After completing this chapter, the reader will be able to:
1.Define terminology related to phlebotomy.
2.Identify three methods used for blood collection.
3.Describe components of the evacuated tube system.
4.Describe differences between the evacuated tube system method and the syringe system.
5.List indications for testing via capillary puncture.
6.List the various types of anticoagulants used in blood collection.
7.Recognize the importance of the order of the draw for patients requiring multiple tube collections.
8.Identify appropriate veins used for phlebotomy.
9.Describe risks and benefits to blood sampling via a vascular access device (VAD).
10.Differentiate between the discard and the mixing methods used in VAD blood sampling.
11.Describe potential complications of phlebotomy.
12.Summarize pediatric and older adult implications related to phlebotomy.
Blood and other specimen collections are important to the health assessment of the patient. The term phlebotomy is derived from the Greek words “phlebos,” meaning vein, and “tome,” meaning incision. Phlebotomy is accomplished through venipuncture and also via capillary puncture, which is the collection of blood through a skin puncture with a lancet (McCall, 2021). Blood may also be withdrawn from a vascular access device (VAD), most often by the registered nurse.
Advances in laboratory technology have resulted in making point-of-care testing (POCT) (e.g., blood glucose, international normalized ratio [INR]) more common, with advantages including rapid results and blood conservation, although procedures for quality control must be in place to ensure testing accuracy. Blood collection is used for three important purposes:
1.Diagnostic testing and monitoring of prescribed treatment
2.Blood donation for transfusion
3.Therapeutic reasons such as treatment for polycythemia (McCall, 2021)
Professional Competency
The term phlebotomist is applied to a person who has been trained to collect blood. The role of the nurse may include phlebotomy. The nurse has the unique ability to perform a single venipuncture, permitting both the withdrawal of blood for testing and the initiation of an infusion, thereby preserving veins.
As many health professionals are cross-trained to perform phlebotomy, the term phlebotomist may be applied to anyone who has been trained to collect blood specimens. Table 7-1 lists the duties and responsibilities of the phlebotomist. The nurse performing phlebotomy procedures or the dedicated phlebotomist must be competent. It is important to recognize that most errors in the laboratory testing process occur in the “preanalytical” phase before the sample reaches the laboratory and include phlebotomy procedures (Cornes et al., 2017). As addressed in Chapter 1, competence includes knowledge, skill, ability, and judgment. When clinicians are educated and have demonstrated competency with equipment and techniques, outcomes include decreased frequency of daily blood tests, number of rejected samples, contaminated blood cultures, and hemolysis rates (Gorski et al., 2021, p. S126). Some areas of competency assessment relevant to safe phlebotomy include:
- Knowledge of basic anatomy and physiology, medical terminology, potential sources for laboratory error/inconsistencies, infection prevention practices including standard and transmission-based precautions and Aseptic Non Touch Technique (ANTT)® (Chapter 2)
- Demonstration of skills such as preparing the patient, selecting the best venipuncture site, conducting the venipuncture, and obtaining an accurate specimen collection based on organizational policies and procedures
Table 7-1 Phlebotomist: Functions and Responsibilities
1.Prepare patients for blood collection procedures. 2.Maintain patient confidentiality. 3.Comply with all procedures instituted in the organizational procedures manual. 4.Adhere to standard and transmission-based precautions. 5.Perform venipuncture and collect venous specimens for testing. 6.Perform point-of-care testing. 7.Prepare specimens for transport. 8.Perform quality control checks while performing clerical, clinical, and technical duties. 9.Transport specimens to the laboratory. 10.Perform laboratory computer operations.
