Hematology Lec

Blood collection parts 1 - 4 | Vanessa Lee Calimbo

FACTORS AFFECTING RESULTS creatinine levels are still
high, then this may indicate
1.) These are variables that are under the a pathological factor
control of the patient and the phlebotomist d.) Stress
2.) Pre-analytical variations in lab test results i.) If the patient is
a.) Posture (supine or erect) experiencing stress (i.e.
i.) Lying to Standing or Sitting anxiety; this is also
= shift in body water from especially for pediatric
blood vessels to interstitial patients who tends to cry
fluid = False increase in even before blood
concentration of some collection), these blood
blood constituents (e.g. components/constituents
total protein, cholesterol, will falsely increase
etc.) (1) Leukocytes / WBC
b.) Diurnal rhythms count
i.) Refers to the day and night ii.) Write down the
cycle of body fluid observations (i.e. patient is
fluctuations or changes crying / anxious during
that occur in some blood collection) in the remarks
constituents section to avoid
ii.) E.g. the level of cortisol (aka misinterpretations of results
stress hormone) varies e.) Diet (fasting or not)
depending on the time of i.) Always ask the patient
day. when was their last meal for
(1) Cortisol helps us to tests that require fasting
keep us awake and (1) If the patient
to work, especially overfasted, blood
under stressful collection is not
conditions allowed. Instead,
(2) Cortisol level is high tell the patient to
in the morning, but come back next
low during the time but with
afternoon properly timed
iii.) Another example is Thyroid fasting
Stimulating Hormone (TSH) (2) Overfasting in
iv.) Eosinophils also has a Fasting Blood
diurnal rhythm Sugar test will
(1) Lower in the result in a falsely
morning; increases decreased sugar
in the afternoon level; not enough
c.) Exercise fasting results in
i.) After exercise, there is a falsely increased
false increase in: ii.) Lipemic
(1) Creatinine (1) Blood collection
(2) Total protein was done on a
(3) Creatinine Kinase patient who did not
(CK) fast (just finished
(4) Some other blood eating)
constituents (2) Sample is turbid
ii.) E.g. if the patient did not due to increased
perform any exercises prior lipids
to blood collection but their
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 (3) Affects the tests b.) Follow the specific schedule for time
who uses of collection for timed specimen
photometric, collections
spectrophotometric i.) I.e post-prandial blood
, or optical methods sugar test (2 hours after
(a) I.e. meal)
hemoglobi
n, VENIPUNCTURE
Coagulatio
n studies 1.) Things to be done to carry-out phlebotomy
(protime / procedure easier
prothrombi a.) Prepare supplies and have them
n time, and readily available
aPTT b.) Review the minimally acceptable
(activated volume of blood for an individual
partial assay or groups of assays
thrombopla c.) Determine the minimally acceptable
stin time)) volume of blood for each type of
(4) The coagulation collection tube
studies mentioned 2.) Always remember
above are usually a.) A properly collected blood sample is
analyzed using essential to quality laboratory
optical detection outcome
instruments. b.) Strict adherence to the rules of
(a) Uses specimen collection is critical to the
plasma as accuracy of any test
its sample. c.) Pre-analytical errors are major
So, if it is potential sources of errors
turbid, it d.) Anticoagulated blood is the type of
will specimen frequently used for
adversely hematological studies
affect the e.) Always fill the vacutainer tubes
results properly, do not underfill or overfill
f.) Smoking to maintain the proper
i.) Some tests will be affected anticoagulant to blood ratio
(1) I.e leukocyte count i.) This is okay when it comes
/ WBC count to plain tubes (without
(falsely increase) anticoagulants) as they do
3.) Phlebotomist must adhere to the specific not contain anything so
schedule for timed specimen collections and there will be no adverse
accurately record the time of collection effects
a.) Take note of the time of day that ii.) If the anticoagulant tube is
the blood collection was performed underfilled = diluted =
in order to avoid misinterpretation usually falsely decreased
between some physiologic and result
pathological factors. iii.) If overfilled = blood sample
i.) E.g. If the collection was will clot or a portion of it
done in the afternoon, the f.) Use of wrong collection tube
MT will know that the low i.) There are over 9 types of
cortisol level is due to blood collection tubes
physiological factors ii.) Each lab test requires a
(diurnal rhythm) and not specific tube for blood
due to pathologic factors collection

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 iii.) Each tube contains no any adverse effects
different adhesives to regardless of which kind of
prepare the blood sample tube is used
for testing b.) Evacuated system and syringe
iv.) Each tube should be c.) Blood cultures are done first before
collected in a specific the blood tubes to prevent carry
“Order of Draw” to support over of possible contaminants or
quality results pathogens from the external
(1) The order of draw environments towards the blood
is applicable if culture bottle itself
multiple draw is i.) This is to make sure that, if
required or there the blood culture sample
are multiple tests turned out to be positive,
requested we can be certain that it is
(a) ETS is not due to external factors
required if or contamination
multiple d.) Order of draw:
draws /
samples
are
required
(2) The order of draw
was established to
prevent the carry
over of an
anticoagulant to
the next tube
(3) I.e. if the adhesive
in the purple
stopper tube
contaminates the
green stopper tube
this would cause a
falsely decreased
calcium and
increased
potassium

