1: Hand Washing, and Donning and Doffing of

PPE
Infection
 a condition that results when a microorganism is able to invade the body,
multiply and cause injury or disease
 the Chain of Infection begins with:
a. Infectious agent
b. Reservoir
c. Exit pathway
d. Mode of transmission
e. Entry pathway
f. Susceptible host
 
Healthcare Associated Infections (HAIs)
 apply to infections associated with healthcare delivery in any healthcare setting
including home care
 Nosocomial Infection
→ is a HAI acquired only in hospitals
 these remain a major problem in the healthcare industry but are preventable by
appropriate control measures in conjunction with Standard Precautions
→ among these strategies are proper handwashing, and correct donning
and doffing of Personal Protective Equipment (PPE)
 
Hand Hygiene
 is the first line of defense
 all health professionals who are in direct and indirect contact with patients and
their environment must be responsible for reducing microbial transmission by
performing proper hand hygiene
 routine hand washing is a one-minute procedure that is generally considered to
be the single most important method for preventing the spread of infection
→ when hand washing facility is not available, CDC/HICPAC guidelines
recommend the use of alcohol-based antiseptic hand cleaners as long as
the hands are not visibly soiled
 WHO requires all healthcare professionals to practice the 5 Moments for Hand
Hygiene
→ Before touching a patient
→ Before a procedure
→ After a procedure or body fluid exposure risk
→ After touching a patient
→ After contact with objects around the patient
→ Its importance lies in reducing the burden of healthcare
associated infections since they are considered to be a significant
health safety problem and issue throughout the globe
 
Personal Protective Equipment (PPE)
 acts as a barrier between infectious materials and your skin, and mucous
membranes
 they may include items such as gloves, safety glasses, proper footwear,
respirators, lab gowns, etc.
 to minimize the spread of infection PPE must be properly worn (don), removed
(doff), and disposed
 
Hand Washing Technique (40-60 secs.)
 

1. Stand back as to not touch the sink.

2. Turn on the faucet and wet hands under running water.
3. Apply soap and work up a lather.
4. Rub hands palm to palm.
5. Rub right palm over left dorsum with interlaced fingers and vice versa.
6. Rub palm to palm with fingers interlaced.
7. Rub back of fingers to opposing palms with fingers interlocked.
8. Do a rotational rubbing of left thumb clasped in right palm and vice versa.
9. Do a rotational rubbing, backwards and forwards with clasped fingers of right
hand in left palm and vice versa.
→ scrubbing is necessary to dislodge microorganisms from surface
especially between fingers and around knuckles
→ friction helps loosen dead skin, dirt, and debris
→ steps 4-9 should take about 15-20 seconds.
10. Rinse hand with running water in downward motion from wrist to fingertips.
→ the downward motion allows the contaminants to be flushed from the
hands and fingers into the sink rather than flowing back up the arm
11. Dry hands thoroughly with a single use of paper towel.
12. Use towel to turn on faucet.
 
Donning and Doffing of PPE
DONNING
1. Put on laboratory gown.
→ slip arms into the sleeves being careful to touch only the inside of the
gown
→ secure gown by sealing the buttons, or fasten in back, neck, and waist
1. Don mask or respirator.
→ fit snug to face and below chin
2. Wear gloves.
→ open the package being careful not to touch the outside of the gloves
→ pick up the right glove by the cuff and insert it to the right hand, do the
same for the left
→ position cuffs over wrists by using the fingertips
DOFFING
1. Remove gloves.
→ remember that the outside of the glove is contaminated
2. Remove laboratory gown.
→ the front and sleeves are contaminated
→ unbutton and slip hands inside the gown sleeve
→ fold the gown over arms inside-out and dispatch for laundry or discard
into appropriate receptacle
3. Remove mask or respirator.
→ grasp the ties or elastic bands and remove without touching the front
part
 
