lOMoARcPSD|40378844

Lesson 6 Principles of MLS2

BS Medical Laboratory Science (Lyceum of the Philippines University)

Scan to open on Studocu

Studocu is not sponsored or endorsed by any college or university

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)
 lOMoARcPSD|40378844

LESSON 6
PRE-ANALYTICAL CONSIDERATIONS
IN PHLEBOTOMY

At the end of this lesson, the students must be able to:

1. enumerate the physiological variables that influence laboratory test results and
identify the tests most affected by each one;
2. identify problem areas to avoid in site selection, give causes for concern, and describe
the procedure to follow when a difficult situation occurs;
3. specify the various vascular access sites and devices and illustrate what to do when they
are encountered;
4. explain how to handle patient complications associated with blood collection;
5. spell out how to avoid or handle procedural error risks, and reasons for failure to
draw blood; and
6. discuss appropriate specimen quality.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Learning Steps Time Allotment Resources

1. Read Information Sheet 6.0. 2.0 hours Information Sheet 6.0
Pre-Analytical Considerations in Phlebotomy
6.1. Physiological Variables that Influence Laboratory Test
Results
6.2. Problem Areas and Troubleshooting in Site Selection
6.3. Vascular Access Sites and Devices
6.4. Handling Patient Complications Associated with Blood
Collection
6.5. Avoiding and Handling Procedural Error Risks and
Failure to Draw Blood
6.6. Specimen Quality
2. Suggested Self-Directed Activities: 3.0 hours Instructor/Trainer/
Attend lecture session, read related articles, watch Speaker/Student Portal
portal-based presentation on “Pre-Analytical Considerations
in Phlebotomy.”
3. Perform portal-based Self-Check Activity 6.0. Student Portal
4. Perform portal-based summative examination for Lesson 6. Student Portal
5. Report to and consult with your instructor regarding your Summative examination
examination results. results
6. Proceed to Lesson 7. Lesson 7

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

The pre-analytical testing phase includes procedures such as laboratory handling

and identification, which take place prior to any laboratory testing. In this phase, proper
control measures are placed to avoid subsequent issues. It starts when the doctor’s order is
given and ends when the laboratory testing has officially commenced.
During this phase, the phlebotomist must not only be able to draw blood from the
patient, but must also be able to identify factors that affect the process and address them as
needed.
The laboratory test is used by physicians to diagnose and monitor the presence of a
disease. The physicians compare the results to a reference range or reference interval. This
range shows the high and low limits of result values as compared to healthy individuals.
Several factors are considered as part of the reference interval study or the interpretation of the
data obtained.
In phlebotomy, the basal state is ideal in establishing reference range since it represents
the condition of the metabolism of the body early in the morning or after approximately 12
hours of fasting. This can be influenced by age, gender, and conditions of the body.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Physiological Variables that influence

Laboratory Test Results
Listed below are some of the factors that affect blood collection.

Table 6.1
Physiological Variable Blood Composition Affected
Variables
Age Red blood cells (RBC), white blood cells (WBC), creatinine clearance
Altitude Red blood cells (RBC)
Dehydration Hemoconcentration, red blood cells (RBC), enzymes, iron (Fe),
calcium (Ca), sodium (NA)
Diet Glucose, lipids, electrolytes
Diurnal Variation Thyroid-stimulating hormone (TSH), cortisol, iron (Fe)
Drug Therapy Enzymes, hormones
Exercise/IM Injection Potential of hydrogen (pH), carbon dioxide partial pressure (PCO2 ),
creatine kinase (CK), lactic acid dehydrogenase (LDH), glucose
Fever Hormones, cortisol
Gender Red blood cells (RBC), hemoglobin (HgB), hematocrit (Hct)
Jaundice Yellow color interfaces due to increased biliburin
Intramuscular Injection Creatine kinase (CK) and the skeletal muscle fraction of LDH
Position Protein, potassium (K)
Pregnancy Red blood cells (RBC)
Smoking Cholesterol, cortisol, glucose, growth hormones (GH), triglyceride, white
blood cells (WBC)
Stress White blood cells (WBC), iron (Fe), adrenocorticotropic hormone (ACTH),
catecholamine, cortisol
Temperature and Humidity Hemoconcentration

