PHLEBOTOMY PROCEDURE

Effective Date: 
Sun, 07/01/2012
Reviewed: 
Wed, 01/11/2017
Revised: 
Wed, 01/11/2017
Policy: 

PRINCIPLE:

The veins are the primary source of blood for laboratory testing. The phlebotomy procedure must be performed to preserve venous integrity. THE PROCEDURE IS PERFORMED IN SUCH A MANNER AS TO MAINTAIN SAFETY OF THE PATIENT AND THE PHLEBOTOMIST.

MATERIALS:

  • Laboratory coat
  • Latex or vinyl gloves
  • Tourniquet
  • 70% isopropyl  alcohol pads
  • 2 x 2 gauze
  • Safety engineered sterile needles:   20,  21, 22, or 23  gauge  (butterfly or syringe may be  used)
  • Vacutainer holder (Smiths Medical)
  • 12-ml or 20-ml syringes
  • Appropriate Vacutainer tubes
  • Paper tape
Procedure: 

LABORATORY COAT AND GLOVES MUST  BE WORN  DURING PROCEDURE.

  1. Greet the patient with a friendly,  professional manner. Patient cooperation is essential  for successful results.  The tone of the patient encounter is set within the first 30 seconds of communication.
  2. Ask patient for her/his full name and verify that spelling of name is correct on  laboratory request forms.
  3. It is essential to  put patient at ease by answering questions, being  sensitive to  patient's fear level, being  gentle with technique,  and  speaking  with unhurried, authoritative,  but quiet voice. Let the patient know that venipuncture procedure may be a  little painful, but of short duration. Never say "This won't hurt a bit."
  4. Have the patient sit in the phlebotomy chair and  raise or lower the chair  arm accordingly. Patient arm  should not be bent at the elbow.  Add  support under the arm with a  pillow if necessary.  DO  NOT  DRAW BLOOD ON  A STANDING PERSON.
  5. Ask patient  if s/he has had any previous problems having blood drawn.  If necessary,  recline chair If patient is prone to fainting or being ill.
  6. If patient is not conscious,  clinician  must identify the  patient. Document cIinician's initials on laboratory request forms.
  7. Review in-house laboratory request forms for completeness:
    •  FULL NAME,  LAST  NAME FIRST (if written),  LAST NAME  LAST (if sticker)
    •  TELEPHONE NUMBER
    •  PATIENT ID NUMBER (4 numbers)
    •  CLINICIAN'S  NAME OR  INITIALS
    •  DATE OF  REQUEST
    •  TEST REQUEST(S):  check Quest handbook or on-line for specimen requirements
    •  ARRIVAL TIME AND  DATE (stamped by lab personnel)
  8. For reference laboratory testing, the following are required:
    • FULL NAME,  LAST  NAME  FIRST (ifwritten);  LAST NAME  LAST (if sticker)
    • STUDENT ID NUMBER (4 numbers):  write in "Chart #" box
    • TELEPHONE NUMBER
    • SEX
    • BIRTHDATE
    • CLINlCIAN'S NAME
    • TEST  REQUEST(S)
    • DATE AND TIME OF BLOOD DRAW
  9. Ask patient if s/he  is fasting  (usually  at least 8 hours)  if test requested  requires fasting state.  lf therapeutic drug  monitoring is ordered  (l.e.  Lithium, Valproic acid),  ask  patient for time  last pill was taken.  Blood  is usually drawn just prior to scheduled  dose. 
  10. Wash  hands thoroughly  and  prepare materials for phlebotomy.

    USING  SAFETY  ENGINEERED VACUTAINER  HOLDER WlTH ATTACHED NEEDLE COVER (Smiths Medical supplied by Quest Lab):

    a.) Use appropriate size sterile needle (seal must not be broken);  gauges 20 and 21  are used for most procedures.  Gauge 22 may  be used for small  veins.
    b.) Attach needle to safety Vacutainer holder securely.   Needle cover (orange)  may need to be adjusted so that needle bevel is up when  drawing  patient.
    c.Select appropriate Vacutainer tube and push halfway  onto the needle just to secure  it.   If pushed  all the way to the top,  vacuum will be  lost and tube  is unusable.
    d.) If drawing  multiple Vacutainer tubes, follow "ORDER OF  DRAW FOR PHLEBOTOMY
    TUBES" (see following  page).
    e.) Have two 2 x 2 gauze pads and  one alcohol-saturated  pad ready.

    USING  SAFETY ENGINEERED  BUTTERFLY NEEDLE (B-D Safety-Lok):
    a.) Attach self-sheathing  needle to Vacutainer holder.
    b.) Select appropriate Vacutainer tube and push halfway  onto the  needle just to secure it.  lf pushed  all  the way to the top, vacuum will be lost and tube is unusable.
    c.) lf drawing  multiple Vacutainer tubes,  follow "ORDER OF  DRAW FOR PHLEBOTOMY
    TUBES" (see following page).
    d.) Have two 2 x 2 gauze pads and  one alcohol-saturated  pad ready.