KEYPOINTS
 keep hands away from the face
 limit surfaces touched
 change gloves when torn or heavily contaminated
 perform hand hygiene before donning, between each step, and after doffing
2: Specimen Labeling, Centrifugation, and
Aliquoting
Labeling
 proper identification of the specimen must be maintained each step of the
testing process to help assure patient safety
 specimen containers are labeled by writing an indelible pen or by
applying a computer-generated label that has a designated bar code
 this is done after the collection in the presence of the patient
 labels must be written to the body of the containers and NOT on the
cover to avoid confusion when cover is removed
 the minimum information on a label should include:
a. Patient's complete name
b. Age
c. Sex
d. Date of birth
e. Date and time of collection
f. Initials of the person collecting the specimen
 specimens with no label or mislabeled must not be investigated first
before discarding
 
Centrifugation
 the centrifuge performance can be classified as low-speed, high-speed,
and ultra-speed
 it consists of a:
a. head or rotor
b. carriers, or shields that are attached to the vertical shaft of a
motor and enclosed in a metal covering
c. lid
d. power switch
e. brake
f. built-in tachometer which indicates speed
→ some centrifuges are refrigerated
 the applications include:
→ separation of serum or plasma from red blood cells
→ the separation of precipitated solids from the liquid phase of a
mixture
→ the separation of liquids of varying density
 centrifugation is a technique designed to utilize centrifugal forces which
are greater than the force of gravity to speed up the sedimentation rate
of particles
 centrifugal force depends on three variables:
a. mass
b. speed
c. radius
→ particles suspended in a fluid move under the influence of gravity,
towards the bottom of a vessel at a rate that depends on their size and
density
this is achieved by spinning the vessel containing the fluid and
particles about an axis of rotation so that the particles
experience a force acting away from the axis
 → the force is measured in multiples of the Earth's gravitational force 6. Load the tube and its
and is known as the Relative Centrifugal Force (RCF) or "g" force counterbalance opposite
 the RCF generated by a rotor depends on the speed of the roto in with each other in the
revolutions per minute (rpm) and the radius of rotation centrifuge and close the
Converting rpm to RCF lid.
 a good rule of
thumb is one of
even placement
and one of
"opposition"
   exact positioning of
tubes depends on
the design of the
centrifuge holders
ALIQUOTING
 means to separate a portion of the whole blood, serum, plasma, or any
fluid and placed in a separate tube
 specimen may need to be aliquoted for the following reasons:
a. Plasma or serum is required
b. There is no gel separator to separate the serum/plasma from the
cells
c. Storage and stability
Procedure
1. Assemble equipment and disinfect workstation.
2. Perform hand hygiene and wear PPE.
3. Label the specimen provided using marker/indelible pen.
 write the label on the body of the evacuated tubes containing:
a. Patient's complete name
b. Age/Sex
c. Date of birth
d. Date and time of collection
e. Phlebotomist's initials
4. Let the blood inside the red evacuated tube to sit for 45 minutes at room
temperature to clot. Blue evacuated tube must be centrifuged
immediately.
 specimens for tests that require serum must be completely clotted
for 30-60 mins. before centrifugation
 incomplete clotting results in latent fibrin formation that can
interfere with testing
 blue evacuated tube is centrifuged immediately because some
coagulation factors may decrease upon delay
5. Make counter balances for both tubes.
 balancing the centrifuge load is critical, the centrifuge shakes and
vibrates or makes more noise than expected if the load is not
balanced
 to balance, get another tube that has approximately the same
property (plastic:plastic, glass:glass) and approximately the same
weight
 fill the tube with water making sure that it has the same
volume with that of the patient's sample
  the tourniquet
must only be
applied for a
maximum of 1
minute
 recommended that
tourniquet must be
applied twice only
during the
venipuncture
process
1. During vein
selection
2. Immediatel
1. Set the speed and time for centrifugation. y before the
 red tubes: 2200-2500 rpm for 15 mins. puncture is
 blue tubes: 3500 rpm for 15 mins. performed
2. After the centrifuge has stopped, get the tube from the centrifuge holder  Clinical and Laboratory
using forceps carefully in order not to disturb the cells/sediments at the Standards Institute (CLSI)
bottom. recommends that
 the centrifuge cover should remain closed until the centrifuge has tourniquet should be
come to a complete stop to avoid any aerosol contamination released for 2 minutes
 do not get the tubes using bare hands because the area is before re-application
contaminated  it should be placed 3-4
3. Using a pipette/dropper to aspirate the serum/plasma (the liquid at the inches above the
top) without disturbing the sediments at the bottom and transfer inside venipuncture site
the aliquot/secondary tube.  a tourniquet
 to aspirate, depress the bulb of the pipette/dropper and submerge applied too close to
the tip into the upper fluid, release the bulb to allow the fluid flow the site may cause
into the pipette/dropper the vein to collapse
4. Label the aliquot/secondary tube.  a single-use, non-latex
 the aliquot/secondary tube must be labeled with: tourniquet is
a. Patient's complete name recommended for
b. Age/Sex prevention of bacterial
c. Type of Specimen transmission from the
d. Date hands of the
5. Clean the working area and dispose used materials properly. phlebotomists or from the
6. Remove PPE. skin of the patient
7. Perform hand hygiene.
 