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Certification is evidence that an individual has mastered fundamental competencies of a technical area. Usually a phlebotomist must complete a phlebotomy program. Examples of national agencies that certify phlebotomists, along with the title and corresponding initials awarded, are listed as follows:
- American Medical Technologists (AMT)—Registered Phlebotomy Technician (RPT)
- American Certification Agency—Certified Phlebotomy Technician (CPT)
- American Society for Clinical Pathology—Phlebotomy Technician (PBT)
- National Center for Competency Testing (NCCT)—National Certified Phlebotomy Technician (NCPT)
NURSING FAST FACT!The National Patient Safety Goals (NPSGs) for laboratory services include the following: Improve the accuracy of patient identification. Use at least two patient identifiers when obtaining laboratory services. Improve the effectiveness of communication among caregivers. Report critical results of tests and diagnostic procedures on a timely basis. Reduce the risk of health-care-associated infections. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines (The Joint Commission, 2021). |
The nursing process is a five- or six-step process for problem-solving to guide nursing action (see Chapter 1 for details on the steps of the nursing process related to vascular access). The following table focuses on nursing diagnoses, nursing outcomes classification (NOC), and nursing interventions classification (NIC) for patients requiring laboratory analysis. Nursing diagnoses should be patient specific and outcomes and interventions individualized. The NOC and NIC presented here are suggested directions for development of specific outcomes and interventions.
| Nursing Diagnoses Related to Phlebotomy for Laboratory Analysis | Nursing Outcomes Classification (NOC) | Nursing Interventions Classification (NIC) |
|---|
| Risk for infection related to: Invasive procedures | Risk control: Infectious process, immune status | Infection control; infection protection |
| Protection ineffective related to: Abnormal blood profiles, pharmaceutical agents, extremes of age, treatment regimen | Blood coagulation, immune status | Bleeding precautions, infection prevention, infection protection |
| Fear related to: Needles | Fear self-control | Anxiety reduction; coping enhancement |
| Deficient knowledge: Information misinterpretation; unfamiliarity with phlebotomy laboratory procedures/analysis | Knowledge: Treatment procedures; treatment regimen | Teaching: Purpose of phlebotomy and laboratory tests |
| Skin integrity impaired related to: External: Interruption in barrier protection—venipuncture | Tissue integrity: Skin; wound healing | Skin care, skin surveillance, incisional (venipuncture) site care |
Sources: Ackley et al., 2020; Herdman et al., 2021.
- Specimens incorrectly acquired, labeled, or transported by the nurse can result in inaccurate laboratory tests.
- The nurse performing phlebotomy procedures must have the following knowledge base to perform blood withdrawal procedures safely: knowledge of basic anatomy and physiology, medical terminology, sources of error, safety measures and infection control practices, quality control procedures, equipment and methods, and sites for blood collection.
- Two identifiers are always used to verify patient identity.
- Four methods of phlebotomy include the ETS system, the syringe method, capillary puncture, and withdrawal of blood from a VAD. The winged infusion needle set may be beneficial for phlebotomy in some patients with difficult veins.
- The antecubital area is the most frequently used area for blood collection. The median or median cubital veins are preferred for venipuncture. The dorsal side of hand should be used if the arm veins are unsuitable and should only be used in patients who have an actual or planned arteriovenous fistula or graft for hemodialysis.
- The tourniquet should be released once blood begins to flow into the tube (no longer than 1 minute) to avoid hemolysis and inaccurate test results.
- Capillary puncture is often used for neonates/infants and for POCT methods.
- While benefits of VAD blood sampling include avoidance of venipuncture complications and patient anxiety, potential risks include increased risk for VAD occlusion, increased risk for catheter-related bloodstream infection as a result of manipulation at the catheter hub, and the potential for inaccurate laboratory test results associated with adsorption of medications infused via the VAD.
- It is important that the order of tube draw be done correctly to avoid inaccurate test results.
- Safety needles and products are always used to prevent health-care worker injury, regardless of the phlebotomy method used.
- Complications associated with phlebotomy include hematoma, iatrogenic anemia, infection, nerve injury, and vein damage.
Thinking Critically: Case StudyA nurse was assigned to collect blood for laboratory tests at home. She missed the vein and made an additional unsuccessful attempt. The patient complained of pain and developed swelling and bruising in the form of a hematoma. Case Study Questions1.What are the potential consequences of a severe hematoma? 2.What are risk factors for hematoma formation?
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Media Link: Chapter post tests and answers are provided on FADavis.com, along with case studies and critical thinking activities.
- Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
- Adams, S., Toroni, B., & Lele, M. (2018). Effect of the PIVO Device on the procedure of phlebotomy from peripheral IV catheters. Nursing Research and Practice, 7380527. https://doi.org/10.1155/2018/7380527
- Bellieni, C. V., Stazzoni, G., Tei, M., Alagna, M. G., Iacoponi, F., Cornacchione, S., Bertrando, S., Buonocore, G. (2016). How painful is a heelprick or a venipuncture in a newborn? Journal of Maternal Fetal and Neonatal Medicine, 29(2), 202-206.