CLINICAL LABORATORY STANDARDS Note: Some references have different pnemonics

INSTITUTE (CLSI) i.) Blood cultures
(1) Always first
1.) Formerly called National Commission of ii.) Light blue (citrate) Tube
Clinical Laboratory Standards (NCCLS) (1) Comes next after
2.) Determines, approves, and publishes the blood cultures; it is
“order of draw” for coagulation
3.) Same order of draw is used for studies
a.) Glass and plastic venous blood (2) This is done to
collection tubes prevent the blood
i.) It was said before that the sample from
order of draw between clotting before it
glass and plastic tubes were has been put in the
different. However, recent tube
studies show that there are

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Note: If coagulation studies, such as prothrombin (2) For clinical
time and activated partial thromboplastin time, are chemistry tests that
in the request form, some laboratories may require require serum
the use of a discard test tube (especially during the samples
butterfly method). (a) I.e. FBS,
lipid
The discard tube is a non-additive tube or a plain profile, etc
red top tube and will not be utilized for any testing (3) Also for serological
as it is intended to prevent contamination of blood tests that require
samples from tissue factor 3 / tissue serum samples
thromboplastin (clotting factors). Once the tissue (a) I.e.
factor 3 / tissue thromboplastin is activated, it Hepatitis B
starts the clotting cascade thus the contamination surface
of the activated TF 3 will be contained within the antigen
discard tube. test, HIV
test, etc.
It is drawn after blood culture and before the (4) For blood banking
citrated tube (to be utilized in the coagulation (a) I.e.
tests). crossmatch
ing
The other laboratories that do not require this will (5) For immunology
directly use citrated tubes (light blue). If the iv.) Serum Separator Tube
citrated tubes that are used for the coagulation (red-gray tiger top or gold)
studies are contaminated, the coagulation time is (1) Same usage with
shortened resulting in premature or early clotting red tube
which may have its own consequences. It is worth (a) But is not
noting that there have been studies that debunk used for
the need for discard tubes. crossmatch
iii.) Red Tube ing as the
(1) Can be a red top gel
tube with clot separator
activator or plain may
(without) interfere
(a) Clot with the
activator is crossmatch
only there ing
to hasten (2) Does not have an
the clotting additive,
process anticoagulant, nor
(b) For plain clot activator
red tubes, (3) It only has gel /
it usually serum separator
takes v.) Green / Dark Green
around 30 (Heparin)
minutes to Note: Light green top (in the table above) is used
an hour for for chemistry tests. Do not worry if it is not
blood to available as red top tube can also be used for
clot, but chemistry tests
only a few vi.) Purple Top (EDTA)
minutes for (1) For CBC
those with (2) Green should come
clot first before purple.
activator This is because

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 EDTA contains Note: Discard tubes are required when using the
potassium salts butterfly method to address the dead air problem.
that will interfere This is due to the plastic tubing containing dead air
with the spaces. Because of this, the first few amounts of
heparinized blood blood collected will be insufficient in terms of blood
sample, leading to volume and the blood to anticoagulant ratio will
erroneous not be satisfied. This is only done when coagulation
electrolyte result tests are included in the request. Red top tube is
(3) HbA1c / used as a discard tube, but some references say,
Glycosylated for coagulation tests, another light blue tube will be
Hemoglobin test is used as discard tube
the only glucose a.) Light Blue Top (Sodium Citrate)
test that requires b.) Gold Top (Serum Tube / Serum
whole blood as its Separator Tube)
sample instead of c.) Red Top
serum, Hence, it d.) Green (Sodium Heparin) or Light
uses purple tube Green Top (Lithium Heparin -
instead of red, Plasma Separating Tube)
serum separator e.) Lavender or Pink Top (both EDTA)
tube, or f.) Tan Top (EDTA)
oxalate/fluoride g.) Gray Top (Sodium Fluoride)
that is usually used Note: Butterfly method is used for patients that
for chemistry tests have very thin veins and are difficult to extract
(a) This test is blood using the usual methods, and also for
also used pediatric patients who usually have small veins. The
to monitor needle gauge used in butterfly method is usually
the success 25-26
of the
diabetes EQUIPMENT NECESSARY TO PERFORM
treatment VENIPUNCTURE
(test is
done 3
months
after).
vii.) Light Gray Top (oxalate /
fluoride)
(1) For glucose
4.) Order of Draw (Butterfly method)

1.) Gloves
2.) Needles
a.) Butterfly needle
i.) In the event the patient’s
vein is extremely thin or
when drawing from
pediatric patients
3.) The Hub
4.) Evacuated Collection Tubes
a.) For multiple tests
5.) Alcohol Wipes
6.) Syringes / Vacutainer

