ACTIVITY 1

BLOOD COLLECTION

A. SKIN PUNCTURE

Methodology
A. Materials Required

 Gauze pads or cotton

 70% alcohol
 Sterile disposablelancets
 Collecting materials (capillary tubes, pipettes, slips and etc.)

B. Procedure
Things to remember when doing skin puncture

 Puncture should be less than 2mm deep so as to hit the capillary bed thus promoting free flow of blood
 Avoid squeezing the puncture region so as to minimize the admixture of blood with tissue juices which
may alter the result
 Wipe the first few drops of blood
 An alteration of hematocrit and WBC result must also be noted

1. Obtain and examine the requisition form

2. Patient identification and Assembling of equipment and supplies

 Greet the patient/guardian; identify the patient by having the patient verbally state his or her name
 Verify any diet restrictions
 Position the patient, allow him/her to sit comfortably preferably in an armchair
 Organize equipment and supply

3. Selection of puncture site

 Rub the site vigorously with a gauze pad or cottonmoistened with 70% alcohol to remove dirt
andepithelial debris and to increase blood circulation inthe area. Otherwise values significantly higher
than those in venous blood may be obtained.
 If the heel is to be punctured, it should firstbe warmed by immersion in warm water orapplying a hot
towel compress (warming increases free flow of blood seven-folds).

4. Puncturing skin

 After the skin has dried, make a firm and quick puncture approximately 2 mm deep with a sterile lancet.
A rapid and firm punctureshould be made with control of the depth. A deeppuncture is no more painful
than a superficial oneand makes repeated punctures unnecessary.

5. Thefirst drop of blood which contains tissue juicesshould be wiped away. The site should not besqueezed or
pressed to get blood since this dilutes itwith fluid from the tissues. Rather, a freely flowingblood should be
taken or a moderate pressure somedistance above the puncture site is allowable.

 Make blood smears if requested

  Collect specimen and mix as needed. If an insufficient sample has been obtained because the blood
flow stopped repeat the puncture at a different site with all new equipment
 Order of collection is as follows
o Tubes for Blood gasses determination
o Slides unless made from the EDTA microcollection tube
o EDTA microcollection tube
o Other microcollection tubes
o Serum microcollection tubes
 Label the specimens with required information

6. Stop the blood flow by applying slight pressure with a gauze pad or cotton at the site.

B. Venous Blood Collection

A venous blood sample is used for most tests thatrequire anticoagulation or larger quantities of
blood,plasma or serum. It is the easiest and most convenient method of obtaining enough volume of venous
blood suitable for a variety of tests.

2 Methods of collecting blood by venipuncture:

 Syringe Method
 Vacutainer method (evacuated tube method)
o Does not require prior preparation as compared to conventional syringe method
o Offers variety of tube sizes
o Way safer with an avoidance of syringe breakage

Sites of Puncture
The veins that are generally used for venipunctureare those in the forearm, wrist or ankle. The veins
inthe antecubital fossa of the arm are the preferredsites for venipuncture. They are larger than those inthe wrist
or ankle regions and hence are easilylocated and palpated in most people.

In newborn infants up to 18 months old:( code: SET )

 Superior longitudinal sinus

 External jugular vein
 Temporal vein (scalp vein)

In older children 18 months to 3 years old: ( code: FLAP )

 Femoral vein
 Long saphenous vein
 Ankle vein
 Popliteal vein

In 3 years old up to adult life

 Wrist vein
 Veins on dorsal of hand and fingers
  Veins on antecubital fossa
o Cephalic
o Basilic
o Median cubital(Recommended; stable and large)

Fig 5 venipuncture sites

Advantages:

 It reduces the possibility of error resulting from dilution with interstitial fluid or constriction of skin
vessels by cold that may occur in taking blood by skin puncture.
 Large amount of blood can be obtained
 Additional and repeated test can be done
 Blood sample can be stored for future use
 Ideal for blood chemistry

Disadvantages

 Requires more time and skills

 Requires more equipment
 More complications may arise
 Hard to do on infants, children and obese individuals
Methodology
A. Materials
Sterile syringe and needle, vacuum tube, vacuum tubeholder and two-way needle (if the vacutainer method
isto be employed), tourniquet, gauze pads or cotton, 70%alcohol, test tubes with or without anticoagulant.

