c4-PHLEBOTOMY PROCEDURES.docx

PHLEBOTOMY PROCEDURES ===================== Anchoring below the venipuncture site ------------------------------------- Proper anchoring below the venipuncture site along with a quick insertion helps prevent veins from rolling away from the needle. To anchor, place the thumb of your nondominant ha...

PHLEBOTOMY PROCEDURES ===================== Anchoring below the venipuncture site ------------------------------------- Proper anchoring below the venipuncture site along with a quick insertion helps prevent veins from rolling away from the needle. To anchor, place the thumb of your nondominant hand approximately 2 inches below the intended site of insertion. Hold down firmly with a slight distal tug downwards. Avoid pushing hard or directly into the skin, which can cause pain to the patient or potential bruising. Holding the skin tightly also helps reduce pain when the needle is being inserted and helps keep the vessel steady. Avoid using a C method of anchoring (one finger above the site of the intended venipuncture site and the thumb below, forming a C). This method does hold the skin taut, but also increases the risk of an accidental needle stick of your own finger. Venipuncture insertion process ------------------------------ When performing a venipuncture in the antecubital region, the bevel should always be up (regardless of needle used). Insert the needle at a 15° to 30° angle, depending on the depth of the vessel. The deeper the vein is located in the arm, the greater the angle (not to exceed 30°). A vein close to the surface of the skin should be collected at a shallower angle, but no shallower than 15°. An angle greater than 30° runs the risk of going too far into the antecubital region and possibly hurting the patient or injuring a nerve. An angle that is too shallow runs a risk of forcing the bevel to adhere itself to the wall of the vessel (slowing or stopping the blood flow) or missing entirely (going between the vessel and the skin). The proper angle for a dorsal hand blood collection is 10°. When performing a dorsal hand collection, the angle should be shallower due to the large number of nerves and tendons in the hand. The insertion in all venipuncture locations should be performed with a quick smooth movement to enter the skin. A swift entry helps reduce pain and prevent the vein from moving away from the needle, resulting in an unsuccessful attempt. Gauging the depth of the entry requires an understanding of where the needle will be inserted. When the needle is inserted, the skin and the wall of the vessel are both punctured. Insert the needle until you feel a change in resistance; at that point, stop the insertion and gently push the ETS tube in place. You can feel resistance when you puncture the skin, another resistance when you puncture the wall of the vein, and then a change in the resistance that indicates you are in the lumen (middle) of the vein. This location will help provide the best blood flow for the test required. Inserting the needle to a point where it only partially penetrates the vein will result in blood leaking into the surrounding tissues and results in a hematoma. Inserting the needle too deeply can pierce through the vessel and transfix the vein (going completely through the vein) and yield no blood. The insertion should also follow the direction that the vein is located. Following the direction of the vein will help prevent missing the vessel or piercing through the side of the wall of the vessel. Correct order for venipuncture steps ------------------------------------ Whether you are collecting blood via the evacuated tube, syringe, or winged infusion method, similar cleansing and safety processes must be followed. The following sections outline the variances and key points to remember when choosing between them. ***\ *** ***Evacuated tube method:*** The following is the step-by-step process for performing a blood collection using the evacuated tube method. 1. 2. Introduce yourself to the patient. 3. Identify the patient using at least two identifiers. 4. Have the patient sit or lie down. 5. Wash your hands, and don gloves. 6. Assemble the needed equipment. 7. Position the patient\'s arm in a slightly bent, downward position. (For the butterfly method, have the patient position their hand with the palm facing down.) 8. Apply the tourniquet. 9. Palpate for a vein. 10. Choose the most accessible vein. 11. Cleanse the venipuncture site. 12. Uncap the needle and inspect it for burrs or blunt edges. 13. Stabilize the vein with the thumb of the nondominant hand by gently but firmly pulling down on the skin below the vein. 14. Alert the patient that they will feel a pinch or poke. (Avoid terms that can have double meanings.) 15. Insert the needle at a 15° to 30° angle (10° for a hand collection). 