Problem
Areas to
Avoid and
Troublesho
oting in the
Site
Selection

Phlebotomists
should be aware of the
following problem areas
Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)
 lOMoARcPSD|40378844

when selecting the venipuncture site. They could choose an

alternative site, or perform the procedure under special conditions.
1. Burns, Scars, and Tattoos – It is not advisable to choose a site
that has burns, scars, or tattoos because veins in the area may
be difficult to examine and blood circulation may be impaired.
Burns may be too painful to touch and tattoos may also be
susceptible to infection due to the dyes used that may interfere
with the process.
2. Damaged Veins – Aside from being difficult to perform,
puncturing damaged veins may also produce inaccurate results.
Veins could be sclerosed or hardened or thrombosed or clotted.
3. Edema – Edema, also known as oedema, is an abnormal swelling
caused by the accumulation of fluid in the tissues. The tissues
become fragile, making the task of locating the veins harder. This
condition may be due to reactions from medications, pregnancy,
infections, and other medical problems.
4. Hematoma – Hematoma is a solid swelling or mass of blood in
the tissues caused by the leakage of blood from the vessels during
venipuncture. Selecting a venipuncture site with hematoma will
be painful for the patient because it will obstruct the blood flow.
It could also lead to the contamination of blood sample.
5. Mastectomy – This procedure, often done to breast cancer
patients, refers to the removal of the breast through surgery.
Blood drawing from patients who had undergone this procedure
becomes a challenge since the lymph flow is obstructed, and
there may be swelling and infection after the surgery. In addition,
tourniquet cannot be applied because it can cause injury. It could Figure 6.1 Patient with
also change the blood composition. Hematoma
6. Obesity – This is the condition in which the individual is grossly
overweight. Patients who are obese have veins that are deep and
difficult to locate. A solution is using a longer tourniquet or
locating the cephalic or cubital vein.
1.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Vascular Access Sites and Devices

There are cases when vascular access devices (VADs) are needed for
blood sampling, infusing medication, central venous pressure readings,
and blood transfusion of a patient. Choosing vascular access sites is based
on the needs of the patient, the purpose, and the length of time the device
is to remain in the body. Listed are vascular access sites and devices used
in phlebotomy.
1. Arterial Line
To obtain samples for arterial blood gas and laboratory
studies, critically ill patients require arterial lines where a
thin catheter is inserted into an artery. This is also used to
monitor blood pressure continuously. Neither tourniquet nor
venipuncture is allowed in the arm with an arterial line.
2. Arteriovenous Shunt or Fistula
An arteriovenous shunt or fistula is a passageway created
through surgery, and is usually in the arms with the intention of
connecting the artery and a vein directly. This may be created for
hemodialysis treatment or pathological process such as erosion of
arterial aneurysm.

Figure 6.2 Venous Arterial 3. Blood-sampling Device

Blood Management A blood-sampling device is used to avoid the use of needle-
Protection System (VAMP)
Adult Closed Blood
sticks, prevent infections, and reduce wastage from line draws.
Sampling Device The device collects blood from the arterial or central venous
catheter where it is connected.
4. Heparin or Saline Lock
The heparin or saline lock, which is commonly called a
“hep-lock,” is an intravenous (IV) catheter attached to a stopcock
or cap with diaphragm. Its basic function is to provide access for
administering medicine or drawing blood from the patient. It is
threaded in the peripheral vein, which is in the lower arm above
Figure 6.3 Heparin Lock Drip the wrist for up to 48 hours. It is usually flushed with heparin
Saline Solution or saline (to prevent clogging) and capped for future use.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

5. Intravenous (IV) Sites

An IV line is a thin plastic tube or catheter inserted into
a vein in the forearm to inject a volume of fluids into the
bloodstream. The phlebotomist should avoid collecting blood
from the arm with IV because the blood collected could be
contaminated with IV fluid. If blood collection is necessary,
the collection site should be below the IV. Take note that
collection of blood from previously known IV sites should be
avoided for 24 to 48 hours.
6. Central Vascular Access Devices (CVADs)
The central vascular access devices (CVADs), also known
as indwelling lines, are any of the tubings inserted to the main
vein or artery used for blood collection, monitoring the patient’s
pressures, and administering medications and fluids. There are
three (3) types of CVADs: the central venous catheter lines, the
implanted port, and the peripherally inserted central catheter.
a. Central venous catheter is also known as a central line
inserted into the large vein (subclavian) and advanced
into the superior vena cava.

Figure 6.4 Central Vascular

Access Device

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

b. Implanted port is a surgically implanted disk-shaped

chamber attached to the indwelling line. This is usually
placed on the upper chest just below the collarbone.

Figure 6.5 Port-a-Cath

c. Peripherally inserted central catheter (PICC) is a
flexible tube inserted into the veins of extremities and the
central veins.

Figure 6.6 Peripherally

Inserted Central Catheter

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Handling Patient Complications

