Chapter 9

1. Chapter 9 Routine Venipuncture

2. Learning Objectives • List the information that is commonly found on a test requisition. • List in order the steps in a routine venipuncture. • Discuss the information that must be verified for inpatient identification before the blood collection procedure.

3. Learning Objectives • Explain how the identification of outpatients differs from that of inpatients. • Describe the patient preparation and positioning. • Describe how to assemble the evacuated tube system. • Explain how to apply a tourniquet and list three consequences of improper application.

4. Learning Objectives • List the veins that may be used for blood collection, including the advantages and disadvantages of each. • Explain how to clean the venipuncture site. • Describe how to properly insert the needle into the vein. • Discuss how the needle should be removed when the last tube of blood has been collected.

5. Learning Objectives • List the information that must be included on the label of each tube. • Describe how venipuncture using a syringe differs from that of using the evacuated tube system.

6. Test Requisitions • A requisition (order) is used to determine what type of sample to collect from patient. • Minimum information on a requisition: Patient full name, date of birth, sex, race. - For inpatients – hospital ID number, room, bed number. - Tests requested with ICD-9 code. - Test status – stat, timed, fasting.

7. Test Requisitions • Purpose of the requisition: 1 - Allows you to identify the patient correctly. 2 - Tells you what specimen should be collected. 3 - Allows you to gather your equipment before you encounter the patient.

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

9. Routine Venipuncture 1. Greet and identify the patient - Knock before entering the room; announce yourself if there is a curtain. - Let the patient know that the physician has ordered a test but give no other information. - Positive patient identification is the single most important step in phlebotomy. - Ask the patient to state his or her full name.

10. Routine Venipuncture - Check the requisition information against what the patient has told you. Match the name and the hospital ID number which will be unique to that patient. The armband must be attached to the patient. Do not draw the patient until an armband has been placed on the patient’s arm or ankle. - Outpatients do not have armbands, so ask the patient to state his name and date of birth. Compare that information with the requisition.

11. Routine Venipuncture - Ask the patient if he is taking any medication. Patients on blood thinners may require extra pressure post puncture. 2. Position and prepare the patient. - Never draw blood from a standing patient. - Seat outpatients in a phlebotomy chair with arm support. - For inpatients return bed railings to the same position in which you found them.

12. Routine Venipuncture - All foreign objects should be removed from the patient’s mouth to avoid choking. - Explain the procedure and get verbal consent before proceeding with blood draw. - Verify pretest fasting by asking the patient when was the last time he or she had anything to eat or drink except water.

13. Routine Venipuncture 3. Assemble your equipment in front of the patient.

14. Routine Venipuncture 4. Apply the tourniquet about 3-4 inches above the puncture site. - Form an X and then tuck from the top. - The tourniquet should not be on the arm for longer than one minute.

15. Routine Venipuncture - Improper tourniquet application can cause: * Hemoconcentration – an increase in the ratio of formed elements to plasma. * Hemolysis – destruction of RBCs. - Both hemoconcentration and hemolysis can cause test results to be altered. * Petechiae – small red spots on the skin caused by blood leaking into the epithelial.

16. Routine Venipuncture 5. Select the site. - Median cubital vein, well anchored, is the first choice in the antecubital fossa. - The cephalic vein, on the thumb side of the arm, is the second choice. - The basilic vein, on the little finger side of the arm, is the third choice. You may puncture the brachial artery if the needle goes too deep.

17. Routine Venipuncture 6. Palpate the vein. - Touch the vein gently pushing up and down to feel for the bouncy vein. - Determine the depth, diameter and direction of the vein. - If you have difficulty finding the vein, have the patient make a fist, gently massage the arm or use a warm towel over the area.

18. Routine Venipuncture 7. Clean the site with 70% isopropyl alcohol, in concentric circles, working in to out. - Allow the site to air dry for bacteriostatic action. 8. Reapply the tourniquet if it was removed during the cleansing process. 9. Remove the needle cap and examine the needle tip for any defects.

