ROUTINE
VENIPUNCTURE
Shaira Mae Cuevillas, RMT
TOPUC OUTLINE
1. Requisition
2. Greeting the patient
3. Patient’s identification
4. Patient preparation
5. Equipment Selection
6. Handwashing/Sanitizing and application of Gloves
7. Tourniquet application
8. Site application
9. Cleansing the site
10. Assembly of puncture equipment
11. Performing Venipuncture
1. REQUISITION
• All phlebotomy procedures begin with the
receipt of a test requisition form that is
generated by or at the request of a health-care
provider.
• Requisition form part of the patient’s medical
record.
• Importance: Provides the phlebotomist the
essential information to:
a)
correctly identify the patient
b)
organize the necessary
equipment
c)
collect the appropriate samples
d)
provide legal protection
1. REQUISITION
• Phlebotomists should
not collect a sample
without a requisition
form, and this form must
accompany the sample to
the laboratory.
• Multiple copies of
requisition form is usually
made (copy of the patient,
phlebotomist/laboratory,
record-keeping for inpatients, and billing)
Basic information contained in a requisition form:
1. Patient’s name (First, Middle or M.I, and Last name)
2. Identification number (hospital
generated/laboratory assigned number)
3. Patient’s Birthdate
4. Patient’s location/address
5. Ordering health-care provider’s name
6. Tests requested
7. Requested date and time of sample collection
8. Status of sample (Stat/timed/routine)
9. Other information that may be present (Sample
collection info, Special patient information)
10.Billing information
1. REQUISITION
• Always review the requisition form before
leaving the laboratory:
a) Patient’s details
b) Tests to be collected
c) Time and date of collection
d) Any special conditions (ex: fasting)
• When the sample is collected, the
phlebotomist must write the actual date and
time on the requisition and the sample
label.
• Phlebotomists should never collect samples
before receiving or generating the
requisition form.
2. GREETING THE PATIENT
• Establishes confidence and trust in the patient which
can effectively ease patient’s apprehension about the
procedure.
• If In-patient – Politely and lightly knock on the open or
closed door
• Approach the patient:
a) Introduce yourself
b) Explain that there will be a blood collection
as requested by his/her health-care provider
(IN patient)
c) Explain the procedure in nontechnical terms
• Patient’s consent may be in the form of express and
implied (verbal or non-verbal)
• The more relaxed and trusting your patient, the
greater chance of
a successful atraumatic
venipuncture.
• Observe any signs on the patient’s door.
3. PATIENT IDENTIFICATION
• The most important procedure in phlebotomy is
correct identification of the patient.
• Serious diagnostic or treatment errors and even
death can occur when blood is drawn from the
wrong patient.
• Minimum of two identifiers are required
• Verify identification by comparing the information
verbally obtained from the patient, the patient’s
Wrist ID band, and requisition form.
• Representatives or family member must provide
information on a cognitively impaired patient’s
behalf before collecting the sample. Document the
name of the verifier.
3. PATIENT IDENTIFICATION
IN PATIENT
• Always have patients state their names. Do not ask.
• After verbal identification examine the information on
the patient’s wrist ID band, which should always be
present on hospitalized patients.
• Discrepancies between the patient’s ID band the
requisition must be verified before blood is drawn
OUT PATIENT
• Ask the patient to state his or her full name, address,
birth date, and/or unique identification number after
calling him or her back to the drawing area.
• Compare the verbal information with the requisition
form to verify the patient’s identification
• Photo identification may be a requirement for certain
legal tests.
4. PATIENT PREPARATION
• Phlebotomists should demonstrate both concern for the patient’s comfort and
confidence in their own ability to perform the procedure.
• They should not be told that the procedure will be painless.
• Patients often question the phlebotomist about what tests are being
performed or why their blood is being drawn so frequently. The best policy is
to politely suggest that they ask their health-care provider these
questions.
• Verify if the patient has complied with appropriate pretest preparations
such as fasting or abstaining from medications. If not complied, should be
reported to the nurse before drawing the blood. If the sample is still
required, the irregular condition, such as “not fasting,” should be written on
the requisition form and the sample.