- Chan, E., Hovenden, M., Ramage, E., Ling, N., Pham, J. H., Rahim, A., Lam, C., Liu, L., Foster, S., Sambell, R., Jeyachanthiran, K., Crock, C., Stock, A., Hopper, S. M., Cohen, S., Davidson, A., Plummer, K., Mills, E., Craig, S. S., Deng, G., . . . Leong, P. (2019). Virtual reality for pediatric needle procedural pain: Two randomized clinical trials. The Journal of Pediatrics, 209, 160-167.e4. https://doi.org/10.1016/j.jpeds.2019.02.034
- Clinical and Laboratory Standards Institute (CLSI). (2017). Collection of diagnostic venous blood specimens (7th ed.). CLSI standard GP41. CLSI.
- Cornes, M., van Dongen-Lases, E., Grankvist, K., Ibarz, M., Kristensen, G., LippiG., Nybo, M., & Simundic, A. (2017). Order of blood draw: Opinion paper by the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE). Clinical Chemistry and Laboratory Medicine, 55(1), 27-31.
- Coulter, K. (2016). Successful infusion therapy in older adults. Journal of Infusion Nursing, 39(6), 352-358.
- Doenges, M. E., Moorhouse, M. F., & Murr, A.C. (2019). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales (15th ed.). FA Davis.
- Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice (8th ed.). Journal of Infusion Nursing, 44(1S Suppl. 1), S1-S224. https://doi.org/10.1097/NAN.0000000000000396
- Herdman, T. H., Kamitsuru, S., Lopes, C. T. (2021). NANDA International Inc. nursing diagnoses definitions and classification 2020-2023 (12th ed.). Thieme.
- McCall, R. E. (2021). Phlebotomy essentials (7th ed.). Jones & Bartlett Learning.
- Natali, R., Wand, C., Doyle, K., & Noguez, J. H. (2018). Evaluation of a new venous catheter blood draw device and its impact on specimen hemolysis rates. Practical Laboratory Medicine, 10, 38-43. https://doi.org/10.1016/j.plabm.2018.01.002
- Occupational Safety and Health Administration (OSHA). (2015). Disposal of contaminated needles and blood tube holders used for phlebotomy. Safety and Health Information Bulletin. https://www.osha.gov/sites/default/files/publications/shib101503.pdf
- Stevens, B., Yamada, J., Ohlsson, A., Haliburton, S., & Shorkey, A. (2016). Sucrose for analgesia in newborn infants undergoing painful procedures. The Cochrane Database for Systematic Reviews, 2016(7), CD001069. http://doi.10.1002/14651858.CD001069.pub5
- The Joint Commission (TJC). (2022). National patient safety goals effective January 2021 for the Laboratory Program. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_lab_jan2022.pdf
- Van Leeuwen, A. M., & Bladh, M. L. (2021). Davis's Comprehensive manual laboratory and diagnostic tests with nursing implications (9th ed.). F.A. Davis.
PROCEDURES DISPLAY 7-1
Collection of Blood in Evacuated Tube System
Equipment Needed
- Gloves, nonsterile
- Tourniquet—disposable
- Sharps container
- Waste receptacle
- Evacuated tubes for specific laboratory studies
- Tube holder
- Multisample needle
- Labels (barcoded) for tubes
- Transport container
- Skin antiseptic agent (70% alcohol, chlorhexidine gluconate, or povidone-iodine)
- Gauze pads or cotton ball
- Tape
Delegation
This procedure can be delegated to a phlebotomist.
| Procedure | Rationale |
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2.Approach, identify, and prepare the patient. Place the patient in a position of comfort and safety, arm extended and in a dependent position if possible if in a hospital bed. Use a phlebotomy chair in the outpatient setting. Explain the procedure to the patient and verify fasting, if required for ordered laboratory test.
| 2.Establishes the nurse-patient relationship, ensures safety, reduces patient anxiety, and ensures accuracy of test results.
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3.Gather and organize needed supplies on a disinfected surface; verify the correct blood collection tubes and line them up in appropriate sequence for obtaining blood.
| 3.Saves time and prevents interruption during the blood draw and reduces risk for errors; promotes aseptic technique.