Associated with Blood Collection
1. Allergies to Equipment and Supplies
When the patient has adhesive allergy, a gauze should be placed
over the site and should be removed after 15 minutes. The alternative
is to ask the patient to apply pressure for five minutes. When the
patient has antiseptic allergy, simply use a different antiseptic. When
the patient has latex allergy, look for a sign to indicate the allergy and
use a non-latex alternative for gloves, tourniquet, and bandages.
2. Excessive Bleeding
When a patient is on aspirin or anticoagulant, the bleeding may
take a longer time. The pressure should be applied to the site until the
bleeding stops. The attention of the authorized personnel should be
called when the bleeding continues after five minutes.
3. Fainting
Fainting is a temporary loss of consciousness which is caused by
the insufficient flow of blood to the brain. Patients prone to fainting
during venipuncture are asked to lie down during the procedure.
4. Nausea and Vomiting
When the patient feels nauseous and has the tendency to
vomit, the phlebotomist has to discontinue the procedure until the
patient feels better or until the feeling subsides. An emesis basin or
wastebasket should be provided, and a cold damp washcloth should
be applied to the forehead.
5. Pain
The patient should be warned before the needle insertion, and
the phlebotomist should avoid redirection of the needle. If the patient
complains of extreme pain or numbness, remove the needle and
apply ice to the site because this could indicate nerve involvement.
The phlebotomist needs to document the incident if the condition
persists.
6. Petechiae
This condition involves the appearance of small red or purple
spots that look like rashes, which appear on the arm when tourniquet Figure 6.7 Patient with
is applied. Petechiae

7. Seizures or Convulsions
When seizures or convulsions occur, the blood draw should be
discontinued quickly. There must be pressure held over the site but
it must be made certain that movement is not restricted; the mouth
is free from any obstruction and the patient is protected from
self-injury. The first-aid personnel must be notified immediately.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Avoiding and Handling Procedural Error Risks and Failure to

Draw Blood

Hematoma Formation
The phlebotomist should hold pressure over the site immediately after discontinuing the
draw. A cold compress or ice pack may be offered to help address the swelling. The following
are conditions that trigger hematoma:
 There is excessive or blind probing.
 There is inadvertent arterial puncture.
 The size of the vein is too small.
 The needle penetration has gone all through the vein.
 Needle is not completely inserted.
 Tourniquet is still on when the needle was removed.
 The pressure is not adequate.

Iatrogenic Anemia
This results from blood loss due to blood draw. It is important to ensure that only the
required specimen volume is collected because if 10% of the blood volume is removed at
once from the body, the patient could face a threat.

Inadvertent Arterial Puncture

This happens when blood is filling up the tube rapidly and there is a rapid formation of
hematoma on the site.

Infection
Infection can be avoided by making sure that tapes or bandages are not opened ahead
of time; needles are not preloaded into the tube holders; insertion site of the needle is not
touched after sterilization; cap is removed just before venipuncture; and patients are advised to
keep the bandage on the site for at least 15 minutes.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Nerve Injury
Nerve injuries happen when there is improper site selection, rapid needle insertion,
excessive redirection of the needle, and blind probing.
If the initial attempt is unsuccessful, the phlebotomist should try to redirect the needle by
using a slightly forward or backward movement. The next step is to remove the needle and
look for an alternative site.

Reflux of Anticoagulant
Blood that has already been drawn flowing back into the vein from the collection tube may
cause adverse reaction because of the presence of tube additives. To avoid this, make sure that
the arm of the patient is in a downward position and the tube is just below the venipuncture
site.

Vein Damage
Damaging the vein could be avoided by following the proper technique and
avoiding blind probing.

Specimen Quality
1. Hemoconcentration is a decrease in the fluid content or plasma volume which is
usually caused by tourniquet that stagnates the normal flow of blood leading to the
increase in concentration of red blood cells and other non-filterable large molecules.
2. Hemolysis, which is also called haemolysis, refers to the rupture of the red blood cells.
The hemoglobin is then released into the surrounding fluid.
3. Partially filled tube or short draw, happens when the phlebotomist pulls a tube before
reaching the required volume. This may lead to the incorrect blood-to-additive ratio.
4. Specimen contamination means that the specimen is compromised due to incorrect
handling, which involves allowing alcohol, powder or other materials into the sample.
Getting glove powder or perspiration into films and specimens; using the wrong
antiseptic; or simply not following the proper antiseptic procedure could interfere with the
results.
5. Wrong or expired collection tube should not be used because the manufacturer could
not warrant the quality of the seal and pressure after the expiration date indicated in the
tube.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Troubleshooting Failed Venipuncture

Venipuncture attempts could fail due to improper seating of the tube and failure of the
needle to go through the stopper. The phlebotomist must be aware and must take
measures to ensure that the proper procedures are followed.
The needle position is critical to the success of the venipuncture. The phlebotomist should
ensure that the following do not happen:
1. Needle not inserted far enough
2. Bevel partially out of skin
3. Bevel partially into vein
4. Bevel partially through vein
5. Bevel completely through vein
6. Bevel against vein wall
7. Needle beside vein
8. Undetermined position

Collapsed Veins
The collapsed veins usually occur when conditions are less than ideal, which leads to the
veins being blocked, resulting in insufficient blood flow. This happens when there is a strong
pressure in the vacuum of the tube or plunger; the tourniquet is too close to the site or it is too
tight; or when the tourniquet has been removed during the draw.

Tube Vacuum
To avoid failure due to loss of vacuum, the phlebotomist should make sure that the bevel is
not partially out of skin and the tube itself is not damaged.

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)

 lOMoARcPSD|40378844

Downloaded by Coloma, Nylor Ween (macugaynylorween@gmail.com)