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VENIPUNCTURE PROCEDURE
A requisition form must accompany each sample submitted to the laboratory. This
requisition form must contain the proper information in order to process the
specimen. The essential elements of the requisition form are:
A properly labeled sample is essential so that the results of the test match the
patient. The key elements in labeling are:
EQUIPMENT:
ORDER OF DRAW:
PROCEDURAL ISSUES
If possible, speak with the patient during the process. The patient who is at ease
will be less focused on the procedure. Always thank the patient and excuse
yourself courteously when finished.
The Patient's Bill of Rights has been adopted by many hospitals as declared by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The
basic patient rights endorsed by the JCAHO follow in condensed form are given
below.
Although the larger and fuller median cubital and cephalic veins of the arm are
used most frequently, the basilic vein on the dorsum of the arm or dorsal hand
veins are also acceptable for venipuncture. Foot veins are a last resort because of
the higher probability of complications.
o Extensive scars from burns and surgery - it is difficult to puncture the scar
tissue and obtain a specimen.
o The upper extremity on the side of a previous mastectomy - test results
may be affected because of lymphedema.
o Hematoma - may cause erroneous test results. If another site is not
available, collect the specimen distal to the hematoma.
o Intravenous therapy (IV) / blood transfusions - fluid may dilute the
specimen, so collect from the opposite arm if possible. Otherwise,
satisfactory samples may be drawn below the IV by following these
procedures:
o Palpate and trace the path of veins with the index finger. Arteries pulsate,
are most elastic, and have a thick wall. Thrombosed veins lack resilience,
feel cord-like, and roll easily.
o If superficial veins are not readily apparent, you can force blood into the
vein by massaging the arm from wrist to elbow, tap the site with index and
second finger, apply a warm, damp washcloth to the site for 5 minutes, or
lower the extremity over the bedside to allow the veins to fill.
PERFORMANCE OF A VENIPUNCTURE:
o Approach the patient in a friendly, calm manner. Provide for their comfort
as much as possible, and gain the patient's cooperation.
o Identify the patient correctly.
o Properly fill out appropriate requisition forms, indicating the test(s)
ordered.
o Verify the patient's condition. Fasting, dietary restrictions, medications,
timing, and medical treatment are all of concern and should be noted on
the lab requisition.
o Check for any allergies to antiseptics, adhesives, or latex by observing for
armbands and/or by asking the patient.
o Position the patient. The patient should either sit in a chair, lie down or sit
up in bed. Hyperextend the patient's arm.
o Apply the tourniquet 3-4 inches above the selected puncture site. Do not
place too tightly or leave on more than 2 minutes.
o The patient should make a fist without pumping the hand.
o Select the venipuncture site.
o Prepare the patient's arm using an alcohol prep. Cleanse in a circular
fashion, beginning at the site and working outward. Allow to air dry.
o Grasp the patient's arm firmly using your thumb to draw the skin taut and
anchor the vein. The needle should form a 15 to 30 degree angle with the
surface of the arm. Swiftly insert the needle through the skin and into the
lumen of the vein. Avoid trauma and excessive probing.
o Patient identification
o Filling out the requisition
o Equipment
o Apply tourniquet and palpate for vein
o Sterilize the site
o Insert needle
o Drawing the specimen
o Drawing the specimen
o Releasing the tourniquet
o Applying pressure over the vein
o Applying bandage
o Disposing needle into sharps
o labeling the specimens
PERFORMANCE OF A FINGERSTICK:
o Follow the procedure as outlined above for greeting and identifying the
patient. As always, properly fill out appropriate requisition forms,
indicating the test(s) ordered.
o Verify the patient's condition. Fasting, dietary restrictions, medications,
timing, and medical treatment are all of concern and should be noted on
the lab requisition.
o Position the patient. The patient should either sit in a chair, lie down or sit
up in bed. Hyperextend the patient's arm.
o The best locations for fingersticks are the 3rd (middle) and 4th (ring)
fingers of the non-dominant hand. Do not use the tip of the finger or the
center of the finger. Avoid the side of the finger where there is less soft
tissue, where vessels and nerves are located, and where the bone is closer
to the surface. The 2nd (index) finger tends to have thicker, callused skin.
