VENIPUNCTURE

• Phlebotomy procedures

  • Venipuncture
  • Capillary Puncture
  • Arterial Puncture
• Phlebotomy procedures

  1. Begin with the receipt of a test requisition form handed by nurses or doctors

  2. Requisitions must contain certain basic information to ensure correlation of sample drawn and test results with the appropriate patient
• Information on requisition forms

  • Patient’s location states which ward the patient is in, the floor, and room number
  • In the Philippines, there can be more than 1 requisition form for each patient for different tests
  • Some specimens will be requested immediately or at a specific time
  • Status of sample (ASAP, immediate collection, etc.)
  • Number and type of collection tubes usually found in barcode systems
  • Fasting requirement if indicated by the physician
  • Allergy to latex should be checked
  • Identification of the patient is confirmed by comparing information verbally and from the patient’s wrist ID band with the information on the requisition form
• Patient preparation

  1. Patient should be given a brief explanation of the procedure

  2. Positioning the patient conveniently and safely

  3. Always ask the patient if allergic to latex

  4. May be necessary to move a hospitalized patient slightly for accessibility

  5. Place a pillow or towel under the patient’s arm for better support and positioning
• Patient should not be told that the procedure will be painless
• When injecting a needle, it is painful, so patients should be informed that it will hurt but will be a fast procedure
• Gloves should be worn during phlebotomy procedures
• Permission should be asked before moving a hospitalized patient for accessibility
• A pillow or towel should be placed under the patient’s arm for better support and positioning
• Positioning a hospitalized patient for venipuncture

  Make the arm more accessible by placing a pillow or towel under it for better support and to position it in a straight line downward
• Gloves and tourniquet application

  1. Gloves should be worn when performing a venipuncture procedure

  2. Practice palpating the vein while wearing gloves

  3. Initial tourniquet application should last only 1 minute to avoid hemoconcentration
• Tourniquet

  • Impedes venous blood flow, causing blood to accumulate in the veins making them more easily located
  • Provides a larger amount of blood for collection
• IV selection

  1. The preferred site for venipuncture is the antecubital fossa located anterior and below the bend of the elbow

  2. 3 Veins: Median, Cephalic, and Basilic Vein
• Median Cephalic Vein


  • Preferred vein for venipuncture because it is large, stationary, least painful, and bruises less easily
  • Does not need as much anchoring of the elbow due to bone support
• Cephalic Vein


  • Second choice for venipuncture, close to the skin and easily felt in obese patients
• Basilic Vein


  • Not well anchored, rolls easily, high risk of puncturing median cutaneous nerve or the brachial artery
• Other sites for venipuncture

  • Veins on the underside of the wrists should never be used
  • Leg, ankle, and foot veins are sometimes used with permission of the patient’s physician
  • Vein of the longitudinal sinus or sagittal sinus
  • Femoral vein, wrist vein (anterior portions)
  • Saphenous vein
  • Veins on the dorsal portion of the hand (IV transfusion)
• Cleansing the site


  Use 70% Isopropyl alcohol in concentric circles (2-3 inches in diameter)
• Assembly of equipment

  1. Check equipment for defects and expiration dates

  2. Check needle and syringe if properly screwed

  3. Have extra tubes near at hand

  4. Do not place collection tray on patient’s bed, use the bedside table
• Performing the venipuncture

  1. Re-apply tourniquet first

  2. Examine needle – BEVEL UP

  3. Anchoring vein

  4. Insertion of needle (30-40 degrees)

  5. Filling tubes

  6. Removal of needle

  7. Remove tourniquet before completion
• Performing the Venipuncture

  1. Examine needle – BEVEL UP

  2. Anchoring Vein

  3. Insertion of Needle (30-40 degrees)

  4. Filling Tubes

  5. Removal of Needle

  6. Disposal of Needle

  7. Labelling Tubes (full name, age, sex, date and time of collection, initials of the phlebotomist [include the time of the last meal of the patient, if fasting])

  8. Bandaging Patient’s Arm

  9. Disposing Used Supplies

  10. Leaving Patient (check the patient if the patient is fine [numbing, signs of nausea, pain])
• Remove tourniquet before needle

  Important: Re-apply tourniquet first
• Sleeping patients and unconscious patients

  1. Sleeping patients should be gently awakened

  2. If the patient has a companion, the companion is the one you’ll wake up

  3. Unconscious patients should be greeted in the same manner as conscious ones

  4. Nursing personnel can assist patient
• Unavailable patient


  Seek assistance from attending nurse/nurse station to locate patient
• Young and cognitively impaired patients

  Ask the patient’s nurse, relative, or a friend to identify the patient
• Basal state


  The ideal time to collect blood from a patient: Refrained from strenuous exercise, Has not ingested food or beverages except water for 12 hours, The patient did not change position for 10-15 mins
• Patient complications