16. Gently push an evacuated tube in place, label down, using the proper order of the draw. 17. Ensure blood flow into the tube. 18. Remove the tourniquet once blood flow is established unless it is feared that doing so would cause the vein to collapse. Never leave on for more than 1 minute. 19. Remove each tube, inverting immediately. 20. Remove the needle swiftly with the same angle of insertion. 21. Engage the needle safety device. 22. Dispose of the used needle in the sharps container immediately. 23. Provide pressure at the site of the collection. 24. Check the site to ensure that it is not still bleeding. If the site is still bleeding, continue to provide pressure. 25. Apply a bandage. 26. Label all specimens collected in front of the patient. 27. Thank the patient. 28. Observe the patient for any complications (syncope, bleeding, seizure). 29. Collect all garbage, checking the floor to make sure that anything dropped is discarded. 30. Remove gloves. 31. Wash hands. **Winged infusion (butterfly) method:** When a patient has veins that are small or difficult to access, a winged infusion set (butterfly) can be used. The steps for collection are almost the same as for the evacuated tube system with the following exceptions. While ETS needles can be boxed in packages of 50 or loose in a tray, butterfly needles are individually packaged. If the package is open or torn, do not use the needle; dispose of it into a sharps container. Fit the hub end onto a syringe or an evacuated tube adaptor. Before the collection, look for the safety so you do not accidently activate it before the collection is complete. Knowing where the safety is located also helps prevent an accidental needle stick when the collection is complete. Hold the butterfly needle by the wings, not by the adapter. After the needle has been inserted, there should be a flash of blood at the base of the winged infusion set. This flash indicates that the needle is in the vein. Then, slowly pull back on the plunger of the syringe or gently attach the evacuated tube. **Syringe method:** When a patient has easy-to-collapse or fragile veins, a syringe method can be used to perform the blood collection. The following is the step-by-step process for a syringe collection. 1. 2. Introduce yourself to the patient. 3. Identify the patient using at least two identifiers. 4. Have the patient sit or lie down. 5. Wash hands, and don gloves. 6. Assemble the needed equipment. 7. Pull the plunger in and out of the syringe to ensure a smooth collection. 8. Push the plunger all the way forward to make sure that there is no air in the barrel. 9. Calculate how much blood is necessary to fill the tubes for the tests required. 10. Determine how much blood will be collected into the syringe. Round up to make sure that enough blood is collected to completely fill tubes. 11. Position the patient\'s arm in a slightly bent, downward position. 12. Apply the tourniquet. 13. Palpate for a vein. 14. Choose the most accessible vein. 15. Cleanse the venipuncture site. 16. Uncap the needle and inspect it for burrs or blunt edges. 17. Stabilize the vein with the thumb of the nondominant hand by gently but firmly pulling down on the skin below the vein. 18. Alert the patient that they will feel a pinch or a poke. 19. Insert the needle at a 15° to 30° angle (10° for a hand collection). 20. Weigh fingers down with the first and second finger on the skin to help keep the syringe in place. 21. Pull back slowly on the plunger with the nondominant hand to collect blood. 22. Remove the tourniquet once blood flow is established unless it is feared that doing so would cause the vein to collapse. Never leave on for more than 1 minute. 23. Collect the correct amount of blood into the syringe to fill tubes for the tests required. 24. Remove the needle with the same angle of insertion. 25. Engage the safety on the needle. 26. Provide pressure at the site of the collection. 27. Ask the patient to place pressure or have another medical professional hold pressure. 28. Use a transfer device to move blood from the syringe into evacuated tubes in the proper order of the draw. Allow the vacuum to fill the tubes. Do not push down on the plunger of the syringe. 29. Invert tubes to mix in the additives. 30. Dispose of the transfer device and syringe in a sharps container. 31. Check the site to see that it is not still bleeding. If the site is still bleeding, continue to provide pressure. 32. Apply bandage. 33. Label all specimens collected in front of the patient. 34. Thank the patient. 35. Observe the patient for any complications (syncope, bleeding, seizure). 36. Remove gloves. 