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BLOOD COLLECTION:

ROUTINE VENIPUNCTURE AND SPECIMEN


HANDLING

Objectives for the tutorial:

• Describe and perform the venipuncture process including:


1. Proper patient identification procedures.
2. Proper equipment selection and use.
3. Proper labeling procedures and completion of laboratory requisitions.
4. Order of draw for multiple tube phlebotomy.
5. Preferred venous access sites, and factors to consider in site selection, and
ability to differentiate between the feel of a vein, tendon and artery.
6. Patient care following completion of venipuncture.
7. Safety and infection control procedures.
8. Quality assurance issues.
• Identify the additive, additive function, volume, and specimen considerations to
be followed for each of the various color coded tubes.
• List six areas to be avoided when performing venipuncture and the reasons for the
restrictions.
• Summarize the problems that may be encountered in accessing a vein, including
the procedure to follow when a specimen is not obtained.
• List several effects of exercise, posture, and tourniquet application upon
laboratory values.

VENIPUNCTURE PROCEDURE

The venipuncture procedure is complex, requiring both knowledge and skill to


perform. Each phlebotomist generally establishes a routine that is comfortable for
her or him. Several essential steps are required for every successful collection
procedure:

1. Identify the patient.


2. Assess the patient's physical disposition (i.e. diet, exercise, stress,
basal state).
3. Check the requisition form for requested tests, patient information,
and any special requirements.
4. Select a suitable site for venipuncture.
5. Prepare the equipment, the patient and the puncture site.
6. Perform the venipuncture.
7. Collect the sample in the appropriate container.
8. Recognize complications associated with the phlebotomy
procedure.
9. Assess the need for sample recollection and/or rejection.
10. Label the collection tubes at the bedside or drawing area.
11. Promptly send the specimens with the requisition to the laboratory.

ORDER FORM / REQUISITION

A requisition form must accompany each sample submitted to the laboratory. This
requisition form must contain the proper information in order to process the
specimen. The essential elements of the requisition form are:

• Patient's surname, first name, and middle initial.


• Patient's ID number.
• Patient's date of birth and sex.
• Requesting physician's complete name.
• Source of specimen. This information must be given when requesting
microbiology, cytology, fluid analysis, or other testing where analysis and
reporting is site specific.
• Date and time of collection.
• Initials of phlebotomist.
• Indicating the test(s) requested.

An example of a simple requisition form with the essential elements is shown


below:
LABELING THE SAMPLE

A properly labeled sample is essential so that the results of the test match the
patient. The key elements in labeling are:

o Patient's surname, first and middle.


o Patient's ID number.
o NOTE: Both of the above MUST match the same on the requisition form.
o Date, time and initials of the phlebotomist must be on the label of EACH
tube.

Automated systems may include labels with bar codes.

Examples of labeled collection tubes are shown below:

EQUIPMENT:

THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE:

o Evacuated Collection Tubes - The tubes are designed to fill with a


predetermined volume of blood by vacuum. The rubber stoppers are color
coded according to the additive that the tube contains. Various sizes are
available. Blood should NEVER be poured from one tube to another since
the tubes can have different additives or coatings (see illustrations at end).
o Needles - The gauge number indicates the bore size: the larger the gauge
number, the smaller the needle bore. Needles are available for evacuated
systems and for use with a syringe, single draw or butterfly system.
o Holder/Adapter - use with the evacuated collection system.
o Tourniquet - Wipe off with alcohol and replace frequently.
o Alcohol Wipes - 70% isopropyl alcohol.
o Povidone-iodine wipes/swabs - Used if blood culture is to be drawn.
o Gauze sponges - for application on the site from which the needle is
withdrawn.
o Adhesive bandages / tape - protects the venipuncture site after collection.
o Needle disposal unit - needles should NEVER be broken, bent, or
recapped. Needles should be placed in a proper disposal unit
IMMEDIATELY after their use.
o Gloves - can be made of latex, rubber, vinyl, etc.; worn to protect the
patient and the phlebotomist.
o Syringes - may be used in place of the evacuated collection tube for
special circumstances.

ORDER OF DRAW:

Blood collection tubes must be drawn in a specific order to avoid cross-


contamination of additives between tubes. The recommended order of draw for
plastic vacutainer tubes is:

1. First - blood culture bottle or tube (yellow or yellow-black top)


2. Second - coagulation tube (light blue top). If just a routine coagulation
assay is the only test ordered, then a single light blue top tube may be
drawn. If there is a concern regarding contamination by tissue fluids or
thromboplastins, then one may draw a non-additive tube first, and then the
light blue top tube.
3. Third - non-additive tube (red top)
4. Last draw - additive tubes in this order:
1. SST (red-gray or gold top). Contains a gel separator and clot
activator.
2