3: Tourniquet Application, Vein Selection, and
Site Disinfection
Tourniquet
 serves two functions in the venipuncture procedure:
1. To impede venous blood flow making the veins more easily
located because of the blood accumulated
2. Provides a larger amount of blood for collection
 the use of this material can alter some test results due to
hemoconcentration or the increase in ratio of analytes and cellular
elements to plasma, and hemolysis or the destruction of red blood cells
 c. Basilic
 this
is
the
last
choi
ce
beca
use
it is
firml
y
anch
ored
thus
it
has
a
tend
ency
to
roll,
and
it is
near
to
the
medi
an
nerv
e
and
brac
hial
arter
y
 
Palpation
 is the process of locating
Vein Selection veins by sight and by
 the preferred site is the antecubital fossa touch
 this is located anterior and below the bend of the elbow  it is performed by using
 there are three major veins of this area and these are: the index finger of the
a. Median cubital non-dominant hand to
 this is the vein of choice because it is large, not probe the site
movable, closer to the surface of the skin, more  it is achieved
isolated from underlying structures, and the least through a pushing
painful motion rather than
b. Cephalic stroking
 this is the next vein of choice and is located on the
thumb side, however, it is difficult to locate and
has more tendency to move
  the direction, size and depth of the vein must be properly
evaluated
 to locate deep veins, pressure upon palpitation must be applied
 veins are spongy and resilient tube-like structures which are different
from rigid tendons
 they do not pulsate which are different from arteries
 the thumb must NOT be used to palpate because it has a pulse beat
 
Venipuncture
 when an appropriate vein has been located, the tourniquet is released
and the area is cleansed
 degerming the site is achieved through the use of 70% isopropyl
alcohol with friction in a back and forth motion
 for maximum bacteriostatic action, the alcohol should be allowed
to air dry for 30-60 secs.
 performing a venipuncture BEFORE the alcohol has dried causes a stinging
sensation to the patient and can hemolyze the sample
 wiping with cotton, gauze, or blowing the site causes re-
introduction of microorganisms to the site
Procedure
1. Assemble equipment and disinfect the workstation.
2. Perform hand hygiene and wear PPE.
3. Position the tourniquet (vinyl or non-latex strip) 3-4 inches above the
venipuncture site.
4. Grasp both sides of the tourniquet and, while maintaining the tension,
cross the tourniquet over the patient's arm.
5. Hold both ends between the thumb and forefinger of one hand close to
the arm.

