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.
It is the phlebotomist’s responsibility to make sure that information on the requisition is correct before drawing the patient’s blood.

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.
Labels may accompany computer generated labels. The requisition may indicate the need for any special handling like chilling or protection from light.

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.
Resolve any discrepancies before drawing the patient.

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.
Specific information about test purposes and results should come from the physician.
ID errors can lead to incorrect patient diagnosis, treatment and possibly death.

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.
You may also ask an outpatient to present a photo ID.

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.
Make sure to practice standard precautions by washing your hands at the beginning and end of the procedure and wearing gloves.
Standing patients could faint and there is no way to stabilize the arm.

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.
If the patient is of legal age and of sound mind, you must get his consent. A patient does have the right to refuse.

13. Routine Venipuncture
3. Assemble your equipment in front of the patient.
Point out all the equipment and demonstrate how to assemble.

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.
On hairy arms, tie the tourniquet over clothing. Do not place the tourniquet over a rash or open sore.

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.
The tourniquet should not be on so tight that the arm turns red or purple; fingers should not tingle and you should be able to still feel a radial pulse.

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.
Blood can be drawn from the wrist and hand, but will require the use of a winged infusion set to avoid hemolysis.

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.
The antecubital fossa is the anterior surface of the arm distal to the elbow.

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.
No fanning or blowing to speed up the drying time. Doing so will contaminate the site.

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.
If you are right handed, you will anchor with your left thumb and insert the needle with your right hand. Do just the reverse if you are left handed. Make sure that you are wearing gloves. The tighter you pull the skin, the easier the needle goes in.

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.
The slower you go, the more the puncture will hurt.

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.
A hematoma is a red, swollen area where blood collects under the skin. If the needle is removed before the tourniquet, the pressure from the tourniquet forces blood out through the puncture.

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.
It is important to use the dominant hand to steady the holder while the tubes are being changed to prevent the needle from moving in and out of the vein.
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.
Patients on blood thinners may require additional time to get the bleeding to stop.

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.
Never label a tube prior to collection. If manually labeling, make sure to use a black ball point pen or a permanent marker.

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.
On out patients, make sure that the patient is not having any more tests before you tell them to eat; patient may be having x-rays.

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 Prepare the syringe and perform the venipuncture as in steps 8 and 10 of Procedure 9-1.
Make sure to attach the needle tightly to the tip of the syringe so no air can enter the system. Break the seal by moving the plunger back and forth prior to performing the stick.

30. Routine Venipuncture - Syringe
Point out the equipment associated with a syringe draw especially the syringe transfer device.
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.
Remember that there is no additive in the syringe, so the clotting process begins as soon as the blood enters the barrel.
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 Activate safety device.
Remove the needle once the safety device has been activated and discard in a sharps container.
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.
The vacuum in the tubes will draw the blood in; there is no need to push down on the plunger of the syringe.

34. Routine Venipuncture - Syringe
Make sure to note that the syringe is upright and that there is no need to push on the syringe for the tubes to fill.
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 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.