37. Wash hands. In some instances, you might use a syringe with a butterfly needle. Follow the steps for the proper holding and assembling of the butterfly needle. Once a flash of blood is seen, slowly pull back on the plunger of the syringe until the appropriate amount of blood is withdrawn. Use the same order of the draw for a syringe collection as for a routine venipuncture blood collection. Venipuncture order of the draw ------------------------------ The order of the draw was developed by the Clinical and Laboratory Standards Institute (CLSI) to help improve the quality of blood tests and standardize the order in which blood tubes are collected. The order of the draw is important because the use of a double-sided needle results in additive carryover from one evacuated tube to another during a blood collection. When the second needle is applied to the adapter, the sheath covering the needle pushes back and exposes that needle. This needle then pierces the tube, allowing the blood to be filled into the tube by the vacuum. When the tube is removed from the needle and applied to the next tube, some of the additive from the previous tube can cling to the sheath and be transferred to the next tube. This additive carryover can cause test results to be adversely altered. To ensure the most accurate test results, always fill the tubes in the correct order of the draw. The following is CLSI\'s order of the draw for venipuncture. - **Blood culture bottles or yellow tube stopper:** Blood culture bottles come in sets of aerobic and anaerobic. The anaerobic tube is collected first if using a syringe, and the aerobic tube is collected first when the blood collection is performed with a butterfly needle. The yellow stopper tube contains the additive SPS. Both are used to perform bacterial studies, but they are very rarely used together. - **Light blue:** The light blue stopper tube contains the additive sodium citrate and is used to perform blood collections for coagulation tests. Light blue tubes must be filled 100%. - **Serum tubes:** The tube stopper can be red, gold, speckled red and gray, or red and black. Some serum tubes contain no additive, and some contain a clot activator. Serum tubes must be allowed to clot for 30 min prior to centrifugation. Serum tubes are used to perform chemistry blood collections. - **Rapid serum tubes (RST):** The tube stopper is orange. When a stat blood collection is required, an orange serum tube may be used. RST tubes only need to clot for 5 min. - **Green:** Green stopper tubes contain the additive heparin: either lithium heparin or sodium heparin (both are anticoagulants that prevent clotting). - **Lavender or purple:** Lavender or purple stopper tubes contain the additive EDTA and are used for hematology tests. - **Pink:** Pink stopper tubes contain EDTA and are used for blood bank collections. - **Gray:** Gray stopper tubes contain the additives sodium fluoride and potassium oxalate and are used for glucose and alcohol blood collections. - **Light yellow:** The light yellow stopper tubes contain acid citrate dextrose (ACD) and are used for blood collections such as DNA. - **Royal or dark blue:** The dark blue stoppers do not indicate the additive contained in the tube, but that the tube is as free of element contamination as possible. Royal blue stopper tubes can contain EDTA, sodium citrate, or heparin, or be serum tubes. The label on the tube indicates which additive is contained in the tube. Different manufacturers\' ETS tubes can vary slightly in tint. When in doubt about what the tube contains, read the label to determine which additives are in the tube. When an ETS serum tube contains a gel separator, it is called a serum separator tube (SST). When a plasma tube contains a gel separator, it is called a plasma separator tube (PST). Some facilities can routinely order special testing that requires additional (different additive) tubes to be used. While it is important to fill all ETS tubes, it is essential that light blue, sodium citrate, tubes are filled 100% in a 9:1 additive ratio (nine parts blood to one part additive). When using a butterfly to collect blood into a light blue tube, a tube without an additive must be used to start the blood flow. This tube is not used in a test, but to clear the air out of the tubing of the butterfly to allow the light blue tube to fill completely. Avoid using this non-additive tube for actual testing because it would have been filled outside of the order of the draw. In addition, depending on the venipuncture method used, extra care can be required when collecting blue top tubes for coagulation testing. Check for the standard procedures at your facility so you can be prepared for any phlebotomy request. To ensure accurate test results, the proper additive tube must be chosen to match the blood test that is being performed. Some evacuated tubes contain no additive and are used for tests that require the blood to clot before being centrifuged. These tubes require serum. Always allow serum tubes to clot completely, usually 30 minutes. These tubes are used for collections that require serum and are used for chemistry tests. Other tubes contain anticoagulants that prevent the blood from clotting and are used for tests that require plasma. The anticoagulant that is chosen depends upon the function of the additive on the blood. The following are a few of the most commonly used anticoagulants: - **Sodium