• Ask patient if he or she has latex allergy.
4. PATIENT PREPARATION
A. POSITIONING THE PATIENT
• The patient must be positioned conveniently and safely.
• Blood should never be drawn from a patient who is in a
standing position. Outpatients are seated or reclined at a
drawing station.
• The patient’s arm should be firmly supported and extended
downward in a straight line, allowing the tubes to fill from the
bottom up to prevent reflux and anticoagulant carryover
between tubes.
• Asking the patient to make a fist with the hand of the arm
not being used and placing it behind the elbow will provide
support and make the vein easier to locate
• Observe and be alert for sudden change in the patient’s
condition (ex: fainting, hyperventilation)
• When supporting the patient’s arm, do not hyperextend the
elbow. This may make vein palpation difficult. Sometimes
bending the elbow very slightly may aid in vein palpation.
5. EQUIPMENT SELECTION
• Collect all necessary supplies upon examining the
requisition form
• Blood collection tray should not be placed on the
bed or on the patient’s eating table. Place supplies
on the same side as your free hand during blood
collection to avoid reaching across the patient and
causing unnecessary movement of the needle in the
patient’s vein.
• Choose the appropriate blood collection system:
ETS, Syringe method, or winged blood collection
set) and the number and type of collection tubes
taking into consideration age of the patient and the
amount to be collected.
• Perform quality control: check expiration of tubes
and quality of needles.
6. WASH HANDS AND APPLY GLOVES
• In front of the patient, the phlebotomist should wash his or
her hands using the procedure.
• OSHA regulations mandate that gloves be worn when
performing a venipuncture procedure.
• Patients are often reassured that proper safety measures are
being followed when gloves are donned in their presence.
7. TOURNIQUET APPLICATION
Two Functions:
a) By impeding venous, but not arterial,
blood flow, the tourniquet causes blood to
accumulate in the veins making them more
easily located
b) provides a larger amount of blood for
collection
• The use of disposable one-time use tourniquets
is advised, although not required, as part of
good infection control practice to avoid healthcare acquired infections (HAIs) for patients.
7. TOURNIQUET APPLICATION
Maximum period
• the tourniquet should remain in a patient’s arms is 1 minute.
• This requires This requires that the tourniquet be applied twice during the
venipuncture procedure:
a) First when vein selection is being made and
**(CLSI recommends 2 minutes gap before reapplication)
a) Second, immediately before the puncture is performed.
Reason:
• Use of a tourniquet can alter some test results by increasing the ratio of
cellular elements to plasma (hemoconcentration)and by causing
hemolysis
7. TOURNIQUET APPLICATION
• It must be placed on the arm 3 to 4 inches
above the venipuncture site.
• Reason: A tourniquet applied too close to the
venipuncture site may cause the vein to
collapse.
• Too tight application indicators:
a) Uncomfortable for the patient
b) Obstruct blood flow to the area
c) Appearance of Petechiae (small, red-dish
discoloration) on the patient’s arms
d) Blanching of the skin around the tourniquet
7. TOURNIQUET APPLICATION
7. TOURNIQUET APPLICATION
7. TOURNIQUET APPLICATION
8. SITE SELECTION
• The preferred site for
venipuncture is the antecubital
fossa located anterior and
below the bend of the elbow
where the three major veins are
located:
a) Median cubital
b) Cephalic
c) Basilic
8. SITE SELECTION
• Vein patterns vary among individuals.
The most often seen arrangement of
veins in the antecubital fossa are:
• “H-shaped” pattern - includes the:
a) Cephalic
b) Median cubital
c) Basilic veins
“M-shaped” pattern – most prominent
veins are:
a) Cephalic
b) Median cephalic
c) Median basilic
d) Basilic veins.
8. SITE SELECTION
MEDIAN CUBITAL VEIN
•
•
•
•
Vein of choice because it is large
and does not tend to move when
the needle is inserted
It is often closer to the surface of
the skin, more isolated from
underlying structures.
the least painful to puncture as
there are fewer nerve endings in
this area.
