Carig, Jelli Bernadette T.
BSMLS 1 – E
PMLS 2 LEC (Midterms)
10:30 – 11:30 WF
Pre-analytical Considerations in Phlebotomy
Site selection limitations when collecting venous blood
sample
A. Sites that must not be used
1. Fistula
o Surgically created to permit passage of
fluids or secretion
o Rationale: it threatens vein integrity of
fistulas and vascular which can lead to
serious patient complications
2. Arteries
o Arterial blood and venous blood
specimens are not equivalent for many
analytes
o Rationale: risk of result interpretations
leading to patient mismanagement;
possess significantly higher risk of injury
and complications than venous access
3. Veins on lateral and palmar surface of the wrist
(underside of the wrist)
o Rationale: increase risk of nerve, tendon
and arterial involvement
4. Infected sites
o Rationale: potential alteration of test
results; exacerbation (worsening the
condition) of infection; patient
discomfort
B. Sites that require a physician’s permission
o Limbs of the site of mastectomy
Rationale: risk of lymph edema (due to
faulty lymphatic drainage) and potential
altered test results
o Thrombophlebitis is an inflammatory
process that causes blood clot to form or
block one or more veins
o Coagulopathies is when the patient’s
blood’s ability to coagulate is impaired
1. End part of the lower extremities
o Rationale: risk tissue necrosis in diabetic
patients and thrombophlebitis in patients
with coagulopathies
C. Sites that should be avoided
1. Extensive scarring/Healed burns
o Rationale: palpation and needle insertion
complications; inability to detect adverse
effect or reactions
2. Hematoma
o Rationale: may cause discomfort with the
patients and potential altered test results
3. Above and below infusing fluids
o Rationale: possible contamination of
specimen with IV fluids
4. Inflamed sites
o Including inflamed tattoos
o Rationale: patient discomfort and
possible complications
5. Edematous sites
o Rationale: potential altered test results
6. Extremities affected by stroke/injury
o Rationale: inability to detect adverse
effects or reactions (e.g. nerve injury,
nerve pain and infections)
Phlebotomy associated patient reactions and complications
1. Fainting/Syncope
o Loss of consciousness
o Insufficient blood flow to the brain
o Patient may experience dizziness, nausea
(vomiting)
o Nausea is the feeling you have in the
stomach when you think you are going to
vomit
o Do not give patients who fainted
ammonia because it may be associated
with adverse effects and must not be
used
o Management:
The phlebotomist must be
aware of the patient’s condition
If the patient has a history of
fainting, it is better to position
the patient lying on bed, but for
laboratories, use reclining chair
If the patient fainted during
phlebotomy procedures,
terminate the procedure and
make sure the patient doesn’t
fall
Phlebotomist should seek
assistance and remains with
patient who should be placed
with a head-down position
Patients who fainted must be
allowed to leave and advice
them not to drive for at least 30
minutes
2. Hematoma
o Occurs when needle has gone completely
through the vein
o Occurs when bevel opening is partially in vein
o Occurs when not enough pressure is applied
to the site after puncture (should apply
pressure for 3-5 minutes)
o Susceptibility to hematoma may be increased
with patients with bleeding disorders or if the
patient is receiving certain drugs such as
 Carig, Jelli Bernadette T.
BSMLS 1 – E