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5.Apply tourniquet 3-4 inches above intended site; locate the vein, preferably median cubital or median vein in the antecubital fossa; and then release the tourniquet.
| 5.Distends veins. The median cubital or median vein is preferred to promote successful venipuncture and reduce risk for nerve injury.
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6.Provide skin antisepsis, usually 70% alcohol, and allow the skin to air-dry for 30-60 seconds.
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7.Select the appropriate equipment for the size, condition, and location of the vein. Prepare while the site is drying. Attach a multisample needle to an ETS tube holder.
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9.Apply traction to the skin of the forearm, below the intended venipuncture site, to stabilize the vein. With the needle held at an angle of 15-30 degrees to the arm and in line with the vein, insert the needle into the vein, with the bevel up.
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10.Use your thumb to gently but firmly push the ETS tube into the tube holder and push onto the needle using a clockwise twist. Release the tourniquet after blood flow is established. Now use your thumb to gently but firmly push the tube onto the needle.
| 10.Allows the vacuum to pull blood into the tube; blood will not flow until the needle pierces the tube stopper.
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11.Fill the tubes until the vacuum is exhausted and mix them immediately on removal from the holder using 3-10 gentle inversions (depending on the type and manufacturer). Follow the order of draw. If more than one tube is to be drawn, pull the filled tube out of the hub very gently with the hand that pushed it in.
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12.When the last tube of blood is drawn, remove it from the tube holder. Remove the needle from the arm and place a cotton ball or small gauze pad over the puncture site. Ask the patient to put pressure on the area if appropriate.
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15.Examine the patient's arm to verify that bleeding has stopped on the skin surface. If bleeding has stopped, apply bandage and advise patient to keep it in place for a minimum of 15 minutes.
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16.Remove gloves and dispose of used and contaminated materials in sharps container (e.g., tube holder/needle) and in other appropriate receptacles (e.g., used gloves/tourniquet).
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Source: McCall, 2021.
PROCEDURES DISPLAY 7-2
Phlebotomy Using the Syringe System and a Syringe Transfer Device
Equipment Needed
- Gloves, nonsterile
- Tourniquet—disposable
- Sharps container
- Waste receptacle
- Syringe/needle
- Syringe transfer device
- Evacuated tubes for specific laboratory studies
- Labels (barcoded) for tubes
- Transport container
- Skin antiseptic agent (70% alcohol, chlorhexidine gluconate, or povidone-iodine)
- Gauze pads
- Tape
Delegation
This procedure can be delegated to a phlebotomist.
| Procedure | Rationale |
|---|
| |
2.Approach, identify, and prepare the patient. Place the patient in a position of comfort and safety, arm extended and in a dependent position if possible if in a hospital bed. Use a phlebotomy chair in outpatient setting. Explain the procedure to the patient and verify fasting, if required for ordered laboratory test.
| 2.Establishes the nurse-patient relationship, ensures safety, reduces patient anxiety, and ensures accuracy of test results.
|
3.Gather and organize needed supplies on a disinfected surface; verify the correct blood collection tubes and line them up in appropriate sequence for obtaining blood.
| 3.Saves time and prevents interruption during the blood draw and reduces risk for errors; promotes aseptic technique.
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5.Apply tourniquet 3-4 inches above intended site; locate the vein, preferably median cubital or median vein in the antecubital fossa; and then release the tourniquet.
| 5.Distends veins. The median cubital or median vein is preferred to promote successful venipuncture and reduce risk for nerve injury.
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6.Provide skin antisepsis, usually 70% alcohol, and allow the skin to air-dry.
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8.Apply traction to the skin of the forearm, below the intended venipuncture site, to stabilize the vein. Hold the syringe in your dominant hand. Place your thumb on top near the needle and fingers underneath. With the needle held at an angle of 15-30 degrees to the arm and in line with the vein, insert the needle into the vein, with the bevel up.
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9.Once you feel that you are in the vein, as indicated by blood in the syringe hub, release the tourniquet and slowly pull back on the syringe plunger to fill with blood.
| 9.Unlike the ETS system, blood does not automatically flow into the syringe.
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10.Remove needle and immediately place a small gauze pad over the puncture site. Ask the patient to put pressure on the area if appropriate.