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7.) Bandages / Tapes / Medi-plast (a) Secures the
8.) Gauze Sponges needle and
9.) Povidone / Iodine / Alcohol Swabs / Wipes the tube
10.) Requisition Form iii.) Evacuated Tubes
11.) Tourniquet (1) Variety of sizes
12.) Sharps Container (2) Variety of
premeasured
EQUIPMENT FOR VENIPUNCTURE additives
(3) With color-coded
1.) Tourniquet stoppers (denote
a.) Disposable elastic strap, a heavier the additives used)
Velcro strap, or a blood pressure
cuff (alternative)
i.) Blood pressure cuffs can be
an alternative if no
tourniquet is available or if
the tourniquet does not fit
around the patient’s arm
b.) Latex-free
c.) Applied 3-4 inches above the
venipuncture site
i.) Book of Rokak - 4-5 fingers Note: Traditional needle of an ETS means that it
wide above the site does not contain a safety device. Unlike with safety
d.) Left on for no longer than 1 minute needles, it contains a safety device (as shown in the
before the venipuncture is picture above)
performed b.) OSHA Recommendation
2.) Collection Tubes i.) Use of plastic tubes
a.) Evacuated Tube System whenever possible
i.) Most widely used system Note: Most glass tubes are coated with silicone to
for venous blood collection help decrease hemolysis and to prevent blood from
ii.) Composition: adhering to the sides of the tube
(1) Evacuated tube 3.) Additives in Collection Tubes
(plastic or glass) a.) Clot Activators
(2) Needle (Two-way) i.) Blood sample for serum
(a) One side testing
has a bevel (1) Samples are left
and is standing for 30-60
longer. One mins to clot
that enters ii.) Purposes
the vein (1) Accelerate clotting
(b) Other side process
is shorter (2) Decrease specimen
and preparation
contains a iii.) Examples:
rubber (1) Glass or silica
sleeve / particles
sheath (to (a) Activates
prevent factor XII
blood from in the
dripping) coagulatio
(3) Adapter / Tube n pathway
holder (2) Thrombin

6
 (a) An i.) EDTA (Ethylene Diamine
activated Tetra-Acetate) Liquid:
coagulatio (1) Types: Sodium (Na)
n factor and K2 EDTA
that (1.5-0.25 mg/ml)
converts (2) Functions by
fibrinogen forming calcium
to fibrin salts to remove
calcium
(3) Uses: most
hematology studies
such as CBC, PCR,
ESR (erythrocyte
sedimentation rate)
and HbA1c
(4) Requires full draw
(5) Invert 8 times
ii.) Light Blue:
(1) Sodium Citrate (1:9
ratio)
(2) Anticoagulant: 32
b.) Anticoagulants g/l
i.) Chelation of Calcium (3) Action: Remove
(1) EDTA calcium
(2) Citrate (4) Uses: coagulation
(3) Oxalate studies
(a) Calcium - a (prothrombin time,
cofactor activated partial
that is thromboplastin
needed for time, fibrin
clotting by degradation
forming product test /
insoluble assay, etc) and
calcium platelet function
salts Note: If we want to determine the platelet COUNT,
ii.) Heparin EDTA should be used. But, if we’re after the platelet
(1) Binds to FUNCTION, light blue tube should be used
antithrombin in the iii.) Dark Green
plasma and (1) Sodium Heparin or
inhibiting thrombin Lithium Heparin
(no conversion of (2) Action: inactivate
fibrinogen to fibrin) thrombin and
and activated thromboplastin
coagulation factor (3) Uses:
X (a) For Lithium
iii.) Tubes with anticoagulant be level use
gently inverted immediately Sodium
after collection Heparin
iv.) Tubes with anticoagulant (b) For
are either tested as whole Ammonia
blood or are centrifuged to level use
yield plasma Sodium or
c.) Anticoagulant Tubes

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 Lithium (1) Plasma separating
Heparin tube with Lithium
iv.) Black Heparin
(1) Sodium Citrate (1:4 (2) Uses: Chemistries
ratio) Note: Serum or plasma from tubes with separator
(2) Action: Removes gels cannot be used with certain instruments of for
calcium blood bank procedures (gel may interfere with
(3) Uses: indicated for some testing)
Erythrocyte
Sedimentation Rate Remember to gently invert all tubes with
(ESR) studies anticoagulants with their proper inversions after
(particularly using collection to ensure proper mixing of the additive
the Westergren and blood
Sedimentation Rate
method) For red top tubes and tubes with separator gels, do
v.) Red (Plain Tube) not mix / invert them. Instead, let them stand and
(1) No preservative / wait for clotting to take place (30m - 1h)
anticoagulant 4.) Needles
(2) Uses: usually for a.) Sterile; single use
blood bank tests, b.) Available in a variety of lengths and
toxicology, and gauges (bore or opening size)
serology c.) Needle gauge number is inversely
d.) Antiglycolytic Agent related to the bore size
i.) Inhibits glucose i.) Smaller the gauge number
metabolism by blood cells = the larger the bore
ii.) Such inhibition may be d.) Needles for drawing blood:
necessary if testing for the i.) 19-23G
glucose level is delayed e.) Most common needle size (adult)
iii.) Example: Sodium Fluoride i.) 21G (1 inch long)
(Gray top tube) f.) Most common needle size
e.) Separator Gel (pediatric)
i.) An inert material that i.) 23G or 25-26G
undergoes a temporary 5.) Needle Holders
change in viscosity during a.) Needles and holders have a safety
centrifugation process feature to prevent accidental needle
ii.) This enables it to serve as a sticks (as per OSHA’s
separation barrier between recommendation)
the liquid (serum or plasma) b.) Examples of safety needles and
and cells holders
iii.) Two types
(1) Serum Separator
Tube (SST)
(2) Plasma Separator
Tube (PST)
iv.) SST / Gold Top
(1) No additives
(2) Clotting accelerator
and separation gel
(3) Uses: chemistry, 6.) Winged Blood Collection Set (Butterfly)
immunology, and a.) Consists of a short needle with
serology plastic wings connected to thin
v.) PST / Light Green Top tubing
b.) Features

