PMLS Lesson 4

VENIPUNCTURE PROCEDURE

TEST REQUEST PROCESS, TYPES OF REQUISTIONS USED, AND REQUISITION INFORMATION

The first step of the pre-examination phase is the test request that comes from a physician. The request form
includes information on the type of test ordered and any special instructions or conditions that should be considered
during the pre-examination and examination phases. This form will be part of the patient’s medical record and can be
referred to, should issues regarding the test arise.
Required pieces of information in the requisition form:
1. Patient’s full name including the middle initial
2. Name of the physician who ordered the test
3. The medical record number for inpatients
4. Birthday and age of the patient
5. Room number and bed number if inpatient
6. Type of test ordered
7. Date when the test is to be performed
8. Billing information (if required)
9. Test status
10. Special Precaution
11. Diagnosis
VENIPUNCTURE STEPS
STEP 1: REVIEW AND ACCESSION THE TEST REQUEST
(1) Check the completeness of the required information
(2) Verify the test to be collected including information such as the time and date of collection
(3) Take not of any dietary restrictions or special conditions that should be followed before the actual collection
(4) Determine the test status or priority of collection

Common Test Status Designations

Status Meaning When used Collection Conditions Test Examples Priority

Stat Immediately Results are needed Immediately collect, Glucose, H&H, First
(Short Turn Around for critical patient test, and report result. Electrolytes,
Time) Alert when delivered. Cardiac Enzymes
ER stats are priority
Med Emerg Medical Emergency Results are needed Immediately collect, Glucose, H&H, First
for critical patient test, and report result. Electrolytes,
Alert when delivered. Cardiac Enzymes
ER stats are priority
Timed Collect at a specific Timing of collection Collect close to 2-hour PP, GTT Second
time is important required time and Cortisol, Cardiac
record actual time. Enzymes, TDM,
Blood
ASAP As soon as possible Results needed to Follow hospital Electrolytes, Second or
respond to serious protocol Glucose, H&H Third
but not critical
situation
Fasting Prior to the collection, Eliminate effects of Verify if the patient had Glucose, Fourth
there should be n the diet fasted. If he did not, Cholesterol,
food or drink intake check if the test could Triglycerides
for 8-12 hours still proceed
NPO Nothing by mouth Prior to surgery or Do not give food or N/A N/A
(Nothing per orem) other anesthesia water
procedures
Preop Before an operation Determine Eligibility Collect before surgery CBC, PTT Platelet Second or
(Pre operation) for surgery function studies Third
Postop After an operation Assess condition Collect after surgery H&H Second or
after surgery Third
Routine Relating to Establish diagnosis Collecting on time but CBC, Chem Profile None
established procedure or monitor progress not urgent
STEP 2: APPROACH, IDENTIFY, AND PREPARE THE PATIENT
(1) Knock on the door gently before entering the room.
(2) Make a good impression by greeting the patient warmly
(3) Stay organized and have all supplies available and approach the patient in professional manner that goes
well with having a neat appearance
(4) Maintain a calm expression as most patients are afraid of the blood collection
(5) Introduce yourself and explain the procedure. Obtain the verbal or expressed consent of the patient before
proceeding with the test
(6) Remain compassionate and professional during the procedure
(7) Thank the patient for his/her cooperation before leaving
If there is a physician or clergy in the room, the phlebotomists may interrupt only if the ordered test is stat or timed.
Family members or visitors can stay in the room, but it would be better if they could step out of the room until the
process is finished

Importance of Proper Patient Identification

When identifying patients, confirm the name and date of birth of the patient. The patient’s response should
match the information on the test request form. Otherwise, the difference or error should be resolved and rectified
before collection. The identification bracelets should also match, and the phlebotomist should inform the nurse on duty
if there are any discrepancies or missing IDS.
If the patient is fast asleep, the phlebotomist should wake up the patient gently for proper identification.
If the patient is unconscious, a patient in the emergency room or intensive care unit may be unconscious during
the time of the collection. Ask for the help of a relative, nurse, or physician in identifying the patient. Make sure to note
the name of the person who confirmed the identity of the patient.
If the patient is young, mentally-incapacitated, or there is a language barrier, the phlebotomist should ask a
relative, an attendant, or the nurse to identify the patient. The information provided should match those on record and
pieces of details indicated in the ID bracelet.

Patient Preparation for Testing

The phlebotomist should explain the set procedure to the patient and confirm that the patient understood what
has been discussed. As part of the informed consent advocacy, a verbal or expressed consent should be obtained before
proceeding with the collection.

STEP 3: VERIFY THE PATIENT’S DIET RESTRICTIONS AND LATEX SENSITIVITY

Phlebotomists should verify if there are special instructions on the diet of the patient that need to be followed
such as fasting for about 8 to 10 hours. A patient with allergic reaction to latex can have life-threatening reactions upon
exposure, so it is important to check if all pieces of equipment used on the patient are latex-free, and there are no latex
items in the room.

STEP 4: SANITIZE HANDS

Proper hand hygiene should be observed to prevent the spread of infection.

STEP 5: POSITION THE PATIENT, APPLY THE TORNIQUET, AND ASK PATIENT TO MAKE A FIST
The phlebotomist can then proceed to the tourniquet application and fist clenching. The tourniquet should be
placed 3 to 4 inches from intended site. When the tourniquet is in place, ask the patient to clench his/her fist.