B. Procedure
1. Assembly:

 Assemble the necessary materials and equipment. Remove the syringe from its protective wrapperand
the needle from the cap and assemble themallowing the cap to remain covering the needle. Attach the
needle so that the bevel faces in the same direction as the graduationmark on the syringe
 Check to make sure the needle is sharp, thesyringe moves smoothly and there is no air left inthe barrel.
The gauge and the length of theneedle used depend on the size and depth of thevein to be punctured.
The gauge number variesinversely with the diameter of the needle. Theneedle should not be too fine or
too long; thoseof 19 or 21G are suitable for most adults, and23G for children, the latter especially with a
shortshaft (about 15mm).

(If the vacutainer method is to be used, thread theshort end of the double-pointed needle into theholder and
push the tube forward until the top ofthe stopper meets the guide mark on the holder.The point of the needle
will thus be embedded inthe stopper without puncturing it and losing thevacuum in the tube.

2. Identification

 Identify the patient and allow him/her to sitcomfortably preferably in an armchair stretching his/her
arm.)

When the patient is adult and conscious follow the steps outlined below.

 Introduce yourself to the patient and ask the patient to state their full name
 Make sure that the laboratory form matches the patient’s identity
 Ask the patient for any relevant history regarding the procedure (phobias, allergy, history of fainting and
other)
 Make the patient comfortable in a supine position (if possible)
 Discuss the test to be performed and obtain verbal consent. The patient has a right to refuse a test at
any time before the blood sampling, so it is important to ensure that the patient has understood the
procedure

Explaining the procedure to a patient

Introduction:
Hello, I am __________________________ I work at this health care facility.
What is your name? (Double check patient’s identity and requested tests)
I am trained to take blood for laboratory tests(for medical reasons) and I have the experience in taking
blood.
I will introduce a small needle into your vein and gently draw some blood for _________ tests.
(Disclose the tests requested)
Then I will label them with your name and contact details and send them off for tests to the laboratory.
The results will be returned to Dr. ______________ (mention the name of clinician ordering the tests)
Do you have any questions? Have you understood what I have explained to you? Are you willing to be
tested?
Please sit down and make yourself comfortable
Now, I will ask you few questions so that both of us feel comfortable about the procedure

 Have you ever had blood taken before?

 (If yes) How did it feel? How long ago was that?
 Are you scared of needles?
 Are you allergic to anything?
 Have you ever fainted when your blood was drawn?
 Have you eaten or drunk anything in the past two hours>
 How are you feeling at the moment?
 Shall we start? If you feel unwell or uncomfortable, please let me know at once

3. Blood Extraction

 Prepare the arm by swabbing the antecubital fossawith a gauze pad or cotton moistened with
70%alcohol. Allow it to dry in the air or use a dry pad orcotton. The area should not be touched once
cleaned.
 Apply a tourniquet at a point about 7.5-10 cm above the bend of the elbow making a loop in such a way
thata gentle tug on the protruding ends will release it. It should be just tight enough to reduce
venousblood flow in the area and enlarge
the veins andmake them prominent and
palpable. The patient should also be
instructed to graspand open his/her fist to
aid in the build-up ofpressure in the area of
the puncture. Alternatively, the veins can be
visualized bygently tapping the antecubital
fossa or applying awarm towel
compress.Grasp the back of the patient’s
arm at the elbow andanchor the selected
vein by drawing the skin slightlytaut over
the vein.
 Using the assembled syringe and needle,
enter the skin first and then the vein.
 To insert the needle properly into the vein,
theindex finger is placed alongside the hub
of theneedle with the bevel facing up. The
needleshould be pointing in the same
direction as the vein. The point of the
needle is then advanced0.5-1.0cm into the
subcutaneous tissue (at anangle of 15o)
and is pushed forward at a lesserangle to
pierce the vein wall. If the needle isproperly
in the vein, blood will begin to enter
thesyringe spontaneously. If not, the piston
is gentlywithdrawn at a rate equal to the
flow of blood.