The fifth finger tends to have less soft tissue overlying the bone. Avoid
puncturing a finger that is cold or cyanotic, swollen, scarred, or covered
with a rash.
o Using a sterile lancet, make a skin puncture just off the center of the finger
pad. The puncture should be made perpendicular to the ridges of the
fingerprint so that the drop of blood does not run down the ridges.
o Wipe away the first drop of blood, which tends to contain excess tissue
fluid.
o Collect drops of blood into the collection device by gently massaging the
finger. Avoid excessive pressure that may squeeze tissue fluid into the
drop of blood.
o Cap, rotate and invert the collection device to mix the blood collected.
o Have the patient hold a small gauze pad over the puncture site for a couple
of minutes to stop the bleeding.
o Dispose of contaminated materials/supplies in designated containers.
o Label all appropriate tubes at the patient bedside.
o Deliver specimens promptly to the laboratory.
ADDITIONAL CONSIDERATIONS:
To prevent a hematoma:
PROTECT YOURSELF
TROUBLESHOOTING GUIDELINES:
o Change the position of the needle. Move it forward (it may not be in the
lumen)
o or move it backward (it may have penetrated too far).
o Adjust the angle (the bevel may be against the vein wall).
o The vein may have collapsed; resecure the tourniquet to increase venous
filling. If this is not successful, remove the needle, take care of the
puncture site, and redraw.
o The needle may have pulled out of the vein when switching tubes. Hold
equipment firmly and place fingers against patient's arm, using the flange
for leverage when withdrawing and inserting tubes.
o A hematoma forms under the skin adjacent to the puncture site - release
the tourniquet immediately and withdraw the needle. Apply firm pressure.
o The blood is bright red (arterial) rather than venous. Apply firm pressure
for more than 5 minutes.
o Heelstick on baby
COLLECTION TUBES FOR PHLEBOTOMY
Red Top
ADDITIVE None
MODE OF Blood clots, and the serum is separated by
ACTION centrifugation
Chemistries, Immunology and Serology,
USES
Blood Bank (Crossmatch)
Gold Top
ADDITIVE None
Serum separator tube (SST) contains a gel
MODE OF
at the bottom to separate blood from serum
ACTION
on centrifugation
USES Chemistries, Immunology and Serology
Light
Green Top
Purple Top
ADDITIVE EDTA
MODE OF
Forms calcium salts to remove calcium
ACTION
Hematology (CBC) and Blood Bank
(Crossmatch); requires full draw - invert 8
USES
times to prevent clotting and platelet
clumping
Light Blue
Top
Green Top
Dark Blue
Top
ADDITIVE EDTA-
MODE OF Tube is designed to contain no
ACTION contaminating metals
Trace element testing (zinc, copper, lead,
USES
mercury) and toxicology
Light Gray
Top
Yellow Top
Yellow -
Black Top
Black Top
ADDITIVE Thrombin
MODE OF
Quickly clots blood
ACTION
USES STAT serum chemistries
Light
Brown Top
Pink Top
White Top
SPECIMEN COLLECTION
15. Remove tourniquet within one minute of application.
16. Remove tube when filled and continue with next tube if any.
The order of draw for multiple tubes is:
(1) Yellow top tube (Blood Culture)
(2) Red top tube (Glass) No additive
(3) Blue top tube (Coagulation)
(4) Gold top tube (SST Gel Sep)
(5) Red top tube (Plastic) With clot activator
(6) Green top tube (Heparin)
(7) Lavender top tube (EDTA)
(8) Pink top tube (Blood bank tube)
(9) Grey top tube (Glycolytic inhibitor)
17. Gently invert all additive tubes 5 - 10 times. Avoid aggressive shaking of
tubes.
