Blood Collection Routine Venipuncture

Nurse Aide crosstraining

2. List the required information on a requisition form.
Describe correct patient identification and
specimen labeling procedures.
Describe patient preparation and the variables
that can affect some laboratory tests.

3. Correctly assemble venipuncture equipment and
supplies.
Name and locate the three most frequently used veins
for venipuncture, and describe when these sites would
be unacceptable.
Correctly apply a tourniquet and state why the tourniquet
can be applied for only 1 minute.

4. List four methods used to locate veins that are not
prominent.
Describe the different antiseptics used to cleanse the
venipuncture site.
State the steps in a venipuncture procedure, and
correctly perform a routine venipuncture using an
evacuated tube system.

5. Demonstrate safe disposal of contaminated
needles and supplies.
Deliver specimens to the laboratory in a timely
manner.

6. Recommended step-by-step venipuncture
procedure
Possible complications

8. Purpose
◦Patient identification
◦Organization of
equipment
◦Collection of
appropriate
specimens

10. Name
Identification number
Accession number
Location
Health-care provider’s name
Test requested
Date and time of collection

11. Patient’s date of birth
Special collection information
Special patient information
Numbers and type of collection tubes
Status of specimen

12. Introduce yourself
◦Begin communication process
◦Look and listen
 Explain purpose of visit
◦Informed consent
◦Patient has the right to refuse–Patient Bill of Rights
Guilty of assault if patient has the perception that blood collector is
ignoring his or her refusal
 Wake a sleeping patient
 Greet unconscious patients

13. THIS IS THE MOST
IMPORTANT STEP !
Written protocol
◦Hospital inpatients
◦Outpatients
Two identifiers

14. Primary identifier
Always compare with the
requisition
Must be worn by the patient
◦Wrist of older children and
adults
◦Ankles of newborns
Do not trust room and bed
signs

15. Second identifier
◦Have the patient state full name
◦CLSI requirement

16. Primary identifier
◦Have the patient state full name
Secondary identifier
◦Ask additional information
Date of birth
Spell name
Compare unique data with the requisition form

17. CLSI requires a caregiver or family member to
provide information on patient’s behalf if patient is
unable to before drawing specimen
Document the name of the verifier
Drug testing might require photo ID

18. Unidentified patients
◦Tagged with temporary number
◦Tentative name
Commercial blood bank system
◦ Place additional stickers from ID band on:
Specimen
Requisition form
Units of blood

19. Reassure the patient
Explain procedure
◦Do not explain the purpose of the test!
Do not say procedure is painless!
Alert patient to every step of the procedure
Remind patient to hold still

20. Basal state
◦Preferred state
Fasting
Activities
◦Medications
A variety of both prescription and over-the-counter
medications can influence lab test results

23. Site is convenient and
supported
◦Place pillow under arm
◦Place fist under elbow
◦Place arm at downward angle
to prevent reflux
Safety
◦Patient is sitting or lying down
◦Remove objects from patient’s
mouth
◦Be alert for syncope

25. Place all supplies close to patient
◦Collection equipment
◦Antiseptic pads
◦Gauze
◦Bandage
◦Needle disposal system
◦Examination requisition
form
Number and type of tubes
Extra tubes in case of loss of vacuum

26. Wash hands between patients
Change gloves between patients

27. Vein location
Increase amount of available blood

28. Locate tourniquet 3 to 4 inches above site
Avoid or cover arms with skin conditions
Avoid arms on the side of a mastectomy
Do not use a tourniquet for lactate test

29. Maximum time is 1 minute
Apply for site selection
Release for 2 minutes
Reapply
Release when blood flows
Prolonged tourniquet application
◦Causes hemoconcentration
Increase in the ratio of certain analytes to plasma
Biochemical changes take place in the trapped blood

30. Other causes
◦Excessive squeezing
◦Probing a site
◦Long-term IV therapy
◦Sclerosed or occluded veins
◦Vigorous fist clenching
Increases cellular elements

31. ◦Uncomfortable for patient
◦Obstruct blood flow
◦No radial pulse
◦Appearance of petechiae

32. Major vein
Preferred site is antecubital fossa area

33. Vein of choice
◦Large, well anchored
◦Closer to surface
◦More isolated from
other structures
◦Least painful–fewer
nerve endings

34. ◦Located on thumb side
of arm
◦Second site of choice
◦Close to the surface
Use lower angle of needle
insertion (15°)
Possible blood spurt
◦May be prominent in
larger patients

35. ◦Located on the underside of the
arm
◦Third choice for venipuncture
(H3-A6 recommends using only
as a last resort)
Least firmly anchored (vein may
“roll”)
Near brachial artery and median
nerve
Hematoma formation more likely
Consider using a syringe for
more control

36. Apply tourniquet 3 to 4 inches above venipuncture
site
Have patient form a fist
◦Do not pump fist
Causes hemoconcentration
Only acceptable for blood donations

37. ◦Feeling is more important
than sight
◦Probe with index finger,
thumb has a pulse
◦Push, don’t stroke
◦Determine: size, depth,
direction
◦Remember: veins are
spongy, tendons are rigid,
arteries have a pulse

38. Check both arms
Listen to patient’s suggestions of
previously successful areas

39. Massage the arm upward from the
wrist
Briefly hang the arm down
Apply heat
Transilluminator device

40. Wrists and hands
◦Apply tourniquet to forearm
◦Consider a smaller needle, syringe, winged blood
collection set
H3-A6 states to avoid veins from the underside of
the wrist
◦Possibility of puncturing the radial or ulnar nerve or artery
Can cause permanent nerve
damage and inability to open and close
the hand

