List the required information on a requisition form.

Describe correct patient identification and specimen labeling procedures.

Describe patient preparation and the variables that can affect some laboratory tests.

Correctly assemble venipuncture equipment and supplies.

Name and locate the three most frequently used veins for venipuncture, and describe when these sites would be unacceptable.

Correctly apply a tourniquet and state why the tourniquet can be applied for only 1 minute.

List four methods used to locate veins that are not prominent.

Describe the different antiseptics used to cleanse the venipuncture site.

State the steps in a venipuncture procedure, and correctly perform a routine venipuncture using an evacuated tube system.

Demonstrate safe disposal of contaminated needles and supplies.

Deliver specimens to the laboratory in a timely manner.

Recommended step-by-step venipuncture procedure

Possible complications

Purpose◦ Patient

identification◦ Organization of

equipment◦ Collection of

appropriate specimens

Name Identification number Accession number Location Health-care provider’s name Test requested Date and time of collection

Patient’s date of birthSpecial collection informationSpecial patient informationNumbers and type of collection tubes

Status of specimen

Introduce yourself◦ Begin communication process◦ Look and listen

Explain purpose of visit◦ Informed consent◦ Patient has the right to refuse–Patient Bill of Rights

Guilty of assault if patient has the perception that blood collector is ignoring his or her refusal

Wake a sleeping patient Greet unconscious patients

THIS IS THE MOST IMPORTANT STEP !

Written protocol ◦ Hospital inpatients◦ Outpatients

Two identifiers

Primary identifier Always compare with the

requisition Must be worn by the

patient◦ Wrist of older children

and adults◦ Ankles of newborns

Do not trust room and bed signs

Second identifier◦ Have the patient state full name◦ CLSI requirement

Primary identifier◦ Have the patient state full name

Secondary identifier◦ Ask additional information

Date of birth Spell name Compare unique data with the requisition form

CLSI requires a caregiver or family member to provide information on patient’s behalf if patient is unable to before drawing specimen

Document the name of the verifier Drug testing might require photo ID

Unidentified patients◦ Tagged with temporary number◦ Tentative name

Commercial blood bank system◦ Place additional stickers from ID band on:

Specimen Requisition form Units of blood

Reassure the patient Explain procedure

◦ Do not explain the purpose of the test! Do not say procedure is painless!

Alert patient to every step of the procedure Remind patient to hold still

Basal state◦ Preferred state

Fasting Activities

◦ Medications A variety of both prescription and over-the-counter

medications can influence lab test results

Site is convenient and supported◦ Place pillow under arm◦ Place fist under elbow◦ Place arm at downward

angle to prevent reflux Safety

◦ Patient is sitting or lying down

◦ Remove objects from patient’s mouth

◦ Be alert for syncope

Place all supplies close to patient◦ Collection equipment◦ Antiseptic pads◦ Gauze◦ Bandage◦ Needle disposal system◦ Examination requisition

form Number and type of tubes Extra tubes in case of loss of vacuum

Wash hands between patients Change gloves between patients

Vein locationIncrease amount of available blood

Locate tourniquet 3 to 4 inches above site Avoid or cover arms with skin conditions Avoid arms on the side of a mastectomy Do not use a tourniquet for lactate test

Maximum time is 1 minute Apply for site selection Release for 2 minutes Reapply Release when blood flows Prolonged tourniquet application

◦ Causes hemoconcentration Increase in the ratio of certain analytes to plasma Biochemical changes take place in the trapped blood

Other causes◦ Excessive squeezing◦ Probing a site◦ Long-term IV therapy◦ Sclerosed or occluded veins◦ Vigorous fist clenching

Increases cellular elements

◦ Uncomfortable for patient◦ Obstruct blood flow◦ No radial pulse◦ Appearance of petechiae

Major veinPreferred site is antecubital fossa area

Vein of choice◦ Large, well

anchored◦ Closer to surface◦ More isolated from

other structures◦ Least painful–fewer

nerve endings

◦ Located on thumb side of arm

◦ Second site of choice◦ Close to the surface

Use lower angle of needle insertion (15°)

Possible blood spurt◦ May be prominent in

larger patients

◦ Located on the underside of the arm

◦ Third choice for venipuncture (H3-A6 recommends using only as a last resort) Least firmly anchored (vein

may “roll”) Near brachial artery and

median nerve Hematoma formation more

likely Consider using a syringe for

more control

Apply tourniquet 3 to 4 inches above venipuncture site

Have patient form a fist◦ Do not pump fist

Causes hemoconcentration Only acceptable for blood donations

◦ Feeling is more important than sight

◦ Probe with index finger, thumb has a pulse

◦ Push, don’t stroke◦ Determine: size, depth,

direction◦ Remember: veins are

spongy, tendons are rigid, arteries have a pulse

Check both arms Listen to patient’s suggestions of previously successful areas

Massage the arm upward from the wrist

Briefly hang the arm down Apply heat Transilluminator device

Wrists and hands◦ Apply tourniquet to forearm◦ Consider a smaller needle, syringe, winged blood

collection set H3-A6 states to avoid veins from the

underside of the wrist◦ Possibility of puncturing the radial or ulnar nerve

or artery Can cause permanent nerve

damage and inability to open and close the hand

Require physician approval More susceptible to infection and thrombi

Avoid in patients with diabetes, cardiac problems, coagulation disorders

Occluded veins◦ Thrombi◦ Multiple punctures◦ Feel hard◦ Impaired circulation

Hematomas◦ Do not puncture hematoma, noncirculation of blood◦ Draw below hematoma◦ Use other arm