citrate:** Found in the light blue tubes and used for clotting tests, because it performs the best at preserving the coagulation factors. - **EDTA:** Found in the lavender or pink tubes and used for most hematology tests, because it helps preserve the shape of cells and reduces platelet clumping. - **Heparin:** Found in green tubes and used for most chemistry tests, because it prevents blood clots from causing falsely elevated results, especially in potassium and electrolyte tests. - **Potassium oxalate/Sodium fluoride:** Found in grey tubes and used for testing sugar, because the additive helps preserve the glucose and prevent glycolysis. Using the incorrect tube for a blood test can adversely alter test results and patient care. Patient safety throughout the collection ---------------------------------------- Maintaining the patient\'s safety during the phlebotomy procedure starts with a quick, basic assessment of the surrounding area where the blood collection will be performed. Look for any tripping risks or any environmental hazards that could result in injury to you or the patient. Be observant of the patient\'s emotional, mental, and physical state to help determine if any extra care is necessary when performing the blood collection. Factors that can affect how the collection is performed include an IV in the patient\'s arm, tattoos, burns, edema, or a hematoma at the anticipated site of venipuncture. For patients who have a mental state that can inhibit their understanding (children, clients who have cognitive deficits, clients who have dementia), you will need to work closely with their guardian to help make sure that all information about the procedure is understood and determine if they can tolerate the blood collection. A patient\'s emotional state can affect the chances for syncope (fainting) or other adverse reactions, both during and after the procedure. Needle phobia is common; do not make the patient feel uncomfortable if they experience fear of having their blood collected. Talk calmly to the patient. Reassure them that feelings of nervousness are normal and experienced by other patients. Observe the patient closely before, during, and after the blood collection to determine whether they are tolerating the procedure. Most patients tolerate venipuncture with ease and report that needle insertion causes only temporary discomfort. However, some people react strongly to having a needle puncture their skin. This reaction can be severe enough to result in a patient experiencing syncope. It is essential that all procedures begin with the patient in a safe position. Patients should be sitting in a chair without wheels (preferably with arms), or they can be lying down. If the patient reports past experiences of syncope, it is safest to begin the procedure with the patient lying down. Before the venipuncture begins, ask the patient to tell you if they are feeling any pain other than the slight pinch expected with the insertion of the needle. Always tell the patient that you are going to insert the needle, with a simple statement such as \"you will feel a small poke\" or \"you will feel a small pinch\" immediately before insertion. Warning the patient that the collection is about to happen can remind them not to jerk their arm away. Avoid warnings that can have double meanings or that can startle the patient. A countdown to insertion can also be used. If the patient states they are in pain, ask if they want you to stop the procedure. In many cases, the patient will say that they want the collection to continue. Be observant of the patient throughout the collection, listening for a change in breathing, excessive sweating, or any change that seems out of the ordinary. Continue to talk to the patient during the procedure to help keep the patient calm and to stay informed of their status. During the blood collection, inform the patient about the progress and when the collection is close to completion. If the patient stops speaking abruptly, ask a question that requires an answer, such as \"How are you doing?\" If they do not respond, this can be a sign of altered or loss of consciousness. If the patient becomes unconscious, stop the procedure immediately and implement first aid measures. At any time during the blood collection, if the patient states they want the collection stopped, you must stop immediately, no matter what stage the blood collection is in. After the blood collection is complete, observe the patient for any signs of potential complications-such as syncope-by looking at their face. Look for any extreme skin tone changes-such as becoming pale or red-because these can be signs of a potential complication. Look for other signs, such as severe sweating, glazed eyes, or a fixed stare. The patient should not be left alone or allowed to leave until you are confident that they are experiencing no complications related to the blood collection. A patient can experience syncope before, during, or