18. Remove needle from patient’s arm. Immediately apply pressure with a 2x2
gauze to
stop bleeding. Continue applying pressure until patient stops bleeding to avoid
unnecessary bruising. Tape gauze to puncture site.
19. Dispose of needle in sharps container and dispose of other waste in proper
container.
20. Label all tubes with a hospital computer label. If one is not available, the label
must
contain the patient’s name and date of birth. Record the date and time of
collection
and the phlebotomist’s initials on the requisition slip or collection list.
21. Insert specimen in specimen bag (or specimen racks for 6:00 am draws).
22. Remove gloves and wash hands.
23. Deliver to the Laboratory, Central Receiving room 1249 within 2 hours of
collection.
24. After phlebotomy, cleanse the site with 70% isopropyl alcohol pad to remove
remaining iodine, which can cause irritation in some patients.
rotating tourniquet
[rō′tāting]
Etymology: L, rotare, to rotate; Fr, tourniquet, garrote
one of four constricting devices used in a rotating order to pool blood in the extremities.
The purpose is to relieve congestion in the lungs in the treatment of acute pulmonary
edema. Use of the rotating tourniquet has declined with the development of vasodilating
drugs and diuretics.
rotating tourniquet
Cardiology A modality for ↓ preload in acute cardiogenic pulmonary edema, in which the
blood flow to the extremities is blocked by RTs; because preload is ↓ more precisely with
nitroprusside, RTs are rarely used
I.
Description
Provides instruction for performing a venipuncture on an adult
Table of Contents
I.
Description ............................................................................................................................
............. 1
II.
Rationale ...............................................................................................................................
............. 1
III.
Policy/Procedure ...................................................................................................................
............. 1
A.
Policy.....................................................................................................................................
....... 1
B.
Procedure...............................................................................................................................
...... 1
IV.
References .............................................................................................................................
............ 4
V. Reviewed/Approved
by ....................................................................................................................... 4
VI. Original Policy Date and
Revisions ..................................................................................................... 4
Figure / Table List
Table 1: Tube Draw
Order ........................................................................................................................ 3
II.
Rationale
Accurate specimen collection and proper specimen handling are of the utmost importance
because errors are more likely to occur in these areas than during the laboratory analysis
itself.
III.
Policy/Procedure
A.
Policy
The blood collection procedure requires both skill and knowledge. Several steps in this
process are an essential part of every successful collection. It is important that each
phlebotomist establish a routine for blood collection that incorporates these essential
steps. Performing a venipuncture should be comfortable for the phlebotomist and should
enable the phlebotomist to complete the procedure in a timely manner
B.
Procedure
These steps should be followed in order to perform a successful venipuncture.
1.
The request for blood collection must contain the Medical Record Number, patient’s last
name, first name, middle/maiden initial, date of birth, sex and race. The information is
entered into the Laboratory Information System and an LIS order number is accessioned
and printed on the label. The outpatient requisition or computer generated patient label
will be used by the phlebotomist to identify the patient.
2.
Approach the patient in a calm, confident and professional manner. LAB 0025 Page 1 of
4
Adult Venipuncture
LAB 0025 Page 2 of 4
a.
The phlebotomist must gain the patient’s confidence assure the patient that, although the
venipuncture will be slightly painful, it will be short in duration and necessary for the
diagnosis and treatment of their health care problem.
b.
The phlebotomist may be able to help the patient feel more comfortable by giving as
much information as possible regarding the venipuncture procedure. Never, under any
circumstances, should the phlebotomist tell the patient what disease or condition a
specific blood test will detect.
3.
Identify the patient according to Inpatient or Outpatient Identification procedures.
4.
Determine the best site for venipuncture according to the Venipuncture Site Selection
Guidelines procedure.
5.
Select equipment and method of blood collection based on assessment of the patient’s
veins.
a.