aspirin, warfarin and cortisone (they affect 6. Seizures

coagulation) o Abnormal state in which you become
o Strenuous use of the arm may cause unconscious and the body moves in an
hematoma uncontrolled and violent way
o Rapid swelling of the site of collection o Rare complication that may occur during
o Leakage of blood from blood vessels collection
o A mass of usually clotted blood that forms in o If seizure occurs, the phlebotomist should
body spaces or tissues as a result of broken immediately remove tourniquet and needle
blood vessels o Attempt to maintain pressure on puncture site
o Management: and call for help
Tourniquet and needle should be o No attempt should be made to place anything
removed immediately and apply firm on patient’s mouth and do not leave the
pressure to the site at least 5 minutes patient
Phlebotomists are needed to advise 7. Hemoconcentration
patients for firm pressure for o Increased concentration of large molecules
conscious patients and formed elements
Phlebotomist shouldn’t leave an o Caused by excessive massaging of sclerosed
unconscious patient until they are veins
satisfied that hematoma is stabilized o Management:
In hospital setting, phlebotomists Avoid prolonged tourniquet
can pass the responsibility to nurses application
or physicians 8. Hemolysis
3. Thrombosis o Caused by improper venipuncture, small
o Thrombi: solid mass or a clot that resides in gauge, rapid pulling of plunger, shaking of
blood vessels tubes vigorously, puncture site is not dried
o Veins which thrombi are rigid and bumpy and 9. Allergic reactions
lacks elasticity o Patient is allergic either to latex or antiseptics
o Management: o Management: use an alternative material
Avoid collecting blood form 10. Accidental arterial puncture
thrombose veins o Due to needle inserted to deep and failure to
4. Petechiae hit the preferred vein
o Are small red spots appealing on patient’s o Rapidly forming hematoma
skin indicating that minute amount of blood o Management:
escaping into skin’s epithelium Remove needle immediately
o Results from coagulation defects Apply direct, forceful pressure for 5
o Risk of patient bleeding excessively minutes
o May be result of coagulation defects such as Notify staff and document the
platelet abnormalities or other blood incident
disorders 11. Nerve injury
o Patients showing petechiae may bleed o Characterized by:
extensively Shooting, electrical, severe or
o Management: unusual pain
Always make sure bleeding has Tingling or numbness
stopped after venipuncture before Tremors on the limbs
leaving patient o Management:
5. Excessive bleeding Patient reactions or complaints
o Patients on anticoagulation therapy or those Terminate the procedure
taking other medications may bleed for a Document incident
longer period
o Management: Patient factors and Special situations
Apply pressure on the site until 1. Mastectomy
bleeding stops o Surgical removal of one breast or both
Phlebotomist must not leave the o Lymphostasis (increased risk of
patient until bleeding stops or a thrombophlebitis)
nurse takes over to assess patient’s 2. Edema/Dropsy
situation for in patients o Abnormal accumulation of fluid
 Carig, Jelli Bernadette T.
BSMLS 1 – E

o Should be avoided because it can cause Excessive probing

contamination with tissue fluid Tourniquet too near to site of
3. Obesity insertion
o Difficulty to palpate veins o Possible solutions:
4. Intravenous (IV) Therapy Apply firm pressure over swollen
o Veins are usually damaged, sclerosed (veins area
become hard) or occluded (blocked off or Reassure patient that the bruise will
with obstruction) resolve
o Should be avoided but if both arms have IV Repeat venipuncture at different site
devices, should collect blood upstream away 5. Volume draw too large
from the IV site o Inappropriate for pediatric patients
o If IV is downstream, disconnect it then collect o Use smaller volume tubes
blood after 3 minutes and discard the first 6. Hemolysed specimen
tube collected o Possible causes:
o Other hospital institutions use hep lock Vigorous mixing of specimen
(heparin lock; device that has heparin which If required inversions is not meet,
prevents blood from clotting) micro clot can appear and can lead
to erroneous test results
Troubleshooting Hints Transfer of blood from syringe to
- Possible causes of error and quick solutions tubes
Alcohol contamination
1. No blood seen or little blood flow to the tubes Prolonged tourniquet application
o Possible causes:
Bevel on lower part of the vein
Bevel on upper part of the vein
Needle rotated 45˚
Needle passed through the vein
Bevel partially inserted to vein (may
cause leakage0
When vein rolls
Tube lost its vacuum
Tourniquet is too tight or applied for
too long
o Possible solutions:
Reposition the tube
Remove the tube from holder and
discard
Release the tourniquet
Advance the tube
Pull back or advance the needle
2. Underfilling of tubes
o Possible causes:
Premature removal of tube (blood
flow should stop before removing
the tube; ensure the vacuum Is
exhausted)
“dead space” in tubing of winged
collection
Additive – 9:1 ratio
3. Blood stops flowing during collection
o Possible causes:
Collapsed veins (remove the
tourniquet)
Needle movement during collection
4. Occurrence of hematoma
o Possible causes:
Needle insertion errors