VENIPUNCTURE PROCEDURE

• Venipuncture


  The most frequently performed procedure in phlebotomy
• Venipuncture procedure


  • A standardized procedure can reduce or eliminate errors that can affect sample quality and patient test results
• Phlebotomy procedure


  1. Receipt of a test requisition

  2. Phlebotomist must NOT collect a sample without requisition slip

  3. Required information on requisition (patient name, ID, DOB, location, ordering physician, tests requested, sample collection date/time, special instructions, billing)
• Status designation, status priorities and procedures for each status designation

  • STAT (immediately collect, test, and report results)
  • MED EMERG (immediately collect, test, and report results for critical patients)
  • TIMED (collect at a specific time)
  • ASAP (as soon as possible, follow hospital protocol)
  • FASTING (no food or drink intake for 8-12 hours)
  • NPO (nothing by mouth, prior to surgery)
  • PREOP (before an operation, to determine eligibility)
  • POSTOP (after an operation, to assess condition)
  • ROUTINE (relating to established procedure, to establish diagnosis)
• Greeting the patient


  1. Entering the patient's room

  2. Introduction

  3. Explain purpose of visit

  4. Use nontechnical terms

  5. Obtain consent

  6. Observe patient reaction

  7. Provide feedback

  8. Good communication skills
• Room signs


  • Allergic to latex
  • NPO (nothing by mouth)
  • DNR (do not resuscitate)
  • Do not draw blood here
  • Infection control precautions
  • Patient expired
• Entering a patient's room

  1. Knock lightly (whether closed or open) to make your presence known

  2. Respect privacy if curtain is closed
• Patient identification

  • The most important procedure in phlebotomy
  • CLSI, Joint Commission, and CAP recommend two identifiers
  • Comparison of information (wristband, requisition, verbal identification)
• Inpatient identification

  Patient must state their name, wristband with correct and complete information must be present
• Wristband information


  • Patient's name
  • Hospital ID #
  • Date of birth
  • Name of physician
• Precautions for patient identification

  • Identification should be based on ID band attached to patients
  • Wristbands sometimes removed when IV is administered, should be reattached to ankle
  • Ankle bands common for pediatric and newborns
  • Wristband lying on bedside, tied on the bed, or label on the doors are unreliable forms of identification
• Outpatient identification


  • Patient states full name, other identifier, date of birth, address, identification number
  • Compare verbal interpretation with requisition form
  • For impaired patient, relative can provide info
• Barcode technology


  • Wireless handheld bar code scanner interfaced with the laboratory information system (LIS)
  • Capable of creating sample labels
  • Radio frequency identification (RFID) with sample tracking device, can update patient data anytime
• Patient preparation


  1. Brief explanation of the procedure

  2. Do not tell patients procedure will be painless

  3. Do not give details of specific tests, refer patient to health-care provider

  4. Verification of pretest instructions (fasting, medication, latex allergy)
• Positioning the patient


  1. Never draw blood from a standing patient

  2. Outpatient: drawing station, arm fully supported and angled downward

  3. Use recliner/reclining chair for patients with history of syncope

  4. Ask patient to make a fist, other hand can be used for support

  5. Be alert with patient's condition

  6. For hospitalized patients, place pillow or towel under arm

  7. Return bed rails to raised position after phlebotomy

  8. Patient should remove anything in mouth before venipuncture
• Equipment selection


  1. Necessary equipment selected and placed close to patient

  2. No blood collection tray placed on bed

  3. Accessible on same side as free hand

  4. Reexamine requisition

  5. Select appropriate supplies based on patient age and condition

  6. Inspect supplies (expiration date)

  7. Place tubes in "order of draw"

  8. Keep extra tubes handy
• Handwashing and glove application


  1. Perform in front of patient

  2. Gloves changed between each patient
• Tourniquet application


  1. Impedes venous flow, allows arterial flow

  2. Maximum allowable duration is 1 minute

  3. Complications can arise with prolonged application

  4. Tourniquet must be released and reapplied after 2 minutes during vein selection

  5. Tourniquet placed 3-4 inches above puncture site, loop faces downward, free end away from puncture area

  6. Tourniquet should not be applied too tight
• Site selection


  • "H" pattern (70%): median cubital, cephalic, basilic veins
  • "M" pattern: cephalic, median cephalic, median basilic, basilic veins
  • Other sites: lower arm veins, wrist veins (CLSI discourages use), hand veins (use butterfly set)
• Median cubital vein


  Vein of choice for venipuncture, large, close to skin surface, stationary and anchored, least painful, least likely to bruise

  
• Cephalic vein


  Second-choice vein, more difficult to locate, fairly well anchored, often only vein felt in obese patients, easily bruises, possibility of blood spurt
• Basilic vein


  Last-choice vein, large and easy to feel, least firmly anchored, rolls easily, increases risk of puncturing median nerve and brachial artery, easily bruises
• Locating suitable veins


