Hand washing – most important practice to prevent spread of
infectious diseases
Patient identification – most crucial step in venipuncture
PHYSIOLOGIC FACTORS CONTRIBUTING TO TEST RESULTS
• Posture – from supine to sitting (or standing)
o Hemoconcentration = larger molecules (iron)
cannot filter into the tissues (↑ in blood)
• Diurnal Rhythm
o Cortisol, TSH - ↑ in morning ↓ afternoon
o Eosinophil ct. - ↓ morning, ↑ afternoon
• Exercise and stress
o ↑ WBC count
• Diet
o Ate before collection - ↑ glucose and lipid
o ↑ lipid = ↑ turbidity
• Smoking
o Before collection = ↑ WBC and cortisol
o Chronic = ↑ hemoglobin
ADDITIVES IN COLLECTION TUBES
• Clot activators – hasten clotting
o Serum samples: clot for 30 – 60 minutes
o Silica particles -activates XII
o Thrombin – converts F1 to fibrin
• Anticoagulants – prevents clotting (invert immediately)
o EDTA, citrate, oxalate – remove calcium and
form insoluble calcium salts
o Heparin – inhibit thrombin and FX activation
• Antiglycolytic agents – inhibit glucose metabolism
o Sodium fluoride – most common
• Separator gel – separation barrier
o Inert material that undergoes temporary change
in viscosity
TUBE GUIDE (BESIDES KNOWN COLORED TUBES)
• Gold – clot activator + gel (serum separation)
o 5x inversion
• Orange – thrombin-based activator + gel (serum sep.)
o 5 – 6x inversion
• White – K2EDTA + gel (plasma separation)
o 8x inversion
• Clear – no additive; 0 inversion
SOLUTIONS FOR SKIN ANTISEPSIS
• 70% isopropyl alcohol – most common
• Non-alcohol based – legal blood alcohol level collection
• Blood culture – 2-step procedure
o 30 – 60s scrub (70% iso. alcohol) → 1-10%
povidone-iodine
• Antiseptic agents should be in skin for about 30 seconds
VENIPUNCTURE
• Torniquet – 3 – 4 inches above puncture site; not applied
for more than 1 minute
• Needles – adults: 21 gauge, 1- inch
• 9:1 – blood to anticoagulant ratio
• Patient – X pump fist
• Anchor vein: 1- 2 inches below site
• Bevel up, angle less than 30 degrees
• Release torniquet as soon as blood flow is established or
after no longer than 1 minute
ORDER OF DRAW
Venipuncture Skin Puncture
Blood culture (yellow) Blood gas analysis tubes
Coagulation (light blue) Slides
Serum (red, gold) EDTA micro collection tube
Heparin (green) Other anticoagulants
EDTA (lavender) Serum micro collection tubes
Sodium fluoride (gray)
COMPLICATION IN VENIPUNCTURE
• Bruising – most common (small blood leakage)
o Resolve: apply direct pressure to the site
• Hematoma – large blood leakage
o Swelling: remove needle and apply pressure (at
least 2 minutes)
o Cause: through the vein or partial insertion or did
not remove torniquet before needle removal
• Fainting – DO NOT USE ammonia inhalants (CLSI)
o Remove needle, apply pressure and lower
patient’s head
o Loosen constrictive clothing
• Hemoconcentration – increased cell concentration
o Leaving torniquet for too long
o If vein is difficult to find, remove torniquet for 2
minutes and reapply before venipuncture
• Hemolysis – rupture of RBCs = pink plasma/serum
o Too small needle during difficult draw
o Drew blood through an existing hematoma
o Pulled back too quickly the plunger
o Forced blood into a tube from a syringe
o Mixed tube too vigorously
o Contaminated specimen with alcohol
o Physiologic: hemolytic anemias
• Petechiae – red spots (small blood have escaped)
o Possible hemostasis abnormality
o Alert the phlebotomist
• Nerve damage
o Feeling of tingling or numbness in the arm
o Remove and discard needle, apply pressure,
and collect from the other arm
• Seizures
o Remove and discard the needle, apply pressure,
and notify the nurse
• Vomiting
o Provide container and notify the nurse
VENIPUNCTURE IN SPECIAL SITUATIONS
• Edema – avoid edematous sites
o Veins are hard to find, and specimen may be
contaminated with tissue fluid
• Obesity
o Use blood pressure cuff (inflate up to 40 mmHg
only) and not left for more than 1 minute
• Burned, Damaged, Scarred, and occluded Veins
o Avoid because they do not allow the blood to
flow freely
• IV therapy
o Torniquet and collect below the IV
o Stop the infusion for 2 minutes first
• Mastectomy patients
o Avoid because torniquet can lead to pain or
lymphostasis from accumulating lymph fluid
SKIN PUNCTURE

• For therapeutic purposes, extremely obese patients,

elderly patients with fragile veins, and newborns
• Newborns: lateral and medial plantar surface of the heel
o Infants less than 1 year old
o Heel puncture: NOT be more than 2 mm
• Adults: ring or middle finger (nondominant hand)
o Puncture perpendicularly to the fingerprint lines
• Warming – increase blood flow sevenfold
• Povidone – iodine – NOT used (possible contamination)

REASONS FOR SPECIMEN REJECTION

• Mismatch patient identification

• Unlabeled or incorrect labeling
• Hemolyzed specimens
• Specimens collected at wrong time or tube
• Plasma tubes – have clotted samples
• Contamination with IV fluid
• Lipemic specimen
o To reduce lipemia, collect after px fasting

Legal issues: breach of confidentiality and px misidentification