Chapter 9 Routine Venipuncture. Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Learning Objectives List the information.

Chapter 9Chapter 9

Routine VenipunctureRoutine Venipuncture

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

Learning ObjectivesLearning Objectives

List the information that is commonly found List the information that is commonly found on a test requisition.on a test requisition.

List in order the steps in a routine List in order the steps in a routine venipuncture.venipuncture.

Discuss the information that must be verified Discuss the information that must be verified for inpatient identification before the blood for inpatient identification before the blood collection procedure.collection procedure.



Explain how the identification of outpatients Explain how the identification of outpatients differs from that of inpatients.differs from that of inpatients.

Describe the patient preparation and Describe the patient preparation and positioning.positioning.

Describe how to assemble the evacuated Describe how to assemble the evacuated tube system.tube system.

Explain how to apply a tourniquet and list Explain how to apply a tourniquet and list three consequences of improper application.three consequences of improper application.



List the veins that may be used for blood List the veins that may be used for blood collection, including the advantages and collection, including the advantages and disadvantages of each.disadvantages of each.

Explain how to clean the venipuncture site.Explain how to clean the venipuncture site. Describe how to properly insert the needle Describe how to properly insert the needle

into the vein.into the vein. Discuss how the needle should be removed Discuss how the needle should be removed

when the last tube of blood has been when the last tube of blood has been collected.collected.



List the information that must be included on List the information that must be included on the label of each tube.the label of each tube.

Describe how venipuncture using a syringe Describe how venipuncture using a syringe differs from that of using the evacuated tube differs from that of using the evacuated tube system.system.


Test RequisitionsTest Requisitions

A requisition (order) is used to determine A requisition (order) is used to determine what type of sample to collect from patient.what type of sample to collect from patient.

Minimum information on a requisition:Minimum information on a requisition: Patient full name, date of birth, sex, race.Patient full name, date of birth, sex, race. - For inpatients – hospital ID number, room, - For inpatients – hospital ID number, room,

bed number. bed number.

- Tests requested with ICD-9 code.- Tests requested with ICD-9 code.

- Test status – stat, timed, fasting.- Test status – stat, timed, fasting.



Purpose of the requisition:Purpose of the requisition:

1 - 1 - Allows you to identify the patient correctly.Allows you to identify the patient correctly.

2 - 2 - Tells you what specimen should be Tells you what specimen should be collected.collected.

3 - 3 - Allows you to gather your equipment Allows you to gather your equipment before you encounter the patient.before you encounter the patient.



When you receive a test requisition:When you receive a test requisition: - - Examine it to make sure it has the Examine it to make sure it has the required required information: full name, DOB, information: full name, DOB, ordering physician, and test ICD-9 codes.ordering physician, and test ICD-9 codes. - - Check for duplicates.Check for duplicates. - - Prioritize the requisitions (stat first).Prioritize the requisitions (stat first). - - Collect all the equipment you will need Collect all the equipment you will need for for the tests that you are collecting.the tests that you are collecting.



1. Greet and identify the patient 1. Greet and identify the patient - Knock before entering the room; - Knock before entering the room;

announce yourself if there is a curtain.announce yourself if there is a curtain. - Let the patient know that the physician - Let the patient know that the physician

has ordered a test but give no other has ordered a test but give no other information.information.

- Positive patient identification is the single - Positive patient identification is the single most important step in phlebotomy.most important step in phlebotomy.

- Ask the patient to state his or her full - Ask the patient to state his or her full name.name.



- Check the requisition information against what - Check the requisition information against what the patient has told you. Match the name and the patient has told you. Match the name and the hospital ID number which will be unique to the hospital ID number which will be unique to that patient. The armband must be attached that patient. The armband must be attached to the patient. Do not draw the patient until an to the patient. Do not draw the patient until an armband has been placed on the patient’s armband has been placed on the patient’s arm or ankle.arm or ankle.

- Outpatients do not have armbands, so ask the - Outpatients do not have armbands, so ask the patient to state his name and date of birth. patient to state his name and date of birth. Compare that information with the requisition.Compare that information with the requisition.



- Ask the patient if he is taking any - Ask the patient if he is taking any medication. Patients on blood thinners medication. Patients on blood thinners may may require extra pressure post puncture.require extra pressure post puncture.

2. Position and prepare the patient.2. Position and prepare the patient. - Never draw blood from a standing patient.- Never draw blood from a standing patient. - Seat outpatients in a phlebotomy chair - Seat outpatients in a phlebotomy chair

with arm support.with arm support. - For inpatients return bed railings to the - For inpatients return bed railings to the

same position in which you found them.same position in which you found them.