41. Require physician approval
More susceptible to infection and thrombi
Avoid in patients with diabetes, cardiac
problems, coagulation disorders

42. Occluded veins
◦Thrombi
◦Multiple punctures
◦Feel hard
◦Impaired circulation
Hematomas
◦Do not puncture hematoma, noncirculation of blood
◦Draw below hematoma
◦Use other arm
Areas with edema
Areas with extensive burns, scars or tattoos
◦More susceptible to infection
◦Decreased circulation
◦Difficult to palpate

43. Mastectomies
◦Lymphostasis
Increased lymphocytes
Increased waste products
◦Patient danger
Lymphedema
Infection
Double Mastectomies
◦Consult physician
◦Possibly perform fingerstick
Never obtain blood from a finger on the side affected by a mastectomy
(CLSI H$A6) without physician-written permission

44. IV Fluids
◦Ideally use other arm
◦Avoid sites of previous IVs for 24–48 hours
◦Note same arm collection on requisition
◦Select site below infusion site, caregiver turns off IV for 2 minutes
◦Preferably use a different vein
◦Avoid drawing blood at the same time dye for radiological procedure
or blood components are being infused

45. Fistulas
◦Renal dialysis patients
◦Permanent artery-vein connection
◦Must avoid this arm
◦Possibility of infection

46. Cannula
◦Temporary (external) AV shunt
◦T-tube connector with diaphragm
◦Only specially trained personnel can
draw from a cannula

47. Turn off IV for at least 2 minutes
◦Discard first 5 mL blood
◦Collect specimen in a new syringe
◦Coagulation tests, discard 10 mL
Second 5 mL can be used for other tests
Document the type of IV fluid and location on
requisition

49. Apply 70% isopropyl alcohol
using a circular motion cleanse
from inside to outside
Allow to air dry, 30–60 seconds
will give maximum bacteriostatic
action
Avoid wiping off with gauze
Failure to let alcohol dry causes a
stinging sensation for patient
Specimen hemolysis

50. Blood cultures or arterial blood gases
◦Povidone-iodine
◦Tincture of iodine
◦Chlorhexidine gluconate
Blood Alcohol Collection
◦Do not cleanse site with alcohol
◦Soap and water are recommended
◦Iodine or benzalkonium chloride (Zephiran
Chloride) may be acceptable

51. Perform while alcohol is drying
Screw the stopper-puncturing end of
needle into the holder
Insert first collection tube into the
holder
Advance tube only to mark on holder

52. Perform immediately before puncture
◦Blunt end
◦Barbed point

53. Reapply tourniquet
Confirm puncture site
Cleanse gloved palpating finger if
necessary
Place holder in dominant hand
Place thumb on top, fingers underneath
After insertion, fingers can be braced on patient’s
arm

55. Place thumb of nondominant
hand 1–2 inches below site
Place fingers on back of arm
Do not anchor above and
below site with thumb and
index finger
◦Possible accidental self-puncture

57. Bevel up
15-to-30 degree angle
Resistance lessens
when the needle
enters the vein

58. Nondominant hand
can be used after
vein is entered
Use flared ends of
holder

59. Brace the hand
holding the holder
against the patient’s
arm
Gently twist tubes
on and off the
needle

60. Mix tubes as they are removed from
the holder needle
◦Can be done before next tube is inserted
Remove and mix the last tube before
removing the needle from the vein
◦Blood will drip from the needle

61. Remove the tourniquet if still
applied
Failure to remove can cause a
hematoma
Patient may relax fist
Withdraw needle and apply
pressure to gauze at the same
time

62. Capable patients can apply pressure
using digital pressure
Arm is raised and outstretched
◦Do not bend the elbow
Collector must apply pressure if necessary

63. Immediately activate
needle safety device
Dispose in a
conveniently located
sharps container
NEVER BEND, CUT,
OR RECAP NEEDLE

64. Label tube before leaving the
patient
Less chance of tubes being
mixed up
Use a pen
Confirm information on
preprinted labels
Verify correct labeling with the
patient (CLSI H3-A6)

65. Patient’s name and ID number
Date and time of collection
Collector’s initials
Additional information
◦Blood bank identification

66. Check arm before bandaging
H3-A6 states collector must
observe for hematoma formation
before applying bandage
Apply hypoallergenic bandage
over gauze for extra pressure
Self-adhering material
Patient’s instructions
Avoid carrying heavy objects
Remove bandage within 1 hour

67. Pressure must be applied until bleeding stops
◦Patients on anticoagulants/aspirin/herb therapy
Accidental arterial puncture
◦Collector must apply pressure for 5 minutes or until bleeding has
stopped
◦Notify nursing staff and physician
Allergy to adhesive
◦Avoid use in children under 2 years old

68. Place in biohazard containers
Remove gloves
Wash hands

69. Return patient’s bed to original position
Replace bedrails

70. Use designated biohazard
bags/containers

71. Observe any special handling procedures
Deliver as soon as possible
◦No longer than 45 minutes
Transport in an upright position
◦Facilitate clotting
◦Prevent hemolysis
Complete all required paperwork

72. Separate serum and plasma from the cells
within 2 hours of collection
oHemolysis severely affects potassium values
oCellular metabolism decreases glucose levels

73. Coagulation specimens for a PTT can remain
at RT for 4 hours; if patient is on unfractionated
heparin, the plasma must be removed from the
cells within 1 hour, test within 4
PT are stable for 24 hours at RT
Blood smears from EDTA tubes should be
made within 1 hour of collection.
Specimen can be refrigerated for up to 4 hours