What do we already know?
• Standard Precautions
– “All specimens should be treated as if they are
hazardous and infectious.” p. 326 Phillips
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Asepsis
Anatomy of a vein
Circulation physiology
SNS “fright or flight”
Therapeutic communication
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Use of a Tourniquet: Tension
• Purpose: impede venous flow to heart
• Wider : less likely to impede arterial flow
• Use tighter tension:
– Hypotensive (hypovolemia)
– Obese
• Lighter tension:
– Elderly
– Veins easily seen & palpated
• Use of BP cuff: just below diastolic
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Use of a Tourniquet: Duration
• No more than 1 minute at a time
– IV start: Shunting of blood to collateral circulation
– Phlebotomy: hemoconcentration; falsely high
values for protein-based analysis.
• Release & reapply after 2 min.
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Use of a Tourniquet: Position
• Phlebotomy: 3-4 inches above collection site
• IV: 5-6 inches above insertion site
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Evaluating Veins
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Round, firm elastic, engorged
NOT: hard, bumpy or flat
Valves
Don’t keep tourniquet on too long
Alternate: BP cuff to 30-40 mm Hg
Anxiety, cold, hypotensive: veins will
disappear.
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Avoid…
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Fistula &/or vascular graft
Mastectomy side
Hematoma
Drawing above an IV site (phlebotomy)
Healed burn areas
Skin inflammation, disease, bruising, or
breakdown
• Sclerosed or thrombosed veins
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Order of draws
• To prevent specimen contamination with
tube additives
• Blood culture tubes (yellow top)
• Plain tubes: non-additives (red)
• Coagulation tubes
• Additive tubes
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Filling Multiple Tubes
• Fill tube until vacuum is exhausted
• Carefully remove tube and fill additional
tubes in proper order
• Invert tubes as they are filled
• As final tube is filling……….
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The Butterfly Needle
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Special Situations
• Patient has IV
• Timing of peak and trough levels
– peak 1.5-2 hrs. after dose completed
– trough just before dose
• Blood alcohol levels - legal issues and
“chain of custody”
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Specimen Integrity and Pre-Analytic Errors
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Patient Identification
Hemolysis
Hemoconcentration
Correct Tube, Correct Order of draw
Mixing
Labeling
Specimen contamination
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Complications
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Allergies to antiseptic
Pain
Anxiety/fainting
Hematoma
Infection of site
Vein or nerve damage
Arterial puncture
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General considerations
• Start low
– Nondominant arm if possible
• Palm side of wrist only if necessary
• Legs, feet, ankles – only w/MD order
• Dorsum of hand: avoid abx, KCL, vesicant
agents
• Antecubital – nice large vein – avoid for
routine use
• Forearm – good sites for IV
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Selecting a Vein
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Patient’s medical history
Age, size, general condition
Condition of veins
Type of solution
Condition of vein
Duration of therapy
Cannula size
Patient activity
Patients receiving anticoagulation therapy
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When starting an IV, Avoid Veins…
• Below a previous I.V. infiltration
• Below a phlebotic area
• Previously areas listed earlier
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Fistula &/or vascular graft
Mastectomy side
Hematoma
Healed burn areas
Skin inflammation, disease, bruising, or breakdown
Sclerosed or thrombosed veins
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Site preparation
• Do not shave; clipping OK
• Solutions
– Chlorhexidine gluconate (recommended)
– Iodophor (povidone-iodine)
– 70% isopropyl alcohol
• 15 – 20 seconds
• If allergic to prep solution use 70% alcohol for
30 seconds
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Taping
• INS: sterile tape under transparent dressing.
• No tape directly on transparent dressing
• Gauze under hub to stabilize prn
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Educate patient
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Limitations on movement or mobility
Explain all alarms if EID used
Instruct to call for assistance
Report redness, tenderness, or swelling
Inform that site will be checked by
nurse frequently
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Complications - systemic
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Septicemia
Fluid overload & pulmonary edema
Air embolism
Catheter embolism
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Systemic Complication: Septicemia
Cause
• Febrile disease:
microorganisms and
their toxic products
introduced into the
circulatory system
• Health careassociated intravascular
device-related
bloodstream infection is
associated with 12% –
28% mortality rate
Signs and symptoms
• Fluctuating fever,
tremors, chattering
teeth
• Profuse, cold sweat
• Nausea and vomiting
• Diarrhea
• Abdominal pain
• Tachycardia
• Increased respirations
• Evidence of decreased
perfusion
• Elevated WBC
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Systemic Complication: Septicemia
Prevention
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Good hand hygiene
Carefully inspecting IV solutions
Use of only freshly opened solutions
Use of 2% chlorhexidine with alcohol
Implement central line bundles
Use of Luer-Lok connections
Cover infusion sites with sterile dressing
Limit use of add-on devices
Change peripheral cannula after 72 –96 hours
Staff education
Remove peripheral cannula at first sign of inflammation
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