- All foreign objects should be - All foreign objects should be removed from the patient’s removed from the patient’s mouth to avoid choking.mouth to avoid choking.

- Explain the procedure and get - Explain the procedure and get verbal consent before verbal consent before proceeding with blood draw.proceeding with blood draw.

- Verify pretest fasting by asking - Verify pretest fasting by asking the patient when was the last the patient when was the last time he or she had anything to time he or she had anything to eat or drink except water.eat or drink except water.



3. Assemble your equipment in front of the 3. Assemble your equipment in front of the patient.patient.



4. Apply the tourniquet about 3-4 inches above the puncture site.4. Apply the tourniquet about 3-4 inches above the puncture site.

- Form an X and then tuck from the top.- Form an X and then tuck from the top.

- The tourniquet should not be on the arm - The tourniquet should not be on the arm for longer than one for longer than one minute.minute.



- Improper tourniquet application can cause:- Improper tourniquet application can cause:

* Hemoconcentration – an increase in the * Hemoconcentration – an increase in the ratio of formed elements to plasma.ratio of formed elements to plasma.

* Hemolysis – destruction of RBCs.* Hemolysis – destruction of RBCs.

- Both hemoconcentration and hemolysis can - Both hemoconcentration and hemolysis can cause test results to be altered.cause test results to be altered.

* Petechiae – small red spots on the skin * Petechiae – small red spots on the skin

caused by blood leaking into the epithelial.caused by blood leaking into the epithelial.



5. Select the site.5. Select the site.- - Median cubital vein, well Median cubital vein, well

anchored, is the first choice in the anchored, is the first choice in the antecubital fossa.antecubital fossa.

- - The cephalic vein, on the thumb The cephalic vein, on the thumb side of the arm, is the second side of the arm, is the second choice.choice.

- - The basilic vein, on the little finger The basilic vein, on the little finger side of the arm, is the third choice. side of the arm, is the third choice. You may puncture the brachial You may puncture the brachial artery if the needle goes too deep.artery if the needle goes too deep.



6. Palpate the vein.6. Palpate the vein. - Touch the vein gently pushing - Touch the vein gently pushing

up and down to feel for the up and down to feel for the bouncy vein.bouncy vein.

- Determine the depth, diameter - Determine the depth, diameter and direction of the vein.and direction of the vein.

- If you have difficulty finding the - If you have difficulty finding the vein, have the patient make a vein, have the patient make a fist, gently massage the arm fist, gently massage the arm or use a warm towel over the or use a warm towel over the area.area.



7. Clean the site with 70% isopropyl alcohol, 7. Clean the site with 70% isopropyl alcohol, in concentric circles, working in to out.in concentric circles, working in to out. - Allow the site to air dry for bacteriostatic - Allow the site to air dry for bacteriostatic

action.action. 8. Reapply the tourniquet if it was removed 8. Reapply the tourniquet if it was removed

during the cleansing process.during the cleansing process. 9. Remove the needle cap and examine the 9. Remove the needle cap and examine the

needle tip for any defects.needle tip for any defects.



10. Perform the venipuncture 10. Perform the venipuncture using the thumb of your using the thumb of your nondominant hand to nondominant hand to anchor the vein below the anchor the vein below the puncture site.puncture site.

- Hold the tube assembly - Hold the tube assembly with the thumb of your with the thumb of your dominant hand on top of dominant hand on top of the holder and your index the holder and your index finger under the holder.finger under the holder.



- Insert the needle, bevel up with an angle of - Insert the needle, bevel up with an angle of 15 to 30 degrees, in one smooth, quick 15 to 30 degrees, in one smooth, quick motion.motion.

- The vein wall will give as the needle enters - The vein wall will give as the needle enters the vein.the vein.

- Hold the tube holder steady, maintaining the - Hold the tube holder steady, maintaining the angle, while the needle is in the arm.angle, while the needle is in the arm.



11. Push in the tube with the hand that 11. Push in the tube with the hand that anchored the vein, using the flanges to anchored the vein, using the flanges to brace the holder and keep it steady.brace the holder and keep it steady.

Courtesy of Zack Bent. From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals. Philadelphia, Saunders, 2006.



12. Remove the tourniquet as soon as blood 12. Remove the tourniquet as soon as blood flow is established by pulling on the free flow is established by pulling on the free end.end.

- The tourniquet should not remain on for - The tourniquet should not remain on for more than one minute.more than one minute.

-- The tourniquet must be removed prior to The tourniquet must be removed prior to needle removal to prevent hematoma needle removal to prevent hematoma formation.formation.