after the blood collection. If it appears that the patient has lost consciousness, check immediately for breathing. Look at your watch or a clock and document the time the patient loses consciousness. If the patient is not breathing, call 911 and then gently lower the patient to the floor and begin CPR. If the patient is breathing, it is likely that they have fainted. If unconsciousness occurs during the procedure, the blood collection must be stopped. If it seems that the patient has fainted, make sure that their airway is clear and apply a cold compress to their neck or forehead. Do not give liquids to an unconscious patient. Most patients only experience syncope for a very short period of time. Any unconsciousness that lasts longer than 2 minutes requires additional medical assistance, a call to 911, or an alert to the emergency medical professionals at your facility. Make sure that the patient is safe from falling, and do not leave the patient until they have recovered, or help has arrived. Always observe a patient\'s face after a blood collection for signs of oncoming syncope (change in color, excessive sweating, glassy stare). In the inpatient or hospital setting, there can be times that you need to ask another medical professional for assistance. Patients who are agitated, have uncontrollable tremors, or have medical equipment that can interfere with a safe phlebotomy procedure can present a challenge to a safe venipuncture process. When in doubt, ask for help. It is always better to ask for help and not need it than to proceed alone and experience an unfortunate incident or accidental needlestick. Complications from primary collection ------------------------------------- A common problem that can occur with venipuncture is that the phlebotomy technician cannot easily see or palpate a suitable vein. You can warm the area to help find a vessel or lower the arm below the patient\'s heart. Some facilities have a policy that outlines how many times you can retry phlebotomy. It is generally accepted that a phlebotomist tries only twice before asking someone else to collect the sample. So be sure that the site chosen has a good chance of being successful. If you cannot find a vessel, ask another phlebotomy technician to try, ask your supervisor for advice, or notify the provider. If you don\'t see a flash when using a butterfly needle or there is no blood flow into the tube with the ETS system, you might have missed the vein. First pull the needle back very slightly. If you have transfixed the vessel, pulling back on the needle will place it in the vein and blood flow can begin. Vacuum tubes will not fill completely if you have transfixed, so it can be necessary to discard the light blue tube and use another one to continue the blood collection. If blood does not begin to flow after slightly pulling back on the needle, do not dig or probe into the arm blindly. Nerves cannot be seen or felt, and blind moving of the needle could cause excessive pain or damage to the patient. Re-palpate the site and determine if you can feel where the vein is compared to the needle. If the vein is fairly close to the needle, anchor below the needle with your nondominant hand and attempt to move the needle closer to the vein. If the patient expresses any indication of pain, stop the attempt. Occasionally, while performing a venipuncture, blood flow will unexpectedly stop. You might have advanced the needle too far (causing it to touch the back wall of the vein), or not advanced the needle deep enough into the vein. Perform a slight readjustment of the needle to determine if you can restart the blood flow. The blood collection tubes rarely malfunction, but it is possible for the vacuum in the tube to be insufficient to withdraw blood, or the rubber stopper on the tube might not have been properly punctured. If this is suspected, try another tube. However, it is possible that the vein collapsed, and you can need to perform another puncture. Use a new needle for every attempt, even on the same patient. If blood flow stops or if no blood is evacuated into the collection tubes, do not repeatedly move the needle in and out, back and forth, or side to side. This is painful for the patient and can cause excessive bleeding and bruising. This also increases the risk of puncturing an artery or damaging a nerve. It is acceptable in these situations to advance the needle slightly. If that does not work, pull it back slightly; but if this does not work, remove the needle. During or after the venipuncture process, patient complications can occur. Check for any signs or symptoms that indicate the patient is having difficulty tolerating the procedure. But remember that patients might not-for various reasons-speak up even if they are uncomfortable or in pain. Before the start of the procedure, ask patients to let you know if they are having any problems during or after the venipuncture. Knowing how to identify and address these complications