Module 5: Venipuncture procedure

• Venipuncture Procedure


  Process of collecting or drawing blood from a vein of the patient for laboratory testing purposes
• Bedside Manner


  Behavior of healthcare worker as perceived by the patient (OPD or IPD), includes proper patient identification and preparation of patient for testing
• Information included in a Requisition form

  • Patient’s correct and complete name
  • Medical record number
  • Patient’s age and date of birth
  • Patient’s location (OPD or room number of IP)
  • Type of test ordered
  • Name of requesting physician
  • Date and time of sample collection
  • Status of Sample (Stat, Routine, Timed)
  • Billing information
  • Special Precaution
• Avoid Fist pump as it affects potassium and Ionized calcium
• CLSI Standard: tourniquet that has been in place for longer than one minute should be released and reapplied after 2 minutes
• Phlebotomist


  • The person who performs phlebotomy
• Venipuncture Steps

  1. Review and accession the test request

  2. Approach, identify, and prepare patient

  3. Verify the patient’s diet restrictions and latex sensitivity

  4. Sanitize hands and put on gloves

  5. Position patient, apply tourniquet and fist clenching

  6. Select vein, release tourniquet and ask patient to open fist

  7. Clean and air-dry the site

  8. Prepare equipment

  9. Reapply tourniquet, uncap and inspect needle

  10. Ask patient to make a fist, anchor vein, and insert needle
• Do not use latex items for patients with latex allergy
• Palpation


  Locating veins by sight and touch (rolling of fingers on the site)
• Once the cap is removed, do not let the needle touch anything prior to venipuncture. If it does, remove it and replace it with a new one
• Phlebotomy Procedure

  1. Ply tourniquet, uncap and inspect needle

  2. Ask patient to make a fist, anchor vein, and insert needle

  3. Establish blood flow, release tourniquet, and ask patient to open fist

  4. Fill, remove and mix tubes in order of draw, or fill syringe

  5. Place gauze, remove needle, activate safety feature and apply pressure

  6. Discard collection unit, syringe needle, or transfer device

  7. Label tubes

  8. Observe special handling instructions

  9. Check patient's arm and apply bandage

  10. Dispose of contaminated materials

  11. Thank patient, remove gloves, and sanitize hands

  12. Transport specimen to the laboratory
• STEP 1: Review and accession the test request

  1. Test Requisition
  2. Receipt of the Test Request
  3. Reviewing the Requisition
  4. Accessioning the Test Request
• STEP 2: Approach, identify, and prepare patient

  1. Approaching the patient

  • Look for signs
  • Entering Patient’s room
  • Physicians and Clergy
  • Family and Visitors
  • Unavailable patient
  • Identifying yourself
  • Obtaining consent
  • Bedside manner
• STEP 2: Approach, identify, and prepare patient

  B. Patient identification- verify name and DOB

  • ID bracelets
  • Three- way ID
  • ID discrepancies
  • Missing ID
  • Sleeping patients
  • Unconscious patients
  • Neonates and other infants
  • Outpatient ID (ID card)
• STEP 2: Approach, identify, and prepare patient

  C. Preparing the patient

  • Address patient inquiries
  • Handling patient objections
  • Handling difficult patients
  • Cognitively impaired or combative patients
  • Patient in altered mental states
  • Addressing needle phobia
  • Addressing objects in the patient’s mouth
• STEP 3: Verify the patient's diet restrictions and latex sensitivity

  A. Diet Restriction Fasting (8-12 hours) – for tests that are affected by diet

  •Glucose (FBS, OGTT, Post-Prandial Glucose)

  • Lipid Profile

  B. Latex Sensitivity - Do not use latex items for patients with latex allergy
• STEP 4: Sanitize Hands and put on gloves

  2 Methods of Hand hygiene:

  1.Hand Washing -When hands are visibly soiled

  •Before eating

  •After using restroom

  •After exposure to known pathogen

  2. Hand rubbing with alcohol based sanitizers - When hands are not visible soiled
• STEP 5: Position patient, apply tourniquet and fist clenching

  A.Positioning the patient

  B. Tourniquet application and fist clenching

  • 3- 4 inches above the site
  • Closed to the site: collapsed vein
  • Far from the site: ineffective
  • Avoid Fist pump- affects potassium and Ionized calcium
  • Bariatric tourniquet- obese patients
• STEP 6: Select vein, release tourniquet, and ask patient to open fist

