Chapter 14:
Venipuncture Procedures
OVERVIEW
Routine venipuncture is the most common procedure a phlebotomist performs. The most important step in venipuncture is positive identification (ID) of the patient. This is done by matching the information on the requisition with, the information on the patient's ID band and the information provided by the patient. Although most patients are suitable candidates for drawing blood with evacuated tubes , patients with fragile veins may be better candidates for wing-set collection devices.
Venipuncture
-The process of collecting or “drawing” blood from a vein
-Covered in this chapter:
How to correctly identify all types of patients
How to safely obtain high-quality, blood specimens
-Challenges & issues unique to pediatric, geriatric, dialysis, long term care, home care, & hospice patients
Venipuncture Steps
Step 1. Review and Accession Test Request
All blood collection procedures begin with a request for a test from the treating physician. A physician 's request for tests can be presented on the following types:
Types
-Manual requisitions
-Computer requisitions
-Barcode requisitions
Requisitions have the following information:
• Patient demographics, including full name, date of birth, sex, and race
• If an inpatient, hospital ID number and room and bed number
• Name or code of the physician making the request
• Test status (e.g. , short turnaround time, or stat; timed; or fasting)
Phlebotomist Must
-Check to see that required inform is present & complete
-Verify test to be collected & time & date of collection
-Identify diet restrictions other special circumstances
-Accession or record the order received
Step 2. Approach, Identify & Prepare Patient
Approach the patient
-be organized & prepare with paperwork
-Look for signs containing patient info (ex DNR)
-Knock lightly on door
-Ask visitors to step out
-Identify yourself
-Obtain consent for procedure
-Put patient at ease, using professional bedside manner
Patient identification
-Verify name & date of birth
-Check ID bracelet
-Notify nurse of ID discrepancies
-Search for missing IDs
-Wake sleeping patients
-Ask a relative or nurse to identify a patient who is
unconscious, young, or mentally incompetent
Step 2: Approach, identify, & Prepare Patient
Preparing the patient
-Explain the procedure
-Address patient inquiries
-Handle patient objections
-Address difficult patients
-Address objects in patients mouth
Step 3: Verify Diet restrictions & Latex sensitivity
Step 4: Hand Sanitize
Step 5: Position Patient, Apply Touriquet, and ask patient to make fist
Position Patient
-Inpatients; Typically are lying down in bed
-Outpatient; sitting up in blood-drawing chair
-Patients prone to fainting; reclining chair, sofa, or bed
-Support hand or arm that is to be site of venipuncture
Tourniquet application & fist clenching
-apply tourniquet snugly 3 to 4 in above in above
intended site
-Never apply over open sore
-Ask patient to make fist
Step 6: Select Vein, Release Tourniquet, and Ask Patient to open Fist
-Preferred site is antecubital area of arm
-First choices are median cubital & medial veins
-Palpate patients dominant arm with index finger
-Roll finger side to side while pressing against vein to judge size
-Avoid veins that feel hard & cord-like or lack reliance
-Release tourniquet & have patient open fist
Step 7: Clean and Air-Dry the site
-Clean site with an antiseptic to avoid infection or contamination
-Use 70% isopropyl alcohol
-Use circular motion, moving outward in widening concentric circles
-Clean an area about 2 to 3in in diameter
-Avoid veins that feel hard & cord-like or lack resilience
-Allows area to dry 30 seconds to 1 min
-Dont dry alcohol with unsterile gauze or fan or blow on site
-Do not touch site after cleaning it
Step 8: Prepare Equipment and Put on Gloves
-EDTS Equipment preparation
-Preparaton of winged infusion set (butterfly)
-Preparation of syringe equipment
-Positioning equipment for use
Step 9: Reapply Tourniquet, uncap and Inspect needle
Step 10: Ask patient to remake a fist, anchor vein, and insert needle
Anchoring
-Use non-dominant hand to anchor (secure firmly)the view
-Place thumb at least 1 to 2 inches below and slightly to the side of site
-Pull skin towards wrist
Needle insertion
-Hold collection device or butterfly in dominant hand
-with the bevel facing up, position needle above insertion site
-Insert at 30-degree angle or less in smooth, steady forward motion
-NOTE: you should only attempt 2 time to establish insertion into view, if failed to do so, notify patient and allow another phlebotomist to collect the specimen
Step 11: Establish Blood Flow. release Tourniquet, and ask patient to open fist
-Advance collection tube into tube holder until stopper is completely penetrated by needle
-Push tube with thumb whole index and middle fingers straddle
& grasp flanges of tube holder, pulling back slightly
-Blood will begin to flow into tube
-Release tourniquet
-Have patient release fist
Step 12: Fill, Remove and mix tubes in Order of draw or fill syringe
Step 13: Remove needle, Activate Safety Feature, and Apply Pressure with Gauze
-Remember: avoid using cotton balls for pressure over sit because cotton will mesh into fibrinogen and will pull the platelet plug away from site upon removal
Step 14: Discard Collection Unit, Syringe Needle, or Transfer Device
Step 15: Label Tubes
-Patients first & Last Names
-Patients Identification number (if applicable) or date of birth
-Date & time of collection
-Phlebotomist initials
-Pertinent additional information, such as “fasting”
Step 16: Observe Special Handling Instructions
Step 17: check patients arm and apply bandage
Step 18:Dispose of Contaminated Materials
Step 19:Thank Patient, Remove Gloves and Sanitize Hands
Step 20: Transport Specimen to the lab
Pediatric Venipuncture
Overview
-Children under 2 years; limit to superficial views
Challenges
-Small, undeveloped veins
-Considerable risk of permanent damage
-Smaller blood volume in body; risk for anemia
Dealing with Parents or Guardians
-Earn trust the by being warm, friendly calm, confident & caring
-Ask about child past expert
-Allow to stay in room, if desired
Dealing with the child
-Gain trust; approach slowly & determine level of anxiety
-Explain procedure in terms a child can understand
-Emphasize importance or remaining still
-Offer reward for cooperation
Pain Interventions
-Eutectic mixture of local anesthetics (EMLA)
-Available in a cream & in oral solution
-Takes about 1 hour to anesthetize area
Selecting a Method of Restraint
-Infants: Wrap in a blanket
-Toddlers: have parent hold on lap
Equipment Selection
- 23 gauge butterfly needle attached to an evacuated tube or syringe
Procedures
Collect minimum amount of blood required for testing
Geriatric Venipuncture
Challenges
- Skin changes
-Hearing impairment
-Visual impairment
-Mental impairment
-Effects of Disease
Arthritis
Diabetes
Pulmonary Function
Safety issues
-More space needed for wheelchairs & walkers
-Nonslip & Clutter-free floors
Patients in wheelchairs
-Lock wheels when drawing blood, assisting from chair
Patient Identification: don't rely on nods of agreement: verify patient information with a relative or attendant
Equipment Selection: Butterfly needles or short-draw tubes
Tourniquet Application: Loose enough to not damage skin
Site selection: avoid bruised areas from previous venipuncture
Cleaning the site: Don’t rub too vigorously
Performing the Venipuncture: anchor vein firmly to avoid rolling
Holding Pressure: Bleeding may take longer to stop
Patients on Dialysis and Other Settings
Dialysis Patients
-Do not use arm with AV Fistula for venipuncture
Home care Patients
-Home care phlebotomy must have:
: Exceptional Phlebotomy, interpersonal & organizational skills.
: ability to function independently
: ability to be comfortable working in varied & unusual circumstances
Hospice Patients
-Require extra care, kindness, & respect
Venipuncture Procedure
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