will minimize the chance of a negative outcome for you and the patient. Some complications that can occur during or after a blood collection include the following: - **Nerve damage:** If a patient reports moderate to severe pain, a sensation of numbness, or a feeling of pins and needles immediately after you insert the needle, it is possible that a nerve has been hit, and you must stop the procedure immediately. If the pain or numbness continues after the needle is removed, the patient might need additional medical care to determine the extent of the damage to the area. - **Hematoma:** A hematoma is the most common complication associated with phlebotomy. Pushing the needle through both walls of the vein can cause a hematoma to form due to the blood that leaks into the surrounding tissue. Hematomas usually disappear in a few days and cause no harm. If a hematoma develops during a blood collection, it can put pressure on a nearby nerve if it grows too large and could damage the nerve. If a hematoma starts to appear during the blood collection, you must stop the collection immediately. Reduce the risk of causing a hematoma by performing venipuncture smoothly and accurately, applying the right amount of pressure for the right amount of time after removing the needle, and applying a bandage that puts pressure on the site. - **Phlebitis:** Phlebitis is inflammation of a blood vessel. It usually occurs when one vein has been accessed repeatedly. - **Thrombosis:** A thrombus is a solid mass composed of blood (clot) that can partially or fully block a vein or artery, causing difficulty when performing venipuncture. - **Petechiae:** These are small red dots that develop on the skin below the tourniquet. They can result due to routine application of a tourniquet, or in cases where a tourniquet is applied too tightly or left on too long. If you notice petechiae, there is no need to stop the blood collection. The chances of petechiae increase for patients who have platelet abnormalities, so it is important to apply adequate pressure after the collection and make sure that the patient has stopped bleeding before any bandage is applied. - **Hemoconcentration:** When a tourniquet is applied too long or the patient excessively pumps their fist, the blood flow can stagnate in an area, causing hemoconcentration. Hemoconcentration can cause an alteration in test results, especially for ammonia, calcium, coagulate, potassium, and protein tests. To prevent hemoconcentration, make sure to remove the tourniquet prior to the 1-minute time limit. If the patient is pumping their fist, politely ask them to stop and wait a few minutes before performing the blood collection from that arm. - **Other physical reactions:** Minor physical reactions (diaphoresis \[sweating\], dizziness, nausea) can occur during or after a venipuncture, but these are often not serious and usually go away without treatment in a few minutes. Be aware that these reactions can be an indication that the patient is experiencing a complication of the blood collection. Ask the patient how they are feeling and stay with the patient until they have fully recovered. - **Collection/processing errors:** Collection errors can be more common than physical complications, and the consequences of a collection error can be serious or fatal. Examples of collection errors include misidentification of the patient, improper site selection and preparation, using the wrong tube, incorrect order of the draw, underfilling the tubes, failure to invert the tubes, failing to document the time you obtained or received a specimen, and mislabeling of specimens. The physical complications of venipuncture are visible and distressing to the patient, but collection errors can sometimes cause the most harm. - **Syncope:** As a phlebotomist, you cannot prevent syncope, but it is possible to anticipate it. Ask the patient whether they have ever fainted during a venipuncture. If so, have them lie down, and proceed with the collection cautiously. Also, if the patient seems anxious or if it is their first phlebotomy procedure, be prepared and on alert for a syncope episode. Syncope is the result of a sudden lack of blood supply to the brain. It is not unusual for people to faint during a blood collection. If a patient faints during a collection, make sure they do not fall and suffer an injury. Syncope can also be the result of a dangerous medical problem. Keep the patient safe from injury, and immediately call for help. Do not leave the patient alone until they fully recover. Do not continue to collect blood on a patient who is unconscious. - **Seizure:** In some cases, a patient can experience a seizure during a blood collection or while in the care of a phlebotomist. If a patient begins to have a seizure during a blood collection, stop the procedure immediately and seek emergency medical assistance or call 911. Be sure to document the time of the seizure onset. Take steps to help prevent