13. Advance and change the tubes.13. Advance and change the tubes. - - Remove the tube when blood stops Remove the tube when blood stops

flowing by gently pulling the tube while flowing by gently pulling the tube while pushing against the flanges of the pushing against the flanges of the

holder.holder. - - All additive tubes must be gently All additive tubes must be gently

inverted inverted immediately after removal.immediately after removal.




14. Prepare for needle removal.14. Prepare for needle removal.

-- Make sure the tourniquet is off and the Make sure the tourniquet is off and the

patient’s fist is open.patient’s fist is open.

-- Remove the last tube from the back of Remove the last tube from the back of

rubber sheath so that the blood does not rubber sheath so that the blood does not

drip out of the other end of the needle.drip out of the other end of the needle.



15. Withdraw the needle at the same angle 15. Withdraw the needle at the same angle that you entered the skin. that you entered the skin.

-- Apply a gauze square to the puncture Apply a gauze square to the puncture site, but do not press down until the needle site, but do not press down until the needle is withdrawn.is withdrawn.

- Apply direct pressure, no arm bending - Apply direct pressure, no arm bending which could result in a bruise or which could result in a bruise or

hematoma.hematoma.

- Hold pressure until bleeding has stopped.- Hold pressure until bleeding has stopped.


Routine VenipunctureRoutine Venipuncture16. Dispose of the used needle in the needle 16. Dispose of the used needle in the needle

collection container (sharps).collection container (sharps). - Make sure that you have activated the - Make sure that you have activated the

safety device before disposal, and safety device before disposal, and dispose dispose of needle assembly in tact.of needle assembly in tact.

17. Label the tubes.17. Label the tubes. - - Label each tube at the patient’s bedside Label each tube at the patient’s bedside

or before the patient leaves the outpatient or before the patient leaves the outpatient drawing room.drawing room.

- As a minimum, the label must have the - As a minimum, the label must have the patient’s full name, ID number, date, time patient’s full name, ID number, date, time

and initials or code of the phlebotomist. and initials or code of the phlebotomist.



18. Attend to the patient.18. Attend to the patient.

- Check puncture site for active bleeding.- Check puncture site for active bleeding.

- Apply bandage or adhesive tape to site.- Apply bandage or adhesive tape to site.

- Raise bed rail if you lowered it.- Raise bed rail if you lowered it.

- Remove gloves and wash hands.- Remove gloves and wash hands.

- Thank patient.- Thank patient.

- Remove any diet restrictions if fasting.- Remove any diet restrictions if fasting.



19. Deliver the specimen.19. Deliver the specimen.

- Follow lab procedure for logging the - Follow lab procedure for logging the specimen into the tracking system.specimen into the tracking system.

- Make sure that you have completed all - Make sure that you have completed all your paperwork.your paperwork.


Routine Venipuncture - SyringeRoutine Venipuncture - Syringe

1. Follow the beginning steps for a routine 1. Follow the beginning steps for a routine venipuncture – 1,2, 4-7, and 9 of venipuncture – 1,2, 4-7, and 9 of Procedure 9-1.Procedure 9-1.

2. 2. Prepare the syringe and perform the Prepare the syringe and perform the venipuncture as in steps 8 and 10 of venipuncture as in steps 8 and 10 of Procedure 9-1.Procedure 9-1.






3. Fill the syringe.3. Fill the syringe.

- A flash of blood in - A flash of blood in the needle will the needle will

indicate that indicate that you you are in the are in the vein.vein.

- Pull back the - Pull back the plunger gently to plunger gently to

withdraw the withdraw the blood.blood.




4. Withdraw the needle, 4. Withdraw the needle, and transfer the blood and transfer the blood to evacuated tubes.to evacuated tubes.

- Follow steps 12 to 14 - Follow steps 12 to 14 of Procedure 9-1.of Procedure 9-1.

- Activate safety device.- Activate safety device.




4. Withdraw the needle, and transfer the 4. Withdraw the needle, and transfer the blood to evacuated tubes.blood to evacuated tubes.

- Attach a needleless blood transfer - Attach a needleless blood transfer device device to the syringe and hold upright.to the syringe and hold upright.

- Insert tubes into the transfer device in the - Insert tubes into the transfer device in the same order as the ETS, making sure to same order as the ETS, making sure to

invert immediately after removing.invert immediately after removing.






5. Dispose of the syringe and 5. Dispose of the syringe and transfer device together transfer device together into a sharps container.into a sharps container.

6. Complete the Procedure.6. Complete the Procedure.

- Finish as in steps 15-17 - Finish as in steps 15-17 of Procedure 9-1.of Procedure 9-1.


Chapter 9 Routine Venipuncture. Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Learning Objectives List the information.

Documents

imprint of elsevier

test icd

routine venipuncture

test status stat

test requisitions purpose

required information

learning objectives

patient preparation