The preferred procedure for venipuncture is the evacuated tube method. This procedure
should always be the first procedure of choice.
b.
In some instances the phlebotomist may need to use a procedure that allows more
flexibility and stability (i.e. small hand veins or veins in the back of the wrist.). In this
case the butterfly (winged infusion set) needle may be used.
6.
Prepare equipment and don gloves at any point prior to the actual venipuncture.
7.
Insure proper positioning of the patient’s arm. Position the arm so that it is resting on a
table or on the bed alongside the patient. The arm should be supported firmly and should
not be bent at the elbow. If necessary, place a pillow under the arm to provide additional
support. Lower bedrails, if necessary, but be sure to replace rails to the upright position.
8.
Apply the tourniquet.
a.
Under ideal conditions, the tourniquet should be applied to 3 to 4 inch clearance. Always
allow at least a 1 to 2 inch clearance between the IV or med lock and the tourniquet.
b.
Ideally, the tourniquet should not be applied for longer than one or two minutes at a time.
Leaving the tourniquet applied for an excessive period of time (>2 minutes) may cause
localized stasis, formation of a partial filtrate of blood and hemoconcentration. These
may result in erroneously high values for all protein-based analytes, packed cell volume,
and other cellular elements.
9.
Cleanse venipuncture site with alcohol using a circular motion form the center to the
pheriphery.
10.
Allow the area to dry before venipuncture.
11.
Alert the patient before venipuncture.
12.
Anchor the vein and smoothly insert needle with bevel up. Use the thumb to draw the
skin taut. This anchors the vein. The thumb should be 1 or 2 inches below the
venipuncture site.
a.
Each phlebotomist is permitted only two unsuccessful venipunctures per patient. If a third
attempt is needed, the phlebotomist must contact a lead tech for a decision regarding any
subsequent attempts.
b.
A clean, sterile needle must be used for each new collection attempt. NEVER restick a
patient using the same needle.
13.
Calmly make adjustments if blood does not flow.
Adult Venipuncture
LAB 0025 Page 3 of 4
a.
Change the position of the needle.
i.
If the needle has penetrated too far into the vein, pull it back a bit.
ii.
If the needle has not penetrated far enough, advance it further into the vein.
iii.
Carefully rotate the needle to assure that the bevel is up. (This step is particularly useful
when using a butterfly as they tend to turn over if not anchored properly.)
b.
Try another tube if you feel you are in the vein but the tube may lack vacuum.
c.
Loosen the tourniquet. This is particularly helpful with babies, less so with adults.
i.
The tourniquet may have been applied too tightly, thereby stopping the blood flow.
ii.
If blood flow is adequate after tourniquet removal it is not necessary to reapply the
tourniquet.
iii.
If blood flow is still not adequate, loosely reapply the tourniquet.
14.
Release the tourniquet as soon as the blood begins to flow.
15.
Collect the proper amount of blood for tests ordered.
Note:
Collect tubes in proper order according to the NCCLS guidelines. Suggested order of
draw is as follows.
Table 1: Tube Draw Order
a.
Blood Culture
b.
Royal Blue
c.
Red (No additive)
d.
Light Blue (Sodium Citrate)
e.
Serum Separation (Gold Top w/ gel in bottom)
f.
Green (Sodium Heparin)
g.
Yellow (ACD Solution)
h.
Pink (TMS)
i.
Pearl
j.
Lavender (EDTA)
16.
Gently invert anticoagulated tubes as they are collected in order to eliminate clotting.
17.
Apply pressure to site after withdrawing needle.
18.
Dispose of needle properly and carefully in the appropriate container.
19.
Check site to ascertain if bleeding has completely stopped.
20.
Apply a gauze bandage. Tape it down with medical tape. Paper tape is preferred.
21.
Clean up supplies and waste.
22.
Label tubes according to the Specimen Labeling procedure.
23.
Dismiss the patient in a courteous and professional manner