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 i.) Short needle, which has Note: ETS is only good for prominent veins. ETS is
plastic wings, is connected not good for scenarios where syringes will prove to
to a thin tubing which is be better (pediatric and geriatric patients, tiny,
connected to a hub on the fragile, or rolling veins)
other end which is
connected to an adapter / BLOOD-SAMPLING SYSTEMS
tube holder
(1) When using the 1.) N&S / Open system
Butterfly method, it a.) Manual manipulation of plunger
is important to hold b.) Manual transfer of specimen
the plastic wings c.) Risks the problem of contamination
near the needle d.) Examples:
together in a i.) Needle and syringe system
vertical position to ii.) Winged butterfly system
allow flow of blood (syringe)
2.) Vacutainer System / Closed system
a.) Quick and easy fill, no manipulation
needed
b.) Auto and direct transfer of
specimen
c.) Examples
i.) Vacuum extraction system
ii.) Winged butterfly system
(vacuum extraction)

c.) Purposes:
i.) For collecting blood
samples from children
ii.) For collection blood
samples from other
patients from whom it is
difficult to draw blood
7.) Syringes
a.) Useful in drawing blood from the
following:
POSSIBLE SOURCES OF BLOOD
i.) Pediatric patients
ii.) Geriatric patients 1.) Venous Blood
iii.) Patients with tiny, fragile, 2.) Capillary Blood
or rolling veins 3.) Arterial Blood
b.) Disadvantage
i.) If the test/s require a larger METHODS OF BLOOD COLLECTION
volume of blood, then this
may not be possible. 1.) Venipuncture
Instead, make use of ETS a.) Syringe method
b.) Vacuum method (ETS)
c.) Winged or Butterfly method

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2.) Capillary Puncture / Fingerstick
3.) Arterial Puncture

SELECTION OF A VEIN FOR ROUTINE 4.) Hand or Wrist Veins (Dorsal Metacarpal
VENIPUNCTURE Veins)
a.) May be used when Median Cubital
1.) Median Cubital Vein or Cephalic veins are unsuitable or
a.) 1st choice unavailable
i.) Large b.) The clinician must use extra care to
ii.) Well anchored anchor them
iii.) Least painful c.) Have a narrow diameter therefore it
iv.) Least likely to bruise may be necessary to use a small
2.) Cephalic Vein gauge needle and small volume
a.) 2nd choice evacuation tubes (i.e. 23G or 25G)
i.) Not as well anchored as the i.) The only problem with using
median cubital vein smaller gauges is the risk of
ii.) More painful when hemolysis
punctured than the median d.) As much as possible, the angle of
cubital vein the needle should be lessened
3.) Veins to Avoid i.) This is because the hand is
a.) Basilic Vein less fleshy, therefore, veins
i.) It is near the brachial are usually much closer to
artery the bone
ii.) Possible artery puncture Note: When drawing tubes from the hand, the use
iii.) Nerves can be damaged of a butterfly apparatus can be more effective and
less painful

There is no order of choosing hand veins

SPECIMEN COLLECTION: SAFE PUNCTURE

1.) Avoid:
a.) Hitting a nerve
b.) Puncturing arteries

10
 c.) Excessive or blind probing with a
needle
2.) Be aware of site selection when collecting
blood samples
3.) Last resort veins that only highly trained
personnel can collect from (i.e. doctors):
a.) Jugular Vein
b.) Scalp Vein
c.) Femoral Vein

Example: If both the lower and upper extremities Note: Bevel of needle should be facing upwards.
are edematous, these veins can be used as a last The needle should be in a 30° angle or less relative
resort for blood collection. But, in this case, only to the skin surface, otherwise we risk puncturing
highly trained personnel can do so the bone or a through and through puncture

VENIPUNCTURE PROCEDURE (as per CLSI

recommendation)

1.) Prepare the laboratory test request / order

2.) Greet the patient and identify the patient by
having the patient verbally state his or her
full name and confirm with the patient’s
unique identification number, address,
and/or birth date. Ensure the same
5.) Proper and Improper Needle Insertion
information is on the request form
a.) Establish rapport with the patient
3.) Sanitize hands
4.) Verify that any dietary restrictions have
been met (e.g. fasting, if appropriate) and
check for latex sensitivity