19. Routine Venipuncture 10. Perform the venipuncture using the thumb of your nondominant hand to anchor the vein below the puncture site. - Hold the tube assembly with the thumb of your dominant hand on top of the holder and your index finger under the holder.

20. Routine Venipuncture - Insert the needle, bevel up with an angle of 15 to 30 degrees, in one smooth, quick motion. - The vein wall will give as the needle enters the vein. - Hold the tube holder steady, maintaining the angle, while the needle is in the arm.

21. Routine Venipuncture 11. Push in the tube with the hand that anchored the vein, using the flanges to 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.

22. Routine Venipuncture 12. Remove the tourniquet as soon as blood flow is established by pulling on the free end. - The tourniquet should not remain on for more than one minute. - The tourniquet must be removed prior to needle removal to prevent hematoma formation.

23. Routine Venipuncture 13. Advance and change the tubes. - Remove the tube when blood stops flowing by gently pulling the tube while pushing against the flanges of the holder. - All additive tubes must be gently inverted immediately after removal. Courtesy of Zack Bent.  From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals.  Philadelphia, Saunders, 2006.

24. Routine Venipuncture 14. Prepare for needle removal. - Make sure the tourniquet is off and the patient’s fist is open. - Remove the last tube from the back of rubber sheath so that the blood does not drip out of the other end of the needle.

25. Routine Venipuncture 15. Withdraw the needle at the same angle that you entered the skin. - Apply a gauze square to the puncture site, but do not press down until the needle is withdrawn. - Apply direct pressure, no arm bending which could result in a bruise or hematoma. - Hold pressure until bleeding has stopped.

26. Routine Venipuncture 16. Dispose of the used needle in the needle collection container (sharps). - Make sure that you have activated the safety device before disposal, and dispose of needle assembly in tact. 17. Label the tubes. - Label each tube at the patient’s bedside or before the patient leaves the outpatient drawing room. - As a minimum, the label must have the patient’s full name, ID number, date, time and initials or code of the phlebotomist.

27. Routine Venipuncture 18. Attend to the patient. - Check puncture site for active bleeding. - Apply bandage or adhesive tape to site. - Raise bed rail if you lowered it. - Remove gloves and wash hands. - Thank patient. - Remove any diet restrictions if fasting.

28. Routine Venipuncture 19. Deliver the specimen. - Follow lab procedure for logging the specimen into the tracking system. - Make sure that you have completed all your paperwork.

29. Routine Venipuncture - Syringe 1. Follow the beginning steps for a routine venipuncture – 1,2, 4-7, and 9 of Procedure 9-1. 2. Prepare the syringe and perform the venipuncture as in steps 8 and 10 of Procedure 9-1.

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

31. Routine Venipuncture - Syringe 3. Fill the syringe. - A flash of blood in the needle will indicate that you are in the vein. - Pull back the plunger gently to withdraw the blood. Courtesy of Zack Bent.  From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals.  Philadelphia, Saunders, 2006.

32. Routine Venipuncture - Syringe 4. Withdraw the needle, and transfer the blood to evacuated tubes. - Follow steps 12 to 14 of Procedure 9-1. - Activate safety device. Courtesy of Zack Bent.  From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals.  Philadelphia, Saunders, 2006.

33. Routine Venipuncture - Syringe 4. Withdraw the needle, and transfer the blood to evacuated tubes. - Attach a needleless blood transfer device to the syringe and hold upright. - Insert tubes into the transfer device in the same order as the ETS, making sure to invert immediately after removing.

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

35. Routine Venipuncture - Syringe 5. Dispose of the syringe and transfer device together into a sharps container. 6. Complete the Procedure. - Finish as in steps 15-17 of Procedure 9-1. Courtesy of Zack Bent.  From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals.  Philadelphia, Saunders, 2006.