According to the CLSI standard,
an attempt must have been made
to locate the median cubital vein
on both arms before considering
other vein
CEPHALIC VEIN
•
•
•
•
located on the thumb side of the
arm is usually more difficult to
locate, except possibly in larger
patients.
Has more tendencies to move.
The cephalic vein should be the
second choice if the median
cubital is inaccessible in both arms.
Because the cephalic vein is closer
to the surface, there is the
possibility of a blood spurt when
the needle is inserted in to the vein.
This often is controlled by
decreasing the angle of needle
insertion to 15 degrees
BASILIC VEIN
•
•
•
•
•
located on the inner edge of the
antecubital fossa near the median
nerve and brachial artery.
The basilic vein is the least firmly
anchored; therefore, it tends to
“roll” and hematoma formation is
more likely.
It is the last choice because of
median nerve and brachial artery
are in close proximity to it,
increasing the risk of permanent
injury.
Care must be taken not to
accidentally puncture the brachial
artery.
Use of the basilic vein is
discouraged; however, if
necessary, the CLSI standard
recommends locating the brachial
pulse before accessing the basilic
vein.
“H-SHAPED” PATTERN
CEPHALIC
MEDIAN CUBITAL
BASILIC
8. SITE SELECTION
• Small prominent veins are also
located in the back of the hand.
• When necessary, these veins can be
used for venipuncture, but they
may require a smaller needle or
winged blood collection.
• The veins of the lower arm and hand
are also the preferred site for
administering IV fluids because
they allow the patient more arm
flexibility.
8. SITE SELECTION
TWO ROUTINE STEPS IN LOCATING A VEIN:
1. Apply a tourniquet and;
2. Ask the patient to clench his or her fist
**But not continuous clenching or pumping
of the fist because this will result in
hemoconcentration and alter some test
results such as increased potassium levels.
METHOD OF LOCATING A VEIN
• PALPATATION – locating a vein by sight and by touch.
• Palpation is usually performed using the tip of the index finger of the
nondominant hand to probe the antecubital area with a pushing motion rather
than a stroking motion. Feel for the vein in both a vertical and horizontal
direction.
• The thumb should not be used to palpate because it has a pulse beat.
8. SITE SELECTION
• Pressure applied by palpitating:
a) Locates deep veins
b) Distinguishes veins from rigid tendon cords - Veins feel
like spongy, resilient, tube-like structures.
c) Distinguished veins from arteries – Veins are without a
pulse.
• Once an acceptable vein is located, palpation is used to
determine the direction and depth of the vein to aid the
phlebotomist during needle insertion
9. CLEANSING THE SITE
• When an appropriate vein has been located, the
tourniquet is released and the area cleansed
using a 70 percent isopropyl alcohol prep pad to
prevent bacterial contamination of either the
patient or the sample.
HOW:
• Cleansing is performed with a circular motion,
starting at the inside of the venipuncture site
and working outward in widening concentric
circles about 2 to 3 inches.
• Repeat this procedure using a new alcohol pad for
particularly dirty skin.
9. CLEANSING THE SITE
• For maximum bacteriostatic action to
occur, the alcohol should be allowed to
dry for 30 to 60 seconds on the
patient’s arm rather than being wiped off
with a gauze pad.
• Performing a venipuncture before the alcohol has dried will cause a
stinging sensation for the patient and may hemolyze the sample.
• Do not reintroduce microbial contaminants by blowing on the site,
fanning the area, or drying the area with nonsterile gauze.
10. ASSMEBLY OF PUNCTURE EQUIPMENT
• While the alcohol is drying, the phlebotomist can make a final
survey of the supplies at hand.
• Place assembled venipuncture equipment within easy reach;
however, do not place the collection tray on the patient’s bed.
• Visual examination cannot detect defective evacuated tubes;
therefore, extra tubes should be near at hand.
11. PERFORMING THE VENIPUNCTURE
1)
Reapply the tourniquet, and confirm the puncture
site. If necessary, cleanse the gloved palpating finger
for additional vein palpation. Again, ask the patient to
make a fist.