Areas with edema Areas with extensive burns, scars or tattoos

◦ More susceptible to infection◦ Decreased circulation◦ Difficult to palpate

Mastectomies◦ Lymphostasis

Increased lymphocytes Increased waste products

◦ Patient danger Lymphedema Infection

Double Mastectomies◦ Consult physician◦ Possibly perform fingerstick

Never obtain blood from a finger on the side affected by a mastectomy (CLSI H$A6) without physician-written permission

IV Fluids◦ Ideally use other arm◦ Avoid sites of previous IVs for 24–48 hours◦ Note same arm collection on requisition◦ Select site below infusion site, caregiver turns off IV for 2

minutes ◦ Preferably use a different vein◦ Avoid drawing blood at the same time dye for radiological

procedure or blood components are being infused

Fistulas◦Renal dialysis patients ◦Permanent artery-vein connection◦Must avoid this arm ◦Possibility of infection

Cannula◦Temporary (external) AV shunt◦T-tube connector with diaphragm◦Only specially trained personnel can draw from a cannula

Turn off IV for at least 2 minutes◦ Discard first 5 mL blood◦ Collect specimen in a new syringe◦ Coagulation tests, discard 10 mL

Second 5 mL can be used for other tests Document the type of IV fluid and location

on requisition

Apply 70% isopropyl alcohol using a circular motion cleanse from inside to outside

Allow to air dry, 30–60 seconds will give maximum bacteriostatic action

Avoid wiping off with gauze Failure to let alcohol dry

causes a stinging sensation for patient

Specimen hemolysis

Blood cultures or arterial blood gases◦Povidone-iodine◦Tincture of iodine◦Chlorhexidine gluconate

Blood Alcohol Collection◦Do not cleanse site with alcohol◦Soap and water are recommended◦Iodine or benzalkonium chloride (Zephiran

Chloride) may be acceptable

Perform while alcohol is drying Screw the stopper-puncturing end

of needle into the holder Insert first collection tube into the

holder Advance tube only to mark on holder

Perform immediately before puncture◦ Blunt end◦ Barbed point

Reapply tourniquet Confirm puncture site Cleanse gloved palpating finger if

necessary Place holder in dominant hand

Place thumb on top, fingers underneath After insertion, fingers can be braced on

patient’s arm

Place thumb of nondominant hand 1–2 inches below site

Place fingers on back of arm

Do not anchor above and below site with thumb and index finger◦ Possible accidental self-

puncture

Bevel up 15-to-30 degree

angle Resistance lessens

when the needle enters the vein

Nondominant hand can be used after vein is entered

Use flared ends of holder

Brace the hand holding the holder against the patient’s arm

Gently twist tubes on and off the needle

Mix tubes as they are removed from the holder needle◦ Can be done before next tube is inserted

Remove and mix the last tube before removing the needle from the vein◦ Blood will drip from the needle

Remove the tourniquet if still applied Failure to remove can cause

a hematoma Patient may relax fist Withdraw needle and apply

pressure to gauze at the same time

Capable patients can apply pressure using digital pressure

Arm is raised and outstretched◦ Do not bend the elbow

Collector must apply pressure if necessary

Immediately activate needle safety device

Dispose in a conveniently located sharps container

NEVER BEND, CUT, OR RECAP NEEDLE

Label tube before leaving the patient Less chance of tubes being

mixed up Use a pen Confirm information on

preprinted labels Verify correct labeling with

the patient (CLSI H3-A6)

Patient’s name and ID number Date and time of collection Collector’s initials Additional information

◦ Blood bank identification

Check arm before bandaging H3-A6 states collector must

observe for hematoma formation before applying bandage

Apply hypoallergenic bandage over gauze for extra pressure

Self-adhering material Patient’s instructions

Avoid carrying heavy objects Remove bandage within 1

hour

Pressure must be applied until bleeding stops◦ Patients on anticoagulants/aspirin/herb therapy

Accidental arterial puncture◦ Collector must apply pressure for 5 minutes or until bleeding

has stopped◦ Notify nursing staff and physician

Allergy to adhesive◦ Avoid use in children under 2 years old

Place in biohazard containers Remove gloves Wash hands

Return patient’s bed to original position

Replace bedrails

Use designated biohazard bags/containers

Observe any special handling procedures Deliver as soon as possible

◦ No longer than 45 minutes Transport in an upright position

◦ Facilitate clotting◦ Prevent hemolysis

Complete all required paperwork

Separate serum and plasma from the cells within 2 hours of collectiono Hemolysis severely affects potassium valueso Cellular metabolism decreases glucose levels

Coagulation specimens for a PTT can remain at RT for 4 hours; if patient is on unfractionated heparin, the plasma must be removed from the cells within 1 hour, test within 4

PT are stable for 24 hours at RT Blood smears from EDTA tubes should be

made within 1 hour of collection. Specimen can be refrigerated for up to 4

hours