injury to the patient. Do not attempt to restrain the patient or force anything into the patient\'s mouth. Remove anything from the area that can injure the patient. Stay with the patient until the seizure is over, and they have recovered, or emergency personnel have arrived. Do not bring additional attention to the patient and provide as much privacy as the situation allows. After a seizure, a patient often needs several minutes to fully recover. - **Shock:** Common symptoms of shock are cold, clammy, and pale skin; rapid pulse; an increase in shallow breathing; and a blank stare. If you suspect shock, call for help. Ensure that the patient has an open airway. If the patient is lying down, lower the head below the body. Keep the patient warm and safe until help arrives. - **Nausea:** A patient can state that they are feeling nauseous or sick to their stomach. The patient might not say anything but can demonstrate symptoms such as color change to the face or excessive sweating. If a patient is experiencing nausea before a collection, wait to perform the procedure until the patient states that they no longer feel nauseated. If a patient states they are nauseated during the collection, stop and provide a basin, trash can with a liner, or another container in case the patient vomits. Even if the patient does not feel like they are going to vomit, you should still have something ready. If the patient does vomit, make sure that the container used is treated as biowaste. Do not resume the procedure until the nausea is gone. Do not leave a patient who feels nauseated alone. A cold compress on the patient's head or the back of the neck can help them feel better. If the patient vomits, provide a wet cloth or tissue for them to clean off their mouth. You also can provide a glass of water if the patient is not a choking risk or on a fluid restriction. Inform the nurse or provider that the patient has vomited and what actions you took to address it. - **Diaphoresis**: Severe sweating can be a sign of nausea, syncope, or a panic attack. The sweating itself is not a condition, but it can indicate other underlying difficulties. Unless the room is extraordinarily warm, excessive sweating should not be ignored. It is important to try to determine why the patient is diaphoretic by asking, \"How are you feeling?" Provide a tissue or towel for comfort but avoid bringing attention to their condition. Do not leave the patient alone until they stop sweating. Provide a washcloth or tissue for the patient to wipe their face. Observe for other signs of potential complications and notify the nurse or provider. With every patient complication, provide privacy and do not draw attention to the condition. Do not tease or make fun of a patient who has had complications. Advise the patient to alert future phlebotomists about the complication so they can be prepared and take necessary actions. It is important to remember what to do in the case of every complication and keep calm. Keeping calm helps you and the patient move toward a better outcome. Venipuncture removal process ---------------------------- With every type of needle used, the removal is similar. To help reduce the risk of pain and injury to the patient, remove the venipuncture needle bevel-up, at the same angle of insertion, in a swift smooth motion. Immediately engage the safety device, dispose of the needle into the sharps container, and provide pressure to the site. Inverting evacuated tubes ------------------------- Immediately after filling each ETS tube with blood, gently invert the tube three to eight times, depending on what the manufacturer recommends. If a plasma tube is not inverted properly, the specimen can clot. The specimen can be rejected by the laboratory, requiring another blood collection to be performed. If a serum tube is not inverted properly, the blood specimen might not clot completely, which will alter test results and can require another blood collection. Both tubes should be inverted as soon as possible to help ensure the best test results. Shaking or roughly handling a tube can cause hemolysis. Inverting the tube means holding the tube in your hand and then turning your wrist so that the bottom of the tube points up, then reversing the movement. An inversion is one complete turn of the wrist. Point the bottom of the tube up and then down. Avoid vigorous shaking, over-inverting, or inverting roughly. A gentle inversion will help avoid hemolysis of the blood sample and contribute to accurate test results. The number of inversions varies depending on the color of the tube. In general, use the following guidelines. - Light yellow SPS top tubes: Eight to 10 inversions - Light blue top tubes: Three to four inversions - Serum separator tubes (SST, red tops) and serum tubes (red tops without the separating gel): Five inversions - Green top tubes: Eight to 10 inversions - Lavender top tubes: Eight to 10 inversions - Gray top tubes: Eight to 10 inversions