2)
Position the needle for entry into the vein with bevel
facing up
3)
Anchor the vein by the thumb of the non-dominant
hand to anchor the selected vein while inserting the
needle. Place the thumb 1 or 2 inches below and
slightly to the left of the insertion site and the four
fingers on the back of the arm and pull the skin taut.
This will keep the skin tight and will help prevent the
vein from slipping to the side when the needle enters.
11. PERFORMING THE VENIPUNCTURE
NOTE:
• “ROLLING VEINS” = a vein that moves
the side, improper anchor.
• the median cubital vein is the easiest
to anchor and the basilic vein the most
difficult. In general, the closer a vein is to
the surface, the more likely it is to roll
• Anchoring the vein above and below
the site using the thumb and index
finger is not an acceptable technique,
because sudden patient movement
could cause the index finger to be
punctured
11. PERFORMING THE VENIPUNCTURE
4.
Tell the patient that “there will be a little
stick” before needle insertion to alert the
patient to hold very still.
5.
Align the needle with the vein and insert it
bevel up at an angle of 15-30 degrees
depending on the depth of the vein. This
should be done in a smooth movement so
the patient feels the stick only briefly.
Entering the vein too slowly is more painful
for the patient and may cause a spurt of
blood to appear at the venipuncture site.
6.
The phlebotomist will notice a feeling of
lessening of resistance to the needle
movement when the vein has been
entered
11. PERFORMING THE VENIPUNCTURE
7. After insertion is made, the fingers are braced against the patient’s arm
to provide stability while tubes are being changed in the holder, or the
plunger of the syringe is being pulled back.
8. Fill the tubes or pull the plunger if syringe method. Be careful not to pull
up or press down the needle while it is in the vein can cause pain to the
patient or a hematoma formation if blood leaks from the enlarged hole.
9. Before removing the needle, remove the tourniquet by pulling on the free
end and tell the patient to relax his or her hand. Failure to remove the
tourniquet before removing the needle may produce a bruise
(hematoma)
10.Place folded gauze over the venipuncture site and withdraw the needle
carefully and swiftly.
11. PERFORMING THE VENIPUNCTURE
11. Apply pressure to the site as soon as the needle is
withdrawn.
NOTES:
• To prevent blood from leaking into the surrounding
tissue and producing a hematoma, pressure must
be applied until the bleeding has stopped, usually
about 2 to 3 minutes.
• The arm should be held in a raised, outstretched
position.
• Bending the elbow to apply pressure allows blood
to leak more easily into the tissue, causing a
hematoma.
11. PERFORMING THE VENIPUNCTURE
12. Dispose the needle to the proper disposal
container.
13. Label the tubes. It must be done after the sample
has been collected to prevent confusion of samples.
The label must include the following:
a) Patient’s name and Identification number
b) Date and time of collection
c)
Phlebotomist’s Initial
14. Compare the label written to the requisition form
and to the patients’ ID band for in patients. For
outpatient, verify the tube the patient and verbally
asking the patient to confirm the name on the label.
11. PERFORMING THE VENIPUNCTURE
15) Bleeding at the venipuncture site should stop
within 5 minutes. Before applying the adhesive
bandage, the phlebotomist should examine the
patient’s arm to be sure the bleeding has stopped.
The practice of quickly applying tape over the gauze
without checking the puncture site frequently
produces a hematoma.
16) Put the bandage and the patient should be
instructed to remove the bandage within an hour
and to avoid using the arm to carry heavy objects
during that period
17) Dispose the used supplies in proper disposal
containers and wash hands.
11. PERFORMING THE VENIPUNCTURE
18)For inpatient, return them to their original position if they
have been moved. For outpatient, they can leave if the tubes
are labeled and the puncture site has been checked. Give
further instructions needed.
19)Check the specimen and execute proper and special
specimen handling. Enter in the logbook and time stamp in the
requisition form. Inform the nurse that the procedure has been
completed.
20)CLSI recommends centrifugation of clotted tubes and
anticoagulated tubes and separation of the serum or plasma
from the cells within 2 hours.