    USING SYRINGE  FOR  HARD  DRAWS:
    a.) Pull and depress  plunger on syringe to allow easier movement of plunger.
    b.) Using  a 23-gauge butterfly  needle,  remove the  sheath~covered portion below the white plastic end of tubing and attach to appropriate-sized syringe.
    c.) After blood draw,  remove butterfly needle and attach larger gauge needle to allow easier flow of blood  into Vacutainer tubes.

  11. Application of tourniquet:   WEAR  LATEX OR VINYL GLOVES.
    a.) Wrap tourniquet around the arm  approximately 3-4 inches above  area of draw.
    b.) Have patient make a fist which will make veins  more prominent.  Vigorous  pumping should be avoided.
    c.) Palpate  selected  areas using  index finger.  If vein  is difficult to find, check other arm. Take the time to select the  BEST VEIN.  Do not leave tourniquet on  longer than  1  minute.
    d.) Vein  location  may be done without gloves for more sensitivity if necessary.
  12. Cleanse chosen site with  alcohol~saturated pad.  Dry with 2 x 2 gauze  pad or allow to air dry.
  13. Holding safety Vacutainer holder with attached sterile  needle (or butterfly with  needle holder or syringe) with Vacutainer tube  at approximately  15° angle and needle  bevel  up, puncture chosen  vein site with  a smooth,  swift motion.  Skin around puncture site  may  be held  taut with thumb of opposite  hand before drawing (downwards motion).
  14. Push Vacutainer tube into  holder as far as it will go.   If needle  is correctly placed within lumen of vein,  blood will flow into tube.   Have patient relax hand.  If using syringe,  pull gently on plunger to fill  syringe.
  15. lf there is no blood flow:
    a.) Needle is incorrectly positioned;  reposition  by withdrawing slightly and trying  another area.  Index finger may  be used to feel for position of needle  relative to vein.
    b.) Tube has no vacuum; replace with  another.
  16. lf draw is successful,  allow tube to fill completely.  All tubes with additives must be at least half-full to ensure accurate test results.
  17. If multiple tubes are being drawn,  carefully remove first tube  after blood flow stops and
    replace with second tube according to Order of Draw.   Perform in such a  manner so needle remains in  correct position.  lf tube has an additive,  remove and  gently  mix immediately.
  18. lf draw is unsuccessful,  another vein may  be palpated and used.   Do not attempt to draw patient more than twice.   Arrange for a different staff member to attempt third  draw with  patient's consent or arrange for a next day draw after oral  hydration. Inform the ordering clinician if the phlebotomy was not successful.
  19. Release tourniquet:  may be released as soon as blood flows into tube or may be left on during entire procedure up to one minute.
  20. Immediately withdraw needle/ holder with straight,  even motion.   lf using Vacutainer needle holder with attached needle  cover (Portex), press down orange cover on  hard  surface so  that it locks  into place over needle.  Do  not use fingers to push cover over needle.  Discard  entire device into sharps container.  lf using  butterfly needle, push needle  cover upwards and discard entire apparatus into sharps container.  If using syringe,  remove and  replace  needle with larger gauge for transfer of blood into Vacutainer tubes.
  21. Place a clean 2  x 2 gauze  pad  over the site and  have patient apply direct pressure for several minutes.  Do not have patient bend arm as this will  not always stop flow of blood.  After bleeding stops,  apply strip of paper tape over gauze  pad.  Ask patient to keep bandage in place for 30 minutes.

  22. Immediately label tube(s) with the following:
    PATlENT'S  LAST NAME, FIRST NAME
    DATE
    or  APPLY PATlENT STICKER
    Ask patient his/her birth date or last four numbers of Student lD number as an  additional identification  measure.

  23. Collection time is written on  all reference laboratory requests.

  24. Assess patient's state.  Make sure that s/he is all right before allowing  patient to stand  and leave.  THANK THE PATlENT.

  25. Disposition of tubes:
    JUNGLE TOP (SST):  Allow to clot in upright position  for 20-30  minutes but not more than  one hour.  Centrifuge for 15  minutes.
    BLUE,  RED,  LAVENDER TOPS:  Place in reference  lab  specimen  bag.  No centrifuging  is necessary.   Refrigerate.
    LAVENDER TOP:  For in-house testing,  place on aliquot mixer. Remove gloves, wash  hands,  and put on new set of gloves for the  next patient.

Key Points: 

References: Pendergraph, G.E.,  Handbook of Phlebotomy,  Third Edition,  Lea  and Febiger,  Philadelphia,  1992.