VENIPUNCTURE IN SPECIAL SITUATIONS

1.) Sites to be avoided when collecting blood

a.) Site should be free of lesions,
abrasions, scar tissue, any
damaged skin
b.) Never select an arm that is
edematous
i.) Edema is an abnormal
accumulation of fluid in the

11
 intercellular space of the blood for the actual
body testing
ii.) Palpating will be difficult (4) After drawing
and blood extracted from blood, let the nurse
an edematous arm might turn the IV back on
be contaminated by the v.) In the case where the
excess fluid patient has a PICC
Note: When ma’am tried to extract from an (peripherally inserted
edematous arm of a patient (because all of the central catheter) line
patient’s limbs were edematous and she did not
want to take the risk of performing arterial blood
collection), the fluid that entered the hub of the
syringe was not blood but a clear or yellowish
tissue fluid
c.) Do not perform a blood draw above
an IV site
i.) Specimen will become
dilute with IV fluid
ii.) Use other arm or another
site (1) We may ask the
iii.) But, in cases where both nurse if they can
arms are hooked up in IV draw blood for us
lines into a syringe using
(1) We can draw blood the PICC line
from the back of (2) Then we can just
the hand (Dorsal transfer the blood
Metacarpal Veins). from the syringe to
This can only be the tube
done if the IV lines (3) This is to avoid
are inserted in the having to puncture
brachial artery the patient again
(near the cubital d.) Site of a breast removal
fossa) (mastectomy)
iv.) If the IV lines are inserted i.) Use other arm (side of the
in the radial artery (around body without mastectomy)
the wrist or hand area) ii.) Pressure on the arm on the
(1) We can ask the side with the mastectomy
nurse to shut off with a tourniquet can lead
the IV line to pain or lymphostasis
temporarily (we are Note: CLSI requires physician consultation first
not allowed to shut before blood extraction from a patient with
the IV off, we have mastectomy
to wait for the e.) Double mastectomy
nurse) i.) Hand draw
(2) Wait for 2 minutes (1) If the dorsal
after it is shut off, metacarpal veins
then perform are difficult, veins
venipuncture in the foot can be
(3) In these cases, used (done only by
always use two a trained personnel
discard tubes first or physician)
before using the ii.) Capillary puncture
tube to collect the

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 (1) If CBC is the only
request
2.) Dialysis Patient
a.) They pose potential problems when
it comes to the following:
i.) Blood collection
ii.) Frequency of blood testing
iii.) Limited vein access
b.) Blood collection must never be
drawn from the following:
i.) A vein in an arm with
cannula (temporary access c.) Preferred venipuncture site for
device for dialysis) these patients
ii.) Fistula (permanent surgical i.) Hand vein
fusion of a vein and an ii.) Vein away from the fistula
artery) or a vein in arm with on the underside of the arm
fistula d.) Special precaution should be taken
to ensure that dialysis patients DO
NOT BLEED
i.) Most of these patients are
under Heparin therapy
3.) Obese Patients
a.) Need special consideration
b.) Problems with obese patients:
i.) Veins are not readily visible
ii.) Veins are difficult to
palpate
c.) Possible remedy for locating the
vein
i.) Use of a blood pressure cuff
(not higher than 40mmHg)
(1) Should not be left
on the arm for
more than 1 minute
d.) Phlebotomist should not probe
blindly in the patient’s arm as this
may lead to nerve damage

SPECIMEN COLLECTION: PROPER

TOURNIQUET TECHNIQUE

Example of a cannula: 1.) Tourniquet application

a.) Should be tight enough to slow
venous flow without affecting
arterial flow
b.) Should allow more blood to flow into
than out of the area
c.) Should never be left on a patient
longer than one minute
d.) Should not be applied on the arm of
Example of a fistula in an arm: a recent site of mastectomy
i.) As this may cause pain or
lymphostasis