  • Antecubital area/fossa – preferred venipuncture site. (Median cubital, cephalic and basilic)
  • H and M patterns
  • CLSI Standard
  • Attempt must be made to locate the veins in the median on both arms before considering an alternate vein
  • Palpation – locating veins by sight and touch (rolling of fingers on the sight)
  • CLSI Standard: tourniquet that has been in place for longer than one minute should be released and reapplied after 2 minutes.
• STEP 7: Clean and Air-dry the site

  • 70% isopropyl alcohol (alcohol prep pads)
  • Use friction to clean an area 2 to 3 inches in diameter
  • CLSI standards: circular motion moving outwards
  • Dry naturally for 30 seconds to 1 minute
• STEP 8: Prepare equipment

  1. Equipment for

  • ETS
  • Syringe
  • Winged Infusion set

  1. B. Position equipment for use
• STEP 9: Re-apply the tourniquet, uncap and inspect needle?

  • Once the cap is removed, do not let the needle touch anything prior to venipuncture
  • If it does, remove it and replace it with a new one
• STEP 10: Ask patient to make a fist, anchor vein, and insert needle

  1. Anchoring

  • Place thumb 1 to 2 inches below and slightly to the side of the site and pull the skin toward the wrist

  1. Needle insertion

  • Use dominant hand
  • Needle bevel should be facing up
  • Needle angle: 15- 30 degree angle
• STEP 11: Establish blood flow, release tourniquet, and ask patient to open fist

  • Blood will begin to flow once the vein has been successfully entered. If syringe is used, a blood in the syringe hub is seen.
  • Release tourniquet
  • Release the patient’s fist as soon as blood flows freely.
• STEP 12: Fill, remove, and mix tubes in order of draw, or fill syringe

  • CLSI Standards: if coagulation tube is the first tube to be drawn, discard tube should be drawn.
  • allow ETS tubes to fill until the normal vacuum is exhausted and blood ceases to flow.
  • Remove the needle from the arm
  • NOTE: Remove the needle first before releasing the tourniquet.
• STEP 13: Place gauze, remove needle, active safety feature and apply pressure

  • Apply pressure to the site for 3 to 5 minutes or until the bleeding stops.
  • Do not ask the patient to bend the arm up - It increases the chance of bruising -Disrupts the platelet plug formation
• STEP 14: Discard collection unit, syringe needle or transfer device

  OSHA Regulations

  • Prohibit cutting, bending, breaking or recapping blood collection needles or removing them from the tube holders after use.
  • A needle and tube holder must be promptly discarded in a sharps container as a SINGLE UNIT.
• STEP 15: Label tubes

  • Tubes must be labeled in the presence of the patient immediately after blood collection.
  • Use permanent ink pen Tubes must be transported in upright position.
  • Minimum requirements:
  • Patient’s first and last name
  • ID number (in-patient) or DOB (outpatient)
  • Date and time of collection
  • Phlebotomist’s initials
  • Additional information such as fasting etc.
• STEP 16: Observe special handling instructions

  A) cooled or placed

  B) Ammonia

  C) Warming device or heat block

  D) Cold agglutinin

  E) Aluminum foil or light-blocking

  F) Bilirubin

  
• STEP 17: Check patient's arm and apply bandage

  • bleeding from the vein can continue even though it has stopped at the surface of the skin
  • apply an adhesive bandage
  • Instruct an outpatient not to carry heavy objects with that arm for a minimum of 1 hour
  • If allergic to adhesives:
  • Wrap gauze over the gauze placed on the site and fasten with paper tape or use Coban (self-adhering gauze-like material)
  • Leave it for at least 15 minutes then remove
• STEP 18: Dispose of contaminated materials

  • proper biohazard containers
  • other used disposable items in the regular trash other equipment is returned to its proper place
  • Sharps container – used needle
  • Yellow bag – used gloves, tourniquet, holder, barrel, ETS holder, used antiseptic pads/cotton
• STEP 19: Thank patient, remove gloves, and sanitize hands
• STEP 1: Review and accession the test request

  1. Test Requisition
  2. Receipt of the Test
  3. Request Reviewing the Requisition
  4. Accessioning the Test Request