1. Booth, Wallace, and Fitzgerald
CHAPTER 4
PowerPoint ® Presentation to Accompany
Phlebotomy for Health Care Personnel
Booth, Wallace, and Fitzgerald
Chapter 4

2. Performing Venipuncture and Dermal Puncture
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3. Objectives Learning Outcomes
Upon completion of this chapter, you should be able to:
Describe the proper procedure to follow for patient identification.
Explain how to prepare a patient for blood collection.
Identify the correct steps to follow when a patient refuses collection.
Describe the process and time limits for applying a tourniquet to a patient’s arm.
Discuss factors that must be considered when selecting a site for venipuncture or dermal puncture.
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4. Learning Outcomes (cont'd)
Objectives cont’d
Learning Outcomes (cont'd)
Describe the venipuncture and dermal puncture site cleansing procedure.
List the items required on a specimen label and explain the importance of each.
State the maximum number of times that the phlebotomist should stick a patient.
List the steps to follow when unable to obtain a blood specimen.
Describe how to use a butterfly or winged-tipped collection device.
Explain the collection procedure for dermal puncture.
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5. Step-by-Step Approach cont’d 2
Preparing for Venipuncture
Greeting the Patient
Smile and address the patient in a pleasant, calm tone.
Behave in a professional manner.
Always identify yourself.
In an outpatient setting, conduct yourself in a manner that will reduce anxiety, as they may not expect you.
In an inpatient setting, always knock and wait for a response before entering. If a curtain is pulled around the patient’s bed, inform the patient of your presence before entering.
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6. Wake the Patient Gently
If the patient is sleeping:
Gently wake him or her and explain why you are there
Try not startle the patient
Be sure to talk in a soft manner
Inform the patient before turning on the lights
Never attempt to collect a specimen from a sleeping patient!
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7. Step-by-Step Approach cont’d 3
Preparing for Venipuncture
Patient Identification
For Inpatients
For Outpatients
Always check the ID band on the arm or ankle
May require verbal verification by a nurse if patient is sedated
Ask the patient to verify information on the requisition form
At least two to three verification items should be asked to ensure proper identification
The most important step in the venipuncture procedure!!
Always ask for the name and date of birth
Always verify at least two patient identifiers before proceeding
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8. Preparing for Venipuncture
Verifying Dietary Restrictions
Dietary restrictions must be verified because this can interfere with the laboratory results.
The most common dietary restriction affecting specimen collection is fasting.
If a restriction or special diet is required, make note of this on the requisition slip.
Make note of the last time the patient had anything to eat, drink, or smoke, and if special dietary restrictions were followed.
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9. Preparing for Venipuncture
Assembling the Venipuncture Equipment
Supplies for Venipuncture
Gloves
Tourniquet
Alcohol prep pads
Gauze pads
Needle
Evacuated tube holder or syringe
Appropriate evacuated tubes
Sharps container
Adhesive bandage or tape
Permanent marker or label
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10. Preparing for Venipuncture
Assembling the Venipuncture Equipment
Screw the needle into the tube adapter
Insert the first tube to be collected into the tube adapter
Push the tube up to the adapter guideline
Be careful not to push the tube too far, as this can result in loss of vacuum!
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11. Preparing for Venipuncture
Patient Positioning
The patient should be lying supine or sitting in a phlebotomy chair.
A straight chair with an arm is preferable.
If necessary, a pillow or rolled up towel can be placed under the arm for positioning.
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12. Preparing for Venipuncture
The tourniquet:
Should not pinch the skin
Should be kept flat against the skin
Should be applied 3 to 4 inches above the venipuncture site
Apply the tourniquet, which will make the veins more visible and palpable
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13. Petechiae
Petechiae or a hematoma may develop if the tourniquet is left on too long, or if a needle has gone though the vein.
Any form of temporary or permanent disfigurement should be avoided.
Be sure to remove the tourniquet in a timely manner. If a hematoma develops, apply firm pressure to the site.
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14. Preparing for Venipuncture
Selecting the Venipuncture Site
Always examine the antecubital area first
Ask the patient to hold the arm still and make a fist
Palpate the vein using the tip of your index finger
Use a warm, moist compress for 3 to 5 minutes to increase vein size if needed
Select a vein that is large and does not roll
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15. Preparing for Venipuncture
Special Considerations
Never select a site that is edematous or has lesions
Never perform venipuncture above an IV site
Avoid using the arm on the side of a mastectomy
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16. Preparing for Venipuncture
Special Considerations—Children
It is a good practice to ask a child to help with the procedure to decrease the child’s anxiety.
