Summary
Highlights
The requisition form is paramount; it dictates all patient information and testing requirements. Always introduce yourself, state your role, and confirm patient identity using two identifiers (wristband plus verbal for inpatients, ID and verbal for outpatients). Evaluate the patient's level of understanding—if they seem confused or unresponsive, do not draw blood until a physician has assessed them. Educate patients on the procedure and potential complications like pain, nausea, loss of sensation, or excessive bleeding, instructing them to report any issues immediately. For venipuncture, prioritize the antecubital fossa veins (median cubital, cephalic, then basilic). Always confirm fasting or medication requirements with open-ended questions.
Understand causes and remedies for complications. Excessive bleeding (common in anticoagulated patients) requires firm, prolonged pressure and a pressure bandage. Severe pain should subside shortly after the stick; if it persists, apply ice, and if unrelieved, consult a physician. Lack of sensation suggests nerve damage, requiring immediate cessation of the draw and pressure application; persistent numbness needs physician assessment. Excessive bruising (greater than 2x2 gauze) is reduced by pressure and is more likely if the vein is transfixed or in anticoagulated patients. Infection signs include redness, swelling, and pain; avoid drawing from infected sites. Nausea means the patient feels unwell and should be reported to a physician if persistent. Stat draws take precedence even over physician consultations due to urgency. ASAT draws should be collected within the hour.
There are several types of consent: Express consent is verbal or written permission. Informed consent means the patient received ample information in their native language and had opportunities to ask questions. Implied consent occurs when a patient presents for a draw and extends their arm, or in emergencies with an unconscious patient, implying they want help. Minors (under 18) require guardian consent (unless emancipated). Refusal of consent must be documented with the patient's signature on a refusal form, and appropriate steps taken to educate them and involve a nurse if necessary.
Primary sites are the antecubital fossa veins (median cubital, cephalic, basilic; cephalic is often best for obese patients). Dorsal hand veins use a winged infusion set (butterfly). The ankle or foot requires physician approval and should never be used for diabetic patients due to increased infection risk. Capillary punctures are performed on the great and ring fingers, wiping away the first drop of blood to remove interstitial fluid and epithelial cells. Avoid finger sticks on cold, cyanotic, scarred, swollen, or rashy fingers. For infants, heel sticks are done on the outer (lateral) side of the plantar surface, using a lancet no deeper than 2mm for full-term infants to prevent osteomyelitis.
Never perform venipuncture above an IV line (always go below, stopping the IV for 2-5 minutes and discarding 5mL of blood). Avoid arms with dialysis shunts (unless a trained dialysis technician). Do not draw from the same side as a mastectomy (consult physician for double mastectomy). Edematous (swollen) extremities, scarred or stretch-marked areas, and hematomas should be avoided. Do not draw from incoherent or confused patients as they cannot provide consent. Sclerotic (hard), tortuous (twisted), thrombotic (clotted), or fragile/superficial veins should also be avoided due to difficulty, pain, and clot risks.
Isopropyl alcohol (70%) is the standard. Chlorhexidine gluconate (containing alcohol) is unsuitable for blood alcohol tests. Benzalkonium chloride is the best choice for blood alcohol tests or clean-catch midstream urine. For routine venipuncture, clean the area with concentric outward circles (3-4 inches), never re-crossing the cleansed area. For blood cultures, clean twice, scrubbing a small area in a circular motion for 60 seconds to ensure sterility and prevent contamination (used for fevers of unknown origin, drawing aerobic and anaerobic tubes).
Fasting samples require 8-12 hours without food or liquids (except water), confirmed with open-ended questions. Basal state requires resting, fasting, and no exercise for approx. 12 hours. For pediatric draws, use micro-containers and smaller evacuated tubes with a butterfly needle. Always communicate calmly and confidently with children. Needle insertion angles are 15-30 degrees for regular venipuncture and 5-15 degrees for butterfly needles. Use a syringe for fragile/collapsing veins and a butterfly for slow-rolling veins.
To aid in finding veins, use a warmer (3-5 minutes) to increase blood flow sevenfold or a blood pressure cuff (80 mmHg). If no blood upon insertion, adjust the needle, change tubes, or reposition the bevel before withdrawing. For infants under 12 months (non-walking), perform heel sticks. Remember the capillary order of draw: Lavender, Green, Red (different from venipuncture due to rapid coagulation).
Nerve damage: numbness/loss of sensation, stop draw immediately. Hematoma: bruising from bleeding under the skin, apply pressure (2 min for venipuncture, 5 min for arterial). Phlebitis: vein inflammation, apply ice and pressure. Thrombus: clot formation, do not draw and seek medical attention due to severe risks. Physical reactions: diaphoresis (excessive sweating), dizziness, nausea. Petechiae: small red dots from platelet malfunction; complete draw and apply extra pressure. Hemoconcentration: prolonged tourniquet use (>60 seconds) increases potassium. Administration errors (40% of phlebotomy errors) highlight the need for meticulous labeling and requisition checks before leaving the patient's room.
Syncope (fainting): patient becomes pale, sweaty, staring. Stop draw, position head between legs, apply cold compress. Seizures: stop draw, call for help, clear the area, treat bleeding after seizure. Shock (cold and clammy): apply blanket, raise legs. Nausea and diaphoresis (excessive sweating) are common. The standard order of draw is: Yellow, Blue, Red, Green, Lavender, Gray. Remember additives: Sodium Citrate (blue) for coagulation, EDTA (lavender) for hematology (preserves cell morphology), Heparin (green) for chemistry (reflects current body status), and Potassium Oxalate (gray) for glucose (preserves glucose).
