!!!

This is not an official document, only draft summarizing information which may be
usefull for students !!!

Basic steps of standard phlebotomy (EFLM, 2018)

Step 1. Patient identification

Step 2. Verify patient is fasting and properly prepared

Step 3. Obtain supplies required for venous blood collection

Step 4. Labeling and/or identifying tubes

Step 5. Put on gloves. Hands should be cleaned in front of the patient, before putting on
gloves.

Step 6. Apply tourniquet - approximately one hand width (7.5 cm) above the anticipated
puncture site and should be tight enough to stop venous but not arterial blood flow.
Disposable tourniquets, vein illumination devices

Step 7. Select venepuncture site - The cubital vein is the most preferable choice, dorsal hand
veins be used as an alternative. Do not collect blood from previously placed
peripheral venous catheters, indurated veins, paretic arms or arms with lymphatic
drain disorders.

Step 8. Clean sampling site. Do not touch the disinfected site after cleaning.

Step 9. Puncture the vein - with the bevel up. Prevent the rolling veins by extending the
patient's skin, an approximatelly 5-30 degree angle depending on the vein’s depth.
Hold the tube holder steady and by supporting your hand against the patient's arm.
Use device with flash visualisation

Step.10 Fill all sampling tubes – follow the recommended order of tubes

Step.11. The tourniquet should be removed as soon as the blood flows into the first tube.

Step 12. Gently invert the tubes once immediately after collection

Step 14. Remove the needle from the vein and ensure the safety mechanism is activated

Step 15. Dispose of the needle

Step 16. Bandage the puncture site - by applying a patch or a bandage by placing an
adhesive tape tight over a dry pad/gauze square.

Step 17. Tell the patient to apply pressure and do not bend the arm

Elevating the arm may be useful to stop bleeding from the puncture site.

Step 18. Invert all tubes at least 4 times

Step 19. Remove gloves

Step 20. Advise the patient to rest for 5 min

Venipuncture complications
Site to be avoided when collecting blood
 Site should be free of lesions, abrasions, scar tissue any damaged skin
 Never select an arm that is edematous
 Do not perform a blood draw above an IV site - specimen will become dilited with IV fluid – use
anither arm
 Site of a breast removal or double mastectomy - lymphostasis
Potential problem associated with tourniquet application
 Applied to tight – stops flow of blood during blood sampling
 Left on to long – hematoma, hemoconcentration - 1 minute application

Dealing with patient complication

A. Syncopa (fainting)
What to do? Quickly remove needle and tourniquet and call for help. Apply pressure on the site
Lower patient´s head to between their knees. Apply cold compress to the back of the neck and face.

B. Phlebosclerosis – geriatric patient. Frequent venipunctures – will not give adequate amount of
blood. What the site may feel like ? hard/ cordlike, lack resilience. Choose another site

Reasons why blood may not enter a tube

a. Inproper placement of needle in arm: agianst the vein wall, too deep, not deep enought, beside
the vein
b. Turniquet is too tight
c. Insufficient vacuum in the tube
d. Collapsed vein

RULE during blood sampling: 2 sticks only – after the other person may try !!!

Dealing with special situations

a. Hemolysis during sampling
b. Prolonged bleeding from site – more than 5 minutes: medicine - heparin, aspirin, inproper
application of pressure
What to do ? firm pressure + ice
c. Punctured artery (pulsing blood in batterfly needke, bright red color)
What to do ? stop procedure, remove needle, elevate the arm+ aply firm pressure

d. Blood sample is not obtained: change tube, reposition the needle, adjust tourniquet
e. Hematoma (blood is leaking into the tissues)- fragile vein, needle penetrates all the way
though vein. Partly inserted needle, needle removed while tourniquet is still on, inadequate
pressure after sampling
Test questions
Q1: A micro-sample from a 4-month-old infant is generaly collected by
a. finger stick
b. scalp stick
c. heel stick
d. venipuncture

Q2: When collecting a sample of whole blood for testing using alavander-cap tube, how many
inversions are needed to mix the blood with additive?
a. 6
b. 8
c. 2
d. 10

Q3: The maximum length of time a tourniquet shoul be left in placed is

a. One minute
b. Two minutes
c. Three minutes
d. Four minutes

Q4: If a patient had a right mastectomy 6 month ago, blood may be drown from the:
a. Left arm
b. Left or right ankle
c. Right arm - distal area only
d. Left or right arm

Q5: If a patient in the emergency department refuses to have blood drown but the phlebotomist
does so at the physician assistance, the phlebotomist may be charged with?
a. Assault
b. Negligence
c. Malpractice
d. Nothing

Q6: If a very small hematoma is ecident during venipunctue, the best initial response is to?
a. Remove the needle, elevate the arm, and apply pressure
b. Remove the needle and apply an ice compress
c. Remove the needle and apply pressure
d. Observe and complete the venipuncture

Q7: Wearing arteficial nails or long nails by healthcare workers in general especially increases the
risk of harboring:
a. Fungi
b. Viruses
c. G- bacteria
d. G+ bacteria