  1. Place tourniquet, ask patient to close fist (avoid clenching or pumping)

  2. Veins located by sight and touch (palpation)
• Antecubital fossa veins


  • Least painful to puncture (less nerve endings)
  • Least likely to bruise

  
• Cephalic vein


  • Located in the thumb side
  • Second-choice vein
  • More difficult to locate
  • Fairly well anchored (tendency to move)
  • Often the only vein that can be felt in obese patients
  • Easily bruises
  • Possibility of blood spurt (close to the surface)

  
• Basilic vein


  • Located on the medial side (inner edge) of the antecubital fossa
  • Last-choice vein
  • Large and easy to feel
  • Least firmly anchored; rolls easily
  • Increases risk of puncturing median nerve and brachial artery
  • CLSI does not recommend the use of this vein (last resort)
  • Easily bruises (may form hematoma)

  
• Locating suitable veins


  1. Place tourniquet

  2. Ask patient to close fist (avoid clenching or pumping as it can increase blood potassium levels)
• Procedure for vein palpation

  1. Veins are located by sight and touch (palpation)

  2. Palpate and trace the path of veins (both vertical and horizontal motion) with the index finger of the non-dominant hand

  3. Veins feel spongy; resilient; tube/cord-like

  4. Arteries pulsate

  5. Do not use thumb to palpate veins (it has pulse)

  6. Patients have more prominent veins in the dominant arm

  7. If superficial veins are not readily apparent, can tap the site, apply a warm damp washcloth, or lower the extremity over the bedside to allow the veins to fill

  
• Cleansing the site


  1. Antiseptic of choice: 70% isopropyl alcohol (routine)

  2. Manner of Disinfection: Circular outward motion, widening concentric circle inside to outside

  3. Drying time: 30 seconds to 60 seconds (allows for maximum bacteriostatic action)
• Failure to completely air dry the site will cause painful, stinging sensation and hemolysis of sample
• Avoid recontamination of site: do not blow on the site, do not fan the area, do not dry the area with non-sterile gauze, do not touch the site again after disinfection
• For routine venipuncture, the antiseptic of choice is 70% isopropyl alcohol only. Never use iodine as it can affect the results of several tests. Povidone/Tincture of iodine is only used for blood culture collection and blood donation.
• Assembly of puncture equipment

  1. While alcohol is drying, make a final survey of the things needed

  2. Prepare the syringe (needle bore should be in line with the graduations in the barrel)

  3. Assemble the needle and the holder properly

  4. Examine defective and expired tubes; have extra tubes at hand
• Performing the venipuncture


  1. Reapplying tourniquet

  2. Confirm puncture site (if necessary, cleanse the gloved palpating finger for additional vein palpation)

  3. Examine the needle; position the needle "bevel-up"

  4. Anchoring the vein (use non-dominant thumb, can stretch skin if needed)

  5. Inserting needle (bevel up, 15 to 30 degree angle, smoothly)

  6. Filling the tubes (use thumb to push the tubes, index and middle fingers to grasp the flared ends of the holder, tourniquet and fist must be released in one minute time period or until the last tube is filled, tourniquet is removed first before removing the needle, tubes must be held in downward angle to prevent reflux, follow the correct CLSI order of draw, gentle inversion of tube once filled)
• Avoid vigorous mixing of samples as it may cause hemolysis. Poor mixing may cause clot formation and yield erroneous results. Allow tubes to fill until the vacuum is exhausted to ensure correct blood to anticoagulant ratio.
• Correct number of inversions

  • Red (glass): 0x
  • Light Blue: 3-4x
  • Red (plastic; with clot activator), Gold / Tiger Top: 5x
  • Light green, Green, Lavender, Pink, Gray, Tan Yellow, Orange, Royal Blue: 8x
• Removal of needle


  1. Remove tourniquet first before removing the needle

  2. Activate needle safety device if available

  3. Place gauze on venipuncture site

  4. Withdraw the needle in a smooth, swift motion

  5. Apply pressure to site as soon as needle is withdrawn (until bleeding has stopped, about 2-3 minutes)

  6. Arms must be in a raised, outstretched position (bending the elbow will allow blood to leak more easily to tissue and thus can cause hematoma)

  7. A capable patient can be asked to apply pressure to the site
• Upon completion of venipuncture, needles must be properly disposed in an acceptable sharps container. Under no circumstance should the needle be bent, cut, placed on bed or manually recapped.
• Labeling of tubes


  1. Post-collection

  2. Written label or computer-generated label (patient's name, ID number, date and time of collection, phlebotomist's initials)

  3. For inpatients, compare the label with the patient's arm band

  4. For outpatients, verify the name by showing tube label and asking the patient to confirm
• Bandaging the patient


  1. Check if bleeding has completely stopped before applying adhesives

  2. Paper tape can be used for those allergic to adhesives

  3. Instruct patient to remove bandage after an hour and avoid carrying heavy objects during that period