Inversion rates: Yellow, Green, Lavender, Gray - 8-10 times; Red/Serum - 5 times; Light Blue - 3-4 times. Quality checks for equipment: check expiration dates, intact labels/seals, intact bevels, and proper functioning safety devices. Use external liquid controls for new boxes/lot numbers. Match glucometer strips to the glucometer before each use.
Blood smears are for white blood cell differentials. Collect in EDTA tube (if not capillary) and prepare within an hour. Place a dime-sized blood droplet half an inch from the slide edge, use a second slide at a 30-degree angle to push into the drop and pull across to create a feathered edge. Newborn screening: 24-72 hours after birth. Test for PKU (Phenylketonuria) is mandatory. Use absorbent circles on a screening card; milk a large blood drop and let circles absorb naturally, never stacking cards or oversaturating/undersaturating, and allow to dry for 4 hours. Cards must be received within 14 days.
Therapeutic phlebotomy (bloodletting) treats polycythemia vera (overproduction of blood cells). Blood donation requirements: 8 weeks between donations, 18 years old, over 110 lbs, no age cap if healthy. A complete medical history is mandatory to check for blood-borne pathogens (e.g., recent tattoos may cause temporary disqualification). Apheresis separates blood components (e.g., plasmapheresis removes plasma). Autologous donation is self-donation for future use. Iatrogenic anemia is caused by repeated blood draws; never draw more than 10% of total blood volume (calculate by converting to kilograms, then use 1 kg = 1 liter).
Ammonia, lactic acid, and arterial blood gases need to be on ice immediately (use green heparin tube). Cold agglutinins and cryoglobulins must be kept warm. Bilirubin needs protection from light (amber tube or tin foil) as light breaks it down. Post-prandial tests are 2 hours after eating. Peak and trough values measure medication levels; trough is 15 minutes before administration, peak depends on medication and administration route. Label all specimens in front of the patient before leaving the room.
Stool samples must not be mixed with urine and are often tested for occult blood and colorectal cancer. Urine is the most common non-blood sample. Random urine for drug testing. Clean-catch midstream for cultures (prevents contamination). Refrigerate urine not delivered immediately. 24-hour urine collection starts after the first void of the day, includes all subsequent voids, and the container is kept on ice. First voided morning specimen for pregnancy testing. All fluids must be collected in sterile, non-contaminated containers. Semen samples must be kept at body temperature (98.6°F/37°C), protected from light, and delivered to the lab within 2 hours for fertility testing. Sputum requires rinsing the mouth with water only, then an expectorated deep cough to bring up mucus from the lungs (not saliva); often for microbiology (e.g., TB – wear n95, handle poisonous preservatives carefully).
Errors are categorized as pre-analytical (before testing, e.g., transport), analytical (during testing by MLT), and post-analytical (after testing). Chain of custody is extra documentation for legal cases (blood alcohol, drug testing, forensic, paternity DNA); every person handling the specimen signs and dates. Reference laboratories (e.g., Quest, Labcorp) receive samples in biohazard bags, packaged correctly with requisition and ice packs (separated by a barrier to prevent freezing). Point-of-care testing provides immediate bedside results. Critical values (e.g., fasting glucose >126 mg/dL, post-prandial glucose >200 mg/dL) must be reported promptly to the ordering physician or a verifiable staff member (document name, date, time, message). Never release results to patients.
OSHA (Occupational Safety and Health Administration) protects workers, focusing on reducing incident exposures. CDC (Centers for Disease Control) focuses on public education and disease control. MSDS (Material Safety Data Sheets) provide information on chemicals. NIOSH (National Institute for Occupational Safety and Health) regulates sharps containers (leak/puncture-proof, never overfilled, appropriate height, biohazard symbol). Accidental needle stick: flush for 15 min, bandage, record patient info, complete incident report. Joint Commission (JCAHO) accredits healthcare organizations, ensuring safety (e.g., RACE acronym for fire safety). CLSI (Clinical and Laboratory Standards Institute) sets guidelines for standards and operations (e.g., order of draw). HIPAA (Health Insurance Portability and Accountability Act) ensures patient privacy and confidentiality (Protected Health Information – PHI). Standard precautions: treat all bodily fluids as potentially infectious; do not treat certain patients differently. Immunocompromised patients (burn, cancer) are in protective isolation. Contact precautions: gloves, gown. Airborne/droplet precautions (strep, flu): face mask. Splash/spray precautions: face shield/goggles. TB isolation: n95 respirator. Nosocomial infections (hospital-acquired) like MRSA, C. difficile. Hand hygiene is the most effective infection prevention; hand sanitizer is not effective against C. diff. If visible bodily fluids on gloves, wash hands; otherwise, use sanitizer up to three times per OSHA.
CPR training is essential. Start CPR if an individual is not breathing and has no pulse. Use an AED (Automated External Defibrillator) immediately if no pulse. CPR compressions should be 100-120 beats per minute. Single rescuer ratio is 30:2 (compressions:breaths). For child/infant with two rescuers, the ratio changes to 15:2.