Special Considerations—Elderly
Sensory impairment may exist, so extra time may be required
A shallower angle is required during insertion
Skin is fragile and veins tend to roll, so hold the skin taut
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17. Preparing for Venipuncture
Special Considerations—HIV or Hepatitis
Use proper PPE to avoid occupational exposure
Special Considerations—Psychiatric
Evaluate the patient carefully for any signs that the blood collection process could be difficult
If concerned, ask a staff member to assist
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18. Preparing for Venipuncture
Cleansing the Site
Cleaning the site with an antiseptic (70% isopropyl alcohol) helps prevent microbial contamination
Cleanse the site using concentric circles
Allow alcohol to dry completely or use a gauze, but NEVER blow on the site
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19. Use of Alcohol
Be sure to allow the alcohol to dry before attempting the venipuncture procedure. Wet alcohol entering the specimen can affect the laboratory results!
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20. Apply Your Knowledge BRAVO!
You are about to draw blood from Mr. Harrell. When you ask him to be seated in the phlebotomy chair, he states “Why do I need to sit down? This should not take long.” Which of the following would be the best response?
A. “You are right; this will not take long, so you may continue to stand.”
B. “No, this may take much longer than you think, so please be seated.”
C. “No, it should not take long, but it is much safer for you to be seated, and sitting will enable you to keep your hand steady.
Answer: C. Patients should be seated or lying down for safety.
BRAVO!
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21. Apply Your Knowledge
Which anatomical region should be used first when performing a venipuncture?
ANSWER: The antecubital space
Good Job!
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22. Performing the Venipuncture
Reapply the tourniquet
Visually confirm the venipuncture site
Anchor the vein below the puncture site
Insert the needle at a 15 to 30 angle
Insert the evacuated tube and allow it to fill completely
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23. Unsuccessful Venipuncture
If the Venipuncture Is Not Successful
Causes of Blood Collection Failure
Needle inserted too far
Insufficient vacuum in tube
Bevel on lower wall of the vein
Tourniquet too tight
Poor site selection (vein hard and sclerosed)
Patient fails to maintain “still” positioning
Sometimes repositioning the needle will cause blood to flow. Do not “probe” or change the position of the needle while it is inserted.
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24. Collecting the Specimen
Hold the venipuncture equipment steady during the entire tube-filling procedure
Remember, the tourniquet should not be left on the arm longer than 1 minute during specimen collection
The amount of blood needed in the evacuated tube is determined by the amount of additive in the evacuated tube
Overfilling an evacuated tube is not possible unless the stopper is removed and blood is added
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25. Collecting the Specimen Part 2
To change tubes during collection, brace the thumb against the flange of the holder and remove the tube with a pulling and twisting motion
Be sure to invert the tube 8 to 10 times to mix it if an additive is present in the tube
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26. Handling Syncope
Syncope can occur during a phlebotomy procedure. If this occurs, remove the tourniquet and needle, then call for help.
Lower the patient’s head and arms and place them between the patient’s knees.
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27. Removing the Needle Removing the Needle Ecchymosis Hematoma
Remove the last tube from the holder and, with your other hand, prepare your gauze by folding it
Place gauze directly over the area of needle insertion
After the needle is removed, engage the safety mechanism, and then apply gentle pressure over the site for 3 to 5 minutes
Ecchymosis
Bruising or skin discoloration
Hematoma
Collection of blood into the surrounding tissue and skin layer
Possible Complications
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28. Apply Your Knowledge
At what angle should the needle be inserted in performing a venipuncture?
ANSWER: 15o to 30o angle
Great!
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29. Apply Your Knowledge
Name two possible complications when removing the needle.
ANSWER: Hematoma and ecchymosis
Bravo!
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30. Disposing of the Needle
Dispose of the needle and adapter as one piece
Most sharps containers are made of puncture-proof material and display the biohazard symbol. Remember, never overfill a biohazard container!
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31. Labeling the Specimen Labeling the Specimen OR
Use a permanent marker to label
Computer-generated label
Remember for either type of label you must mark the tube after collection with the date, time and your initials.
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32. Labeling the Specimen Part 2
Remember always to label blood tubes after the blood is drawn
Actual time of collection is crucial in fasting specimen and in monitoring therapeutic drug levels.
To prevent mislabeling, do not label before or after you leave the patient. Only label at the time of specimen collection.
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33. Applying the Bandage Applying the Bandage
Check the patient’s arm after about three minutes to see if the bleeding has stopped
Tape or an adhesive bandage can be used to hold the pressure gauze on the site
Do not use tape on anyone with thin, fragile skin or on people with allergies to tape
The patient can remove the bandage after 15 minutes
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34. Transporting the Specimen
Be sure specimens are labeled
Transport to lab in timely manner
Some medical facilities use pneumatic tubes or dumbwaiters to transport specimens to the lab
Laboratories may be located off-site (reference laboratories)
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35. Transporting the Specimen Part 2
Special Handling Procedures
Certain specimens must remain cool, so they are placed in an ice-water mixture
Specimens to be kept warm and protected from light can be wrapped in aluminum foil
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36. Apply Your Knowledge
Where should the needle and adapter be discarded after a venipuncture procedure?
ANSWER: Biohazard container
Good Job!