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 2.) Tourniquet removal 1.) Grasp the patient’s arm / hand with the
a.) Always remove the tourniquet prior thumb on top and fingers wrapped to the
to the removal of the needle back
b.) Failure to do so before withdrawing 2.) Pull the skin taut below the intended
the needle maintains pressure on venipuncture site with the thumb, anchoring
the vein and causes blood to flow the vein to keep it from moving or rolling
out of the vessel 3.) Using a smooth motion, quickly insert the
3.) Always use appropriate PPE needle, bevel up. Stop the needle
4.) Process: advancement when a slight decrease in
a.) Use the tip of the index finger to resistance is felt, signaling entry into the
palpate the vein vein
i.) Helps to determine the size,
depth, and direction of the SPECIMEN COLLECTION: FILLING
vein COLLECTION TUBES
b.) Select a vein which is:
i.) Easily palpated 1.) Insert the collection tube into the port
ii.) Large enough to support 2.) Maintain the tube in a downward position so
good blood flow the blood and any tube additive it contains
iii.) Well-anchored does not touch the needle
c.) Thoroughly clean the venipuncture 3.) Fill the tube until the vacuum is exhausted
site with an antiseptic and/or adequate blood volume for the test
i.) Isopropyl alcohol (70%) is 4.) Remove tube from the holder by applying
commonly used pressure against the flanges of the tube
d.) Start at the center of the site and holder with the thumb and index finger
move outward in ever widening while using a slight twist to remove the tube.
concentric circles Hold the needle steady as tubes are
i.) Failure to follow this removed and inserted
procedure correctly may 5.) If the tube contains an additive, invert it
re-introduce dirt and gently 8-10 times after removal to mix the
bacteria to the blood and additive. Additional mixing can
venipuncture site be performed while other tubes are filling
e.) Use sufficient pressure to remove
surface dirt SPECIMEN COLLECTION: SAMPLE MIXING
f.) Let the site air dry prior to
beginning the venipuncture 1.) Proper technique: Inverting the Tubes
i.) Do not wipe or fan the site, a.) When
as this may re-introduce i.) Immediately after drawing
contaminants specimen
g.) Important: b.) Why
i.) Using the correct needle i.) Most tubes contain an
gauge will result in additive to be mixed with
decreased hemolysis the blood sample
ii.) The larger the bore of the c.) How
needle the less the chance i.) Holding tube upright, gently
of hemolysis invert 180 degrees and
iii.) Needle gauge will vary back 5-10 times
based on patient size

SPECIMEN COLLECTION: PROPER NEEDLE

INSERTION

14

d.) Consequences if not mixed properly
i.) Blood can clot and
specimen may need to be
re-drawn or if too vigorous,
hemolysis can occur
SPECIMEN COLLECTION: POST
COLLECTION SITE CARE
1.) Clean 2” x 2” gauze pads are used to place
pressure over the venipuncture site once the
needle is removed
2.) Do not remove gauze too soon. The clot that
is forming may be disturbed and bleeding
may restart
3.) Use an adhesive bandage to cover the site
once bleeding has ceased
4.) Use paper, cloth, or knitted tape over a
folded gauze square for patients who are
sensitive to adhesive bandage
SPECIMEN COLLECTION: PROPER
DISPOSAL OF SHARPS
1.) Never cut, bend, break, or recap needles
with your bare hands
a.) When recapping needles, use the
scooping technique
2.) As soon as the needle is removed from the
patient, the safety device on the needle
must be activated
3.) Immediately discard all needles in a sharps
container
SPECIMEN COLLECTION: AVOID NEEDLE
STICK INJURIES
1.) Most common causes of needle stick injuries
a.) Most common of all is that safety
device is not activated
b.) Hand-off of needle device after use
c.) Improper disposal
d.) Manipulating the needle in the
patient
e.) Patient moves during the procedure
2.) Safety tips to avoid needle stick injuries
a.) Pre-plan for the disposal of the
needle prior to the procedure
b.) Always activate safety device on
the needle
c.) Work in good lighting
d.) Immediately dispose of used
needles
e.) Do one thing at a time
f.) Explain the procedure to the patient
SPECIMEN COLLECTION: SAMPLE
LABELING
1.) Always:
a.) Verify the information on the tube
labels, match the information on the
order slip and patient ID band
b.) Label tubes after they are drawn in
the presence of the patient to
reduce the risk of specimen
misidentification
c.) If additional information must be
added to the label (e.g. fasting, time
of draw), write with ink, never pencil
2.) Never:
a.) Label tubes prior to the
venipuncture
b.) Leave a patient room before
labeling the tubes
COMPLICATIONS ENCOUNTERED IN
VENIPUNCTURE
1.) Ecchymosis (bruise)
a.) Result of a leakage of a small
amount of blood in the tissue
around the puncture site
b.) Phlebotomist can avoid this by
applying direct pressure to the
venipuncture site with a gauze pad
i.) Patient bending their arm in
the elbow to help hold the
gauze pad in place is not
effective and may lead to
bruising. Better to apply
direct pressure
2.) Hematoma
a.) Result of a leakage of a large
amount of blood in the tissue
around the puncture site
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 i.) Phlebotomist should b.) We would know if this occurred if
remove the needle the plasma or serum appears pink
immediately (do not or red
proceed through the 6.) Petechiae
procedure) 7.) Allergies
ii.) Apply pressure to the site 8.) Nerve damage
with a gauze pad right 9.) Seizures
away for at least 2 minutes 10.) Vomiting
iii.) Hematomas may cause
bruising around the INABILITY TO OBTAIN A BLOOD SPECIMEN
puncture site, pain, and
possible nerve compression 1.) Failure to draw blood
and permanent damage to a.) Reasons
the patient’s arm i.) Vein is missed
3.) Fainting (syncope) (1) Through and
a.) Before the procedure, always ask through
the patient if they had previous (2) Partial insertion of
episodes of fainting during or after needle
blood collection (3) Collapsed vein
b.) If yes, take extra precaution (4) Etc
c.) Should this problem arise, ii.) Insufficient vacuum in
immediately withdraw the needle evacuated tube
and apply pressure on the site with (1) Evacuated tube
a gauze pad might be expired or
d.) It is also better to lower the has a factory
patient's head and loosen any defect where it
constrictive clothing (i.e. tight belts, does not contain
etc.) enough vacuum for
e.) The phlebotomist should also notify it to cause blood to
the designated first-aid providers in fill in
the facility 2.) Patient refusal
4.) Hemoconcentration a.) Maybe due to fear of needles, etc.
a.) Increased concentration of cells 3.) Missing patient
and larger molecules and analytes a.) I.e. the nurse did not inform us that
in the blood the patient was transferred to
b.) This is a result in the shifting of the another hospital or has been
water balance discharged
c.) Can be caused by:
i.) Leaving the tourniquet SPECIMEN COLLECTION: PEDIATRIC
longer than 1 minute PATIENTS
(1) If left for longer
due to difficulty in 1.) Blood volume is a critical factor in pediatric
finding the phlebotomy
patient’s vein, it is a.) Even a small amount of blood taken
best to remove the from a child can be a large
tourniquet for 2 percentage of the child’s total blood
minutes and then volume
reapply before 2.) Blood draws should be tracked in pediatric
puncturing patients to avoid exceeding the amount of
5.) Hemolysis blood that can safely be taken
a.) Result of the rupture of the RBC 3.) Always use appropriate needle gauge size
with a subsequent release or escape a.) 23G or 25-26G
of hemoglobin