  1. Immediate local complications

  2. Fainting (syncope)

  3. Failure of blood to enter the syringe due to:

  4. Hemoconcentration or venous stasis

  5. Seizures

  6. Petechiae
• Fainting (syncope)


  1. Spontaneous loss of consciousness caused by insufficient blood flow to the brain

  2. When a patient is prone to fainting, or because of nervousness

  3. Take a look at the patient while doing the procedure

  4. Prioritize the patient’s safety, rather than the specimen

  5. Signs: Paleness of the skin, hyperventilation, lightheadedness, dizziness, nausea, feeling of warmth/cold, clammy skin

  6. Remedy: Patient’s head is lowered between legs and instructed to breathe deeply; give spirit of ammonia
• Failure of blood to enter the syringe due to:

  1. Excessive pull of the plunger

  2. Going through the vein reaching the musculature

  3. Very small angle of entry

  4. The vein will not be available for some time for blood collection
• Equipment


  • Requisition form
  • Gloves (latex and non-latex)
  • Tourniquet (latex and non-latex)
  • 70% isopropyl alcohol pad
  • Syringe needle (syringes and needles)
  • Evacuated tubes
  • 2x2 gauze
  • Sharps container (portable for out-patients)
  • Indelible pen (manual labelling; notes or refusal of the patients)
  • Bandage
  • Biohazard bag
• Hemoconcentration or venous stasis

  1. Increase in the number formed elements in blood due to decrease plasma volume

  2. Happens on prolonged tourniquet application!

  3. Follow the 1 minute during the first tourniquet application

  4. The second tourniquet application, you can go as far as 2 minutes
• Procedure


  1. Step 1: Obtain and examine requisition form

  2. Step 2: Greet and reassure the patient and explain the procedure to be performed

  3. Step 3: Identify the patient verbally by having him or her state both the first name and last name and compare the information on the patient’s ID band with the requisition form

  4. Step 4: Verify if the patient has fasted, has allergies to latex, or has had previous problems with venipuncture

  5. Step 5: Select correct tubes and equipment for the procedure. Have extra tubes available

  6. Step 6: Wash hands and apply gloves (Standard Precautions)

  7. Step 7: Position the patient’s arm slightly bent in a downward position so that the tubes fill from the bottom up. Do not let the patient hyperextend the arm. Ask the patient to make a fist

  8. Step 8: Apply the tourniquet 3 to 4 inches above the antecubital fossa

  9. Step 9: Clean the site with 70% isopropyl alcohol in concentric circles moving outward and allow it to air dry

  10. Step 10: Assemble the equipment as the alcohol is drying. Attach the hypodermic needle to the syringe. Pull the plunger back to ensure that it moves freely and then push it forward to remove any air in the syringe

  11. Step 11: Reapply the tourniquet, remove the needle cap, and inspect the needle

  12. Step 12: Ask the patient to remake a fist, and anchor the vein by placing the thumb on th
• Seizures


  1. Tourniquet and needle should be removed, pressure applied to the site, and summon help

  2. If the needle is first removed because of seizure, recap then detach the tourniquet

  3. If seizure is controlled, follow the procedure [tourniquet is removed first, before the needle]

  4. Restrain the patient only to the extent that injury is prevented

  5. Document the time that the seizure started and stopped according to institutional policy

  6. Make sure that the patient do not further harm himself
• Petechiae


  1. Small, nonraised red hemorrhagic spots

  2. Will appear immediately

  3. May have prolonged bleeding following venipuncture

  4. Expect bruising later on; avoid hematoma

  5. Patients that have platelet disorders are common to t
• Venipuncture Procedure (Needle and Syringe)

  1. Attach the hypodermic needle to the syringe

  2. Pull the plunger back to ensure that it moves freely and then push it forward to remove any air in the syringe

  3. Reapply the tourniquet, remove the needle cap, and inspect the needle

  4. Ask the patient to remake a fist, and anchor the vein by placing the thumb on the nondominant hand 1 to 2 inches below the site and pulling the skin taut

  5. Hold the syringe in the dominant hand with the thumb on top near the hub and the other fingers underneath

  6. Smoothly insert the needle into the vein at a 15 to 30 degree angle with the bevel up until you feel a lessening of resistance. A flash of blood will appear in the syringe hub when the vein has been entered

  7. Brace the fingers against the arm to prevent movement of the needle when pulling back on the plunger

  8. Pull back the syringe plunger slowly using the nondominant hand to collect the appropriate amount of blood (no excess and no less than requested)

  9. Release the tourniquet and have the patient open the fist

  10. Cover the puncture site with gauze, remove the needle smoothly, and apply pressure

  11. Remove the needle from the syringe, and discard it in the sharps container

  12. Fill tubes in the correct order. Mix anticoagulated tubes as soon as they are removed from the transfer device

  13. After tubes are filled, the entire syringe is discarded into a sharps container

  14. Label the tubes and confirm identification with the patient

  15. Examine the puncture site and apply a bandage

  16. Remove gloves and wash hands
• Elasticity of the veins may attempt to evade
• Actions to take according to institutional policy


  • Make sure that the patient does not further harm himself
• PETECHIAE: Small, nonraised red hemorrhagic spots
• PETECHIAE: Will appear immediately
• PETECHIAE: May have prolonged bleeding following venipuncture