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13.Hold syringe vertically with the tip down and transfer device at the bottom and place the tube in the barrel of the transfer device, allowing the tube vacuum to pull blood into the tube.
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14.Fill the additive tube(s) until the vacuum is exhausted and mix them immediately on removal from the holder using 3-10 gentle inversions (depending on the type and manufacturer). Follow the order of draw.
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16.Examine the patient's arm to verify that bleeding has stopped on the skin surface. If bleeding has stopped, apply bandage and advise patient to keep it in place for a minimum of 15 minutes.
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17.Remove gloves and dispose of used and contaminated materials in sharps container (e.g., tube holder/needle) and in other appropriate receptacles (e.g., used gloves/tourniquet).
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Source: McCall, 2021.
PROCEDURES DISPLAY 7-3
Blood Sampling From a Central Vascular Access Device (CVAD): Discard Method
Equipment Needed
- Clean gloves
- Evacuated tubes for specific laboratory studies
- Tube holder with Luer adapter device
- Alcohol wipes or other disinfectant used by organization
- Appropriate number of empty 10-mL syringes (if vacuum system is not used)
- Prefilled syringes of 10 mL preservative-free 0.9% sodium chloride
- Heparin syringe, if ordered
- Labels (barcoded) for tubes
- Transport container
- Sharps container
- Needleless connector (if organizational policy requires replacement after blood withdrawal)
Delegation
Most institutions do not have phlebotomists draw blood from a central line. This procedure is not delegated to a licensed practical nurse/licensed vocational nurse (LPN/LVN) or unlicensed assistive personnel (UAP)
| Procedure | Rationale |
|---|
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2.Approach, identify, and prepare the patient. Place the patient in a position of comfort and safety, arm extended and in a dependent position if possible if in a hospital bed. Use a phlebotomy care chair in outpatient setting. Explain the procedure to the patient and verify fasting, if required for ordered laboratory test.
| 2.Establishes the nurse-patient relationship, ensures safety, reduces patient anxiety, and ensures accuracy of test results.
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3.Gather and organize needed supplies on a disinfected surface; verify the correct blood collection tubes and line them up in appropriate sequence for obtaining blood.
| 3.Saves time and prevents interruption during the blood draw and reduces risk for errors; promotes aseptic technique.
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5.If CVAD is locked (i.e., no active infusion): Disinfect needleless connector with alcohol for 15 seconds using a twisting motion and allow to dry. (Note: If drawing blood for blood cultures, the needleless connector is changed prior to blood draw.)
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6.If CVAD is in use (i.e., active infusion) and infusion can be safely interrupted: a.Single-lumen: i.Stop infusion. ii.Close catheter clamp. iii.Disconnect administration set tubing from catheter hub/needleless connector. iv.Place sterile cap on the end of the administration set. v.Disinfect needleless connector with alcohol for 15 seconds using a twisting motion and allow to dry.
b.Multilumen: i.Stop all infusions. ii.Use the proximal lumen for blood withdrawal; if infusion running through lumen, follow steps i-v above.
| 6.Prevents air entry into the circulation and thus risk for air embolism; prevents introduction of microorganisms into the system.
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7.Attach the 10-mL syringe of 0.9% sodium chloride, unclamp CVAD, flush CVAD, withdraw 4-5 mL of blood, and discard into sharps container.
| 7.Establishes catheter patency; reduces risk of inaccurate laboratory test results (e.g., elevated drug levels).
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8.Disinfect needleless connector with alcohol for 15 seconds using a twisting motion and allow to dry.
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9.Attach the Luer-Lok tube holder to the needleless connector. (Alternatively, all blood may be withdrawn using a syringe, then placing blood from syringe into the tubes using a syringe transfer device as described in Procedures Display 7-2.)
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10.Insert each blood tube into the tube holder and allow to fill with blood in the correct sequence.
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12.Disinfect needleless connector with alcohol for 15 seconds using a twisting motion and allow to dry.
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14.Replace needleless connector if required by organizational policy; resume infusion as ordered or lock CVAD with prescribed heparin.
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16.Remove gloves and dispose of used and contaminated materials in sharps container (e.g., tube holder/needle) and in other appropriate receptacles (e.g., used gloves/tourniquet).
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Source: Gorski et al., 2021.