16
 b.) Possible problem in using small can be done when CBC is
gauges is the possibility of requested
hemolysis. So take precaution and c.) In newborns, heel sticks are the
utmost care preferred collection method for
c.) Pediatric patients may be difficult small volumes of blood
to handle 2.) Capillary collections may be preferable over
i.) When extracting blood from venipuncture:
pediatric patients who a.) Severely burned patients
keeps moving, we can ask b.) Obese patients
for their parents’ or i.) If after venipuncture
watcher’s help by asking attempts blood collection is
them to restrain the patient still unsuccessful, then
ii.) In the event where they capillary puncture can be
cannot do this, we can done.
restrain the patient ii.) Laboratories have a
ourselves protocol wherein the
(1) This is done by phlebotomist can only
wrapping the make 2 attempts in
patient with a linen venipuncture. If the 2
or any piece of attempts fail, the patient
clean cloth to can be endorsed to another
reduce their phlebotomist
movement c.) Patients with thrombotic tendencies
(a) Wrapping d.) Elderly patients or others in whom
the entire superficial veins are very fragile or
patient is inaccessible
not e.) Patients performing self-testing
necessary, f.) Point-of-care testing
only the g.) Newborn testing
part of the h.) Patients who have a paralyzing fear
body that of needles
is apart 3.) Blood can be obtained from:
from the a.) Heel pulp
selected i.) For infants and newborns
puncture ii.) Fingers of
site infants/newborns are not
iii.) Dealing with pediatric good as they do not contain
patient requires skill, enough flesh, therefore,
especially interpersonal when puncturing, there is a
skills to deal with the risk of puncturing the bone
patient itself and their, iii.) This is not performed on
possibly, distraught parents adult patients because their
heels already have callus
CAPILLARY PUNCTURE skin due to walking

1.) Why perform a skin puncture?

a.) For patients in whom venous access
is difficult
b.) When small quantities of blood are
sufficient for testing
i.) Small volumes are blood is
enough for CBC, hence
capillary / skin puncture

17
 b.) Finger pulp
i.) Can also be done to
pediatric patients if they
are big enough
ii.) But, should not be done to
pediatric patients 1 year old
or below (in which case, use
the heel pulp)
c.) Ear lobule
i.) Rarely performed
4.) Equipment used for capillary puncture
f.) Do not squeeze or apply strong
repetitive pressure to the site. This
may result in hemolysis or increase
tissue fluid in the blood causing
invalid results
6.) Areas for skin puncture
a.) Heel
i.) Puncture is made on the
lateral and medial side of
the heel (blue shaded
areas)
ii.) This puncture site should
only be used with infants
less than 1 year old

b.) Finger
5.) Precautions with skin puncture i.) Puncture is made on the
a.) The finger or heel must be securely palmar surface of the distal
immobilized portion of the 3rd or 4th
b.) Heel punctures in infants should not finger (middle or ring
be made more than 2 mm deep finger)
i.) In premature infants: (1) Other fingers may
preferably less than 2 mm be more callus
c.) Never puncture an area that is ii.) Puncture should be
swollen, bruised, infected, or perpendicular to the
already has been punctured fingerprints or lines (refer
d.) Do not perform skin puncture in to the illustrations above)
patients with the following (1) This is done to
conditions: promote blood flow
i.) Edema
ii.) Dehydration
iii.) Poor peripheral circulation
iv.) Specimen integrity and test
accuracy may be
compromised
e.) Always wipe off the 1st drop of
blood
i.) 1st drop of blood is believed
to contain tissue juices 7.) Skin Puncture (CLSI Recommendation)
which can contaminate / a.) Prepare the accession (test request)
dilute the sample order

