure.
recommended because it is painful and may
cause hematoma.
 If a blood sample can’t be obtained in 2 tries,
do a capillary collection if possible, or have
another person attempt the draw.
TECHNIQUES TO ENHANCE THE VEIN AND RECOVER
A FAILEDVENIPUNCTURE
1) Retie the tourniquet
2) Use a blood pressure cuff
3) Massage the arm. DO NOT SLAP THE ARM
4) Lower the patient’s arm
5) Warm the venipuncture location
6) Reseat the tube in the holder
7) Use a different tube
8) Place tour finger below the site and stretch
the vein slightly
9) Rotate the needle one-quarter to one-half a
turn
10) Pull back or advance the needle slightly
t

(Cuff provides a larger surface area to apply pressure,

and the pressure can be regulated.)

Notes to remember:

 NEVER attempt a venipuncture more than

twice.