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37. Using Syringe & Butterfly Needle Set
Using a Butterfly Needle Set
Butterfly needles range from 21 to 25 gauge in diameter and 1/2 to 3/4 inches in length
Thought to be less painful to patients
Used for individuals with small veins
Attach butterfly needle to a syringe because evacuated tubes have vacuum which can collapse the vein
Phlebotomist can control the amount of pressure applied when using a syringe
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38. Using Syringe & Butterfly Needle Part 2
Using a Butterfly Needle Set (cont.)
Butterfly Needle
The butterfly assembly has a Luer adapter that attaches to the evacuated tube holder or a syringe
Luer Adapter
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39. Performing the Venipuncture with a Butterfly Needle Set
To use a butterfly set, grasp the winged tip to insert the needle
The first sign of a successful venipuncture is blood in the hub, or clear area, of the needle
Complete the syringe collection in the same manner as routine venipuncture
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40. Using Syringe & Butterfly Needle Part 4
Using a Butterfly Needle Set
Be sure not to pull the syringe plunger back too fast or too hard because it can cause hemolysis of the specimen
NOTE: When using a syringe and butterfly needle set, the equipment setup must include the evacuated tubes needed for specimen transfer from a syringe.
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41. Transferring the Specimen to Tubes
Using a Syringe Transfer Device
Insert syringe tip into hub and rotate syringe clockwise to secure.
Peel off backing from transfer device.
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42. Using a Syringe Transfer Device (cont'd)
After removing the evacuated tube, discard the tube holder and syringe in an approved sharps container.
Hold the syringe facing down and push the evacuated tube into the holder. Do not depress the plunger of the syringe.
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43. Apply Your Knowledge
What can happen to the specimen if the plunger is pulled on the syringe too hard?
ANSWER: Hemolysis of the specimen
BRAVO!
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44. Dermal Puncture Dermal Puncture
Dermal puncture is the preferred blood collection technique for infants and small children.
It is difficult to locate a vein that is large enough to withstand the vacuum created by the evacuated collection tubes.
Children do not enjoy venipuncture and usually will not remain still for the length of time venipuncture requires.
Dermal puncture is much easier to perform.
Dermal puncture is less traumatic for the child.
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45. Dermal Puncture Part 2 Dermal Puncture
Selecting the Site for Dermal Puncture
Heels are the site of choice in infants who are less than 1 year old
Fingers are used in adults and children
Attempt to find an unused area
Area should be warm, pink, and free of scars
Do not use the arch of the foot, the back of the heel, or the plantar area of the foot
The site selected for the heel should be well away from the heel bone because puncture of the calcaneus can cause osteomyelitis.
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46. Dermal Puncture Part 3 Dermal Puncture
Plantar Surface
For older children and adults, the preferred site is the palm side of the ring or middle finger
Do not cut in the same direction as the fingerprint
NOTE: Warming the finger or heel will increase blood flow
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47. Dermal Puncture Part 4 Dermal Puncture
Hold the finger in the proper position
Performing a Dermal Puncture
Clean the site with an alcohol pad and allow to dry completely
Puncture the finger with a properly selected safety device
Apply a steady amount of pressure to the site before and during the puncture
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48. Dermal Puncture Part 6 Dermal Puncture
Be sure to make the puncture deep enough to collect the amount of blood needed
Wipe away the first drop of blood
Use a microcollection device to collect the specimen
NOTE: This procedure will cause pain, so be sure to collect an adequate amount of blood initially to prevent repeat sticks.
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49. Dermal Puncture Dispose of the safety lancet in the sharps container
After the Dermal Puncture
Dispose of the safety lancet in the sharps container
Label the microcontainers
Check the site of puncture and apply a bandage if necessary
Collect and dispose of your supplies appropriately
Dismiss the patient
Transport the specimen to the laboratory
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50. Apply Your Knowledge
Which is the site of choice for performing a dermal puncture in an infant under 1 year of age?
ANSWER: The heel
GREAT!
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51. Chapter Summary
Patients must be properly identified for the blood collection procedure.
Prepare a patient for blood collection by explaining the procedure.
Tourniquets slow the blood to the site and should not be left on more than 1 minute.
Venipuncture and dermal puncture sites are selected based upon their location and appearance.
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52. Chapter Summary (cont’d)
Cleaning the site for dermal puncture most often requires the use of an alcohol prep pad. Allow the site to dry thoroughly before collection.
The specimen label includes the patient’s name, record or ID number, date and time of collection, and your initials.
The maximum number of times blood collection should be attempted is two.
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53. Chapter Summary (cont’d)
If you are unable to obtain blood during the procedure, first change tubes, then reposition the needle by pulling back and loosen the tourniquet.
A butterfly needle set should only be used if necessary.
Dermal punctures are similar procedures with the exception of the site of puncture and the type of equipment used.
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54. Pleasure in the job puts perfection in the work. --Aristotle
END OF CHAPTER 4
Pleasure in the job puts perfection in the work.
--Aristotle
Chapter 4