Fig 6 Venipuncture procedure

(With the vacutainer system, when in the vein, thevacuum tube is pushed into the needle holder allthe way so
that the blood flows into the tubeunder vacuum.)
The tourniquet may be released the momentblood starts entering the syringe/vacuum tubesince some
hemoconcentration will develop afterone minute of venous stasis.

3. Post extraction

 Apply a ball of cotton to the puncture site and gentlywithdraw the needle. Instruct the patient to press
onthe cotton.
 With the syringe and needle system, first cover the needle with its cap, remove it from the nozzle of
thesyringe and gently expel the blood into a tube (withor without anticoagulant).
 Label the tubes with patient’s name, hospitalnumber and other information required by thehospital.

4. Patient care

 Reinspect the venipuncture site to ascertain that thebleeding has stopped. Do not let the patient go
untilthe bleeding stops

Difference between peripheral and venous Blood

Venous blood and peripheral blood are not quite thesame, even if the latter is free flowing, and it is likely
thatfree flowing blood obtained by skin puncture is morearteriolar in origin. The PCV, red cell count
andhemoglobin content of peripheral blood are slightlygreater than in venous blood. The total leucocyte
andneutrophil counts are higher by about 8% and the
monocyte count by 12%. Conversely, the platelet countappears to be higher by about 9% in venous
thanperipheral blood. This may be due to adhesion ofplatelets to the site of the skin puncture.

Prevention of Hemolysis

 Make sure the syringe, needle and test tubes

 Use smooth, good quality sharp needles.
 Gentleness should be the watch word.
 Avoid roughhandling of blood at any stage.
 Do not eject theblood from the syringe through the needle as thismay cause mechanical destruction of
the cells.
 Transfer the blood from the syringe by gentlyejecting down the side of the tube.
 Mix blood withanticoagulant by gentle inversion not by shaking.
 Tourniquet should not be too tight and should bereleased before blood is aspirated.
 If examination is to be delayed beyond 1-3 hrs, donot allow the sample to stand unsealed or at
roomtemperature. Store in a refrigerator at 4oC.
 Blood should not be stored in a freezerbecause the red cells will hemolyse on thawing.Make sure that
all solutions with which blood is to bemixed or diluted are correctly prepared and areisotonic.
 Hypotonic solutions will lead to hemolysis.
 When obtaining blood by skin puncture make surethe skin is dry before pricking and to use sharp 2-
3mm lancets that produce clean puncture wounds.
 The blood should be allowed to escape freely.
Things to remember in venipuncture

 All materials should be clean and dry

 Tourniquet should be applied 2-4 inches or 7.5 10 cm above the site of puncture
 Tourniquet should not be too tight or too loose and should not exceed a minute
 Proper disposal of wastes and sharps must always be followed
 Name: _________________________________ Score: _______ Instructor’s Signature: _________
Review Questions
1. What are the sources of blood sample for hematological investigations?

2. What are the anatomical sites of collection in thesesources in the different age groups?

3. What are the advantages as well as the draw backsof taking/using blood samples from each of
thesesources?

4. How do you minimize or avoid the occurrence ofhemolysis in blood samples for
hematologicalinvestigations?

5. What is the difference between samples collectedfrom these two sources in terms of
hematologicalparameters?
 6. What are the DOs and DON’Ts when doing venipuncture?

7. What are the DOs and DON’Ts when doing skin puncture?

8. Enumerate the different complications that may arise in the course or after blood extraction

9. What should be done when all of the possible puncture sites are on IV?

10. Why do we need to wipe off the first few drop of blood during skin puncture?

11. List reasons on why specimens are rejected during blood collection
12. Is fasting required in routine hematology procedure? Why?

13. What are the implications if tourniquet is left to stay longer than a minute?

14. Name and describe the solutions to correct major problems in phlebotomy

15. What are the requirements for a quality specimen?

16. What is the maximum number of attempts allowable during the course of extraction?

17. What are the physiologic factors that could affect the test results?

18. What are the responsibilities of phlebotomist in infection control?