1. Tuck a portion of the left

side under the right side
to make a loop facing the
antecubital area.
 the loop formed
should face
downward toward
the patient’s
antecubital area,
and the free end
should be away
from the
venipuncture area
but in a position
that allows it to be
easily pulled to
release the
pressure
 the tourniquet
should be flat
around the arm and
not rolled or
twisted
  indications of a tourniquet that is tied too tightly:
a. Appearance of small, reddish discolorations (petechiae) on
the patients arm
b. Blanching of the skin around the tourniquet
c. The inability to feel a radial pulse
2. With tourniquet applied, align your index finger of the non-dominant
hand in the direction of the vein.
3. Press on top of the vein with enough pressure to depress the skin.
4. Keep your finger in contact with the skin so that you may feel the
"bounce back" of a resilient, healthy vein.
 make sure to select a vein that is easily palpated and large enough
to support blood flow
 locate the median cubital vein on both arms before considering
other veins
5. After selecting the best vein, untie the tourniquet by pulling the end of
the loop with one hand.
 you are only allowed to tie the tourniquet for a maximum of 1
minute, wait for 2 minutes before re-application
6. Degerm the site using 70% alcohol with friction in a back and forth
motion.
 70% of isopropyl alcohol is ideal than 95-100% of that of pure
alcohol since the latter coagulates protein in contact immediately
 the ring of the coagulated protein would then stop the
alcohol from penetrating farther from the bacterial cell
 the cell would become inactive but not dead
 if 70% alcohol is poured to a single-cell organism, the
diluted alcohol also coagulates the protein, but at a slower
rate, so that it penetrates all the way through the cell
before coagulation can block it
7. Let the cleaned site air dry for 30-60 seconds.
 contact time is also important in killing microorganisms with
alcohol
 if 100% alcohol is used, it will evaporate quickly, reducing
the time required for alcohol to show its effect
 for the diluted one, the contact time will be increased but
the maximum toxic concentration which is required for cell
death will not be achieved
 hence, 70% and air drying is the best option
8. Clean workstation, remove PPE, and perform hand hygiene.

4: Evacuated Tube
System (ETS) of
Venipuncture
Evacuated Tube System (ETS)
  more common than the syringe method
 in here, blood is collected directly into the evacuated tube, eliminating
the need to transfer samples and minimizing the risk of exposure to
biohazards
 the vacuum tube system consists of a multi-sample needle to puncture
the rubber portion of the cap of the collection tube, a holder or adapter
for the needle, and color-coded vacuum tubes
 
Phlebotomists in Conducting Venipuncture
 the ability to perform the venipuncture techniques in an organized and
patient-friendly manner is key to being a successful phlebotomist
 basic rules must be followed to ensure patient and phlebotomist's safety,
produce representative samples of the patient's condition, and provide an
efficient phlebotomy service for the institution
 phlebotomists must demonstrate proficiency in the procedures
 
Procedure of ETS of Venipuncture
1. Examine requisition form.
→ this form is essential to provide the information needed to
correctly identify the patient
→ Consists of:
 Patient's first and last name
 Identification number (may be a hospital-generated
number)
 Patient's date of birth
 Patient's location
 Ordering health-care provider's name
 Tests required
 Requested date and time of sample collection
 Status of sample (stat, timed, routine)
 Billing information
 Other information that may present
2. Greets patient and states procedure to be done.
3. Identifies patient verbally by having them state their complete name.
→ serious diagnostic or treatment errors and even death can occur
when blood is drawn from the wrong patient
→ identification is made by comparing information obtained verbally
and from the patient's wrist ID band
4. Verify if the patient has had previous problems with venipuncture or the
patient preparation such as fasting for tests that require it.
→ ask if the patient has had problems during phlebotomy such as
syncope (fainting), seizures, latex allergies, and others so that you
will be ready for any possible reactions
→ patient preparations such as fasting for the recommended hours is
important to be asked in since it can affect the results later on
5. Assemble equipment and materials.
6. Washes/sanitizes hands.
7. Puts on gloves.

8. Positions patient's arm.

→ the arm should be
firmly supported
 and extended downward in a straight line, allowing the tubes to fill
from the bottom up to prevent reflux and anticoagulant carryover
between tubes
9. Applies tourniquet.
10. Identifies vein by palpation.
11. Releases tourniquet.
→ the tourniquet serves two functions:
 By impeding venous, but not arterial, blood flow, the
tourniquet causes blood to accumulate in the veins
making them more easily located
 Provides a larger amount of blood for collection
12. Cleanses site with friction in a back-and-forth motion and allows it to air
dry.
→ 70% isopropyl alcohol to prevent bacterial contamination of either
the patient or the sample
13. Reapplies tourniquet.
→ a properly applied tourniquet will have the ends pointing up and
away from the venipuncture site
→ the tourniquet should only be on for 1 minute
14. Do not touch the puncture site with unclean finger.
15. Removes needle cap and examines the needle.
→ the plastic cap of the needle is removed and the point of the
needle is visually examined for any defects such as a non-pointed
or rough (barbed) end
16. Anchors vein below puncture site.
→ place the thumb 1 or 2 inches below and slightly to the left of the
insertion site and the four fingers on the back of the arm and pull
the skin taut
17. Smoothly enters vein at appropriate angle with bevel up.
18. Does not move needle with changing tubes.
→ once the vein has been punctured, the hand anchoring the vein
can be moved and used to push the evacuated rube completely
into the holder
→ moving the needle when changing tubes may cause the needle to  
be dislodged from the vein
19. Collects tubes according to the test requested.
→ the amount of blood collected in an evacuated tube ranges from
1.8 - 15 mL and is determined by the size of the tube and amount
of vacuum present
→ tubes must be filled in a specific order to prevent invalid test
results caused by bacterial contamination, tissue fluid
contamination, or carryover of additives or anticoagulants
between tubes

20. Fills tubes completely.

 → allow tubes to be filled to the desired mark to ensure the correct
blood-to-anticoagulant ratio
→ the hand used to hold the needle assembly should remain braced
on the patient's arm
 this is important when evacuated tubes are inserted or
removed from the holder, since a certain amount of
resistance is encountered and can cause the needle to be
pushed through or pulled out of the vein
→ tubes should be gently twisted on and off the puncturing needle
using the flared ends of the holder as an additional brace
21. Mix tubes promptly.
→ gentle inversion of the evacuated tubes for 3-8 times, depending
on the type of tube, should be done as soon as the tube is
removed, before another tube is placed in the assembly
22. Releases tourniquet within 1 minute.
→ the use of a tourniquet can alter some test results by increasing
the ratio of cellular elements to plasma (hemoconcentration) and
by causing hemolysis
→ the maximum amount of time the tourniquet should remain in
place is 1 minute
→ failure to remove the tourniquet before removing the needle may
produce a bruise (hematoma)
23. Removes last tube collected from holder.
24. Covers puncture site with dry gauze.
25. Removes the needle smoothly and applies pressure to the site.
→ removing the needle gently and applying pressure to the site as
soon as the needle is withdrawn is done to stop the bleeding
26. Activates any safety device and disposes needle and the adapter in the
sharp's container.
→ this is important to avoid needlestick injury (wounds caused by
needles that accidentally puncture the skin)
27. Labels tubes.
→ tubes must be labeled after the sample has been collected to
prevent confusion of samples when additional tubes are needed
28. Confirms labeled tubes to the Patient's ID band
29. Examines puncture site.
→ examine the patient's arm to be sure that the bleeding has
stopped
30. Applies bandage.
→ cover the site with bandage or hypodermic paper tape after the
bleeding has stopped
31. Disposes used supplies.
→ use the yellow containers for infections, and black containers for
non-infectious
32. Removes gloves and washes hands.
33. Thanks patient.
34. Converses appropriately with patients during procedure.
5: Syringe Method of Venipuncture
Wednesday, 2 February 2022
4:41 pm
Syringe Method
 this is preferred over the ETS when collecting blood from pediatrics,
elderly patients, and from dorsal hand veins
→ the veins of these patients and this site are usually small and
fragile
 the syringe allows the phlebotomist to control the pressure better than
the ETS to avoid blown veins
 you can also see blood entering the hub when you successfully puncture
the site
 The parts of a syringe and hypodermic needle include:
 Plunger
 Graduated barrel
 Luer lock tip
 Needle hub
 Shaft
 Bevel
 Lumen

Procedure of Syringe Method

 is the same with ETS except that the blood is taken by pulling the plunger
slowly
→ the speed of pulling the plunger must correspond to the rate of
blood flowing through the barrel
→ pulling the plunger too fast may cause hemolysis
 it is important to anchor the hand holding the syringe to the patient's
arm so that the needle does not move when the plunger is pulled
 a needle safety device must be activated to avoid needlestick injury
→ this device is attached already to the hypodermic needle
 to avoid needlestick injury, use a blood transfer device when transferring
blood to evacuated tubes
 the same order of draw is observed for both ETS and syringe method of
venipuncture

Procedure of Venipuncture using Syringe

1. Examines requisition form.
→ the information found in the requisition form include:
 Patient's first and last name, Identification number (may be
a hospital-generated number)
 Patient's date of birth, Patient's location
 Ordering health-care provider's name
  Tests required, requested date and time of sample 26.
collection, status of sample (stat, timed, routine)
 Billing information and other information that may present
2. Greets patient and states procedure to be done.
3. Identifies patient verbally by having them state their complete name.
4. Verify if the patient has had previous problems with venipuncture or the
patient preparation such as fasting for tests that require it.
5. Assemble equipment and materials.
6. Washes/sanitizes hands. Puts on gloves.
7. Positions patient's arm. Applies tourniquet.
8. Identifies vein by palpitation. Releases tourniquet.
9. Cleanses site with friction in a back-and-forth motion and allow it to air
dry.
10. Reapplies tourniquet. Do not touch the puncture site with unclean finger.
11. Removes syringe from the packet and checks the plunger.
it is necessary to check plunger movement by pulling back and
forth 2-3 times since some plungers are too hard to pull or too
loose
loosening the plunger allows free motion
12. Removes the needle cap and examines the needle.
13. Anchors vein below puncture site.
→ place the thumb 1-2 inches below and slightly to the left of the
insertion site and the four fingers on the back of the arm to pull
the skin taut
14. Smoothly enters vein at appropriate angle with bevel up.
→ entering the vein too slowly is more painful and may cause a spurt
of blood to appear at the site  
15. Does not move needle when pulling the plunger.
→ pulling or pressing down on the needle while it is in the vein can
cause pain or hematoma formation
16. Collects appropriate amount of blood.
17. Releases the tourniquet within 1 minute.
18. Removes the needle smoothly and apply pressure to the site.
→ apply pressure to the site as soon as the needle is withdrawn to
stop bleeding
19. Covers puncture site with dry gauze.
→ gauze is preferred since the fibers of cotton might dislodge the clot
formed when being pulled away
20. Transfer blood into appropriate tubes in correct order using a blood
transfer device.
→ the use of blood transfer device prevents needlestick injury
→ tubes must be filled in a specific order to prevent invalid test
results caused by bacterial contamination, tissue fluid
contamination, or carryover of additives or anticoagulants
between tubes
21. Activate needle safety device and dispose the syringe within the needle
attached in the sharp's container.
22. Label tubes. Confirm labeled tubes to the patient's ID band
23. Examine puncture site and applies bandage.
24. Dispose used supplies. Remove gloves and wash hands.
25. Thank the patient. Converse appropriately with the patient during
procedure.