18
 i.) This is also where we can (4) Never use the tip or
see information about the center of the finger
patient iii.) Massage or warm the site
b.) Greet the patient (and parents); (1) Avoid fingers that
identify the patient by having the are cold, cyanotic,
patient (or parent in the case of a swollen, scarred or
child) verbally state his or her full covered with a rash
name and confirm with patient’s (2) Massage to warm
identification number, address, the finger and
and/or birth date increase blood flow
i.) This is also done to by gently
establish rapport with the squeezing from
patient to decrease their hand to fingertip
anxiety if ever 5-6 times
ii.) Ensure that the same iv.) Clean and dry the site
information is on the (1) Cleanse fingertip
requisition form with 70% isopropyl
c.) Position the patient and the parents alcohol
(or individual designated to hold an (2) Wipe dry with clean
infant or small child) as necessary gauze or allow to
d.) Verify that any dietary restrictions air dry
have been met (e.g. fasting), and (3) Caution: alcohol
check for latex sensitivity can falsely elevate
e.) Wash hands and put on gloves or lower blood
f.) Assemble supplies and appropriate glucose results
tubes for the requested tests. Check v.) Hold the finger in an
paperwork and tube selection upward position and lance
g.) Finger puncture: the finger (across the
i.) Preparation for finger stick fingerprint) between the
(1) Place all collection side and the pad with the
materials on top of proper size lancet
disposable pad. (adult/child). Press firmly on
(2) Open the lancet, the finger when making the
alcohol swabs, puncture. Doing so will help
gauze, bandage, you to obtain the amount of
and other items blood you need
(3) Have all items vi.) Finger stick location
ready for blood (1) Using a sterile
collection lancet, make a skin
ii.) Choose the finger carefully puncture just off
(1) Best locations for a the center of the
finger stick is the finger pad
3rd and 4th fingers (2) Wipe away the first
of the drop of blood
non-dominant hand (which tends to
(2) Avoid the 2nd and contain excess
5th fingers if tissue fluid)
possible vii.) Apply slight pressure to
(3) Perform the stick start blood flow. Blot the
off to the side of first drop of blood on a
the center of the gauze pad and discard in
finger appropriate biohazard
container

19
 viii.) Keep the finger in a
downward position and
gently massage it (but do
not “milk”) to maintain
blood flow
h.) Heel Stick / Puncture
i.) Warm site with soft cloth
moistened with warm water
(up to 41°C) for 3-5 minutes
(1) This will promote
blood circulation
ii.) Cleanse site with alcohol
prep
iii.) Wipe dry with sterile gauze
pad
iv.) Puncture heel
v.) Wipe away the first blood
drop with a sterile gauze
pad. Allow another large
blood drop to form
PREPARATION OF PERIPHERAL BLOOD
FILM / SMEAR
1.) 2 ways to make PBS (peripheral blood
smear)
a.) Skin puncture blood
b.) EDTA-anticoagulated venous blood
2.) With a skin puncture
a.) Must wipe away the 1st drop of
blood and use the 2nd drop to make
the blood film
3.) Peripheral blood smears must be prepared
for consisted cellular distribution and proper
clarity
Note: Doctors request PBS to evaluate their
patient’s blood cell morphology, especially if they
are suspecting for blood disorder
When viewing the PBS in a microscope, there
should be 5-10 fields just near the feathering edge
of the blood smear. Do not view at the thicker end
because the tendency is that we can hardly identify
the blood cells as it can be darkly stained or cells
will be overlapping each other
ARTERIAL BLOOD COLLECTION
Note: Can only be performed by physicians or
highly trained personnel (i.e. respiratory therapists)
because this procedure is quite risky as we are
puncturing an artery
Medtechs can perform this procedure but only
those with proper training with this procedure and
if there are no available physicians / hematologists
or highly trained personnel
1.) Estimation of blood gases (ABG)
a.) PH
b.) CO2
c.) O2
2.) Collect quickly, fill completely, and seal both
ends immediately
a.) A delay will mean that there will be
an alteration in the blood gases
3.) No air bubbles
4.) Put in ice water and deliver STAT to the
laboratory
5.) Site selection
a.) Arterial blood can be obtained from
a superficial artery such as the
radial and brachial arteries
b.) Radial Artery
i.) Preferred puncture site for
arterial puncture for adults
and pediatrics
ii.) It is superficial - easy
access
iii.) Entry is easiest, minimizes
pain
iv.) Has collateral circulation
(ulnar artery)
Note: Prior to collection, determine if your patient
requires assessment of adequate collateral
circulation based on their clinical history
v.) Always document the
collection site
vi.) Located to the side where
the thumb is
20
 c.) Brachial artery
i.) Used as an alternative to
the radial artery
ii.) Located to the side where
the pinky finger is
Note: Angle of puncture is 30°. The physician or
personnel should be careful to not puncture the
bones or nerves
6.) Venous vs Arterial Blood
a.) Venous blood
i.) Darker
ii.) Deoxygenated blood
b.) Arterial blood
i.) Lighter
ii.) Oxygenated blood

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