STEP 6: SELECT VEIN. RELEASE TORNIQUET, AND ASK PATIENT TO OPEN FIST
The antecubital area of the arm is preferred venipuncture site. Using the fingers, the phlebotomist should trace
the path to determine a possible entry point. The depth and patency are checked by pressing on the site a couple of
times. If the vein is not suitable, the phlebotomist should look for an alternative site, or a capillary puncture should be
an option.

STEP 7: CLEAN AND AIR-DRY THE SITE

The venipuncture site should be cleansed using an antiseptic, such as 70% isopropyl alcohol, to prevent infection
or contamination. The area should cover about 2 to 3 inches diameter using a circular motion, and mowing outward in
concentric circular motion. Allow the area to dry for about the minute, but do not use unsterilized gauze, and never fan
or blow the site. Avoid touching the site after cleaning

STEP 8: PREPARE THE EQUIPMENT AND PUT ON GLOVES

The age of the patient, volume of blood for collection, and the size and location of the vein are the factors to be
considered when choosing the system, needle size, and volume of the tube that will be used. Make sure that you are
wearing a clean pair of gloves.

STEP 9: ASK THE PATIENT TO REMAKE A FIST, ANCHOR TO VEIN, AND INSERT NEEDLE
 Ask the patient to make a fist. Anchor the antecubital vein by holding the patient’s arm with your free hand. The
fingers should support the back of the arm just below the elbow. Place the thumb at least 1 to 2 inches below, but
slightly on the side of the site of venipuncture, pulling the skin toward the wrist.

STEP 10: ESTABLISH THE BLOOD FLOW, RELEASE THE TORNIQUET, AND ASK THE PATIENT TO OPEN FIST
Press on the collection tube into the tube holder. Make sure that the needle has completely penetrated the
stopper. Push the tube with the thumb while the middle and index finger straddle and grasp the fingers of the tube
holder slightly pulling it back. Let the blood flow into the tube. Release the tourniquet and ask the patient to release
his/her fist.

STEP 11: FILL, REMOVE, AND MIX IN THE TUBES IN ORDER OF DRAW OR FILL THE SYRINGE
The phlebotomists should make sure that the required volume has been collected. Tubes that contain additives
must be inverted gently several times to mix the content. The tourniquet must be released before removing the needle.

STEP 12: PLACE GAUZE, REMOVE THE NEEDLE, ACTIVATE THE SAFETY FEATURE, AND APPLY PRESSURE
Fold a gauze square into fourths and place it lightly over the site where the needles is inserted. Do not apply
pressure. Remove the needle and activate the safety feature (if applicable) while simultaneously applying pressure with
your free hand. The arms should be extended or raised.

STEP 13: DISCARD THE COLLECTION UNIT, SYRINGE NEEDLE, OR TRANSFER DEVICE
STEP 14: LABEL THE TUBES
Necessary Information in the Specimen Tube Labeling
a. Patient’s complete name (first and last name)
b. Date of Birth
c. ID number (if applicable)
d. Date and time of collection
e. Initials of the phlebotomists
f. Additional information such as “fasting”

STEP 15: OBSERVING SPECIAL HANDLING INSTRUCTIONS

STEP 16: CHECK PATIENT’S ARM AND APPLY BANDAGE
STEP 17: DISPOSE OF CONTAMINATED MATERIALS
STEP 18: THANK THE PATIENT, REMOVE GLOVES, AND SANITIZE HANDS
STEP 19: TRANSPORT THE SPECIMENS TO THE LAB

REQUIREMENTS FOR DRAWING BLOOD FROM SPECIAL POPULATION

Pediatric Puncture
This procedure should be limited to superficial veins only to minimize the pain. It can be challenging because the
veins are usually small and underdeveloped making it difficult to draw blood. A considerable risk of damage could be
permanent if procedure isn’t followed and there’s also a risk of anemia since the volume of blood in the body is smaller.
Dealing with parents or guardians could also be a challenge. Challenges to Pediatric:
1. Veins are small
Geriatric Venipuncture 2. Risk of anemia
Elderly patients need special attention because they might have conditions 3. Dealing with parnets or
such as arthritis, diabetes, stroke, etc. Another problem is their hearing, visual, or guardians
mental impairment. They have thinner skin and smaller muscles which cause the vein to roll easily. When human body
ages, veins lose their elasticity, making them prone to collapsed vein. Challenges to Geriatric:
1. Veins roll easily
Note:
2. Prone to collapsed veins
Veins from the leg and foot of a patient with diabetes mellitus
are prone to infections and thrombi.

Long-term Care Patients

Dialysis Patients – use the dorsum of the hand of patients undergoing hemodialysis to preserve the veins of the arms for
hemodialysis access. The phlebotomist should comply and select another site other than the arm used with an
arteriovenous (AV) fistula.
Home-care Patients – Home health services are for patients who need medical attention and assistance from health
professionals from time to time. Home care phlebotomists are independent, flexible, with exceptional interpersonal and
organizational skills, and can carry all the necessary equipment with them during house calls.

Hospice Patients – It is for patients who need end-of-life care, and mostly have a prognosis of six months or less. The
phlebotomist should work with extra care with these patients, treating them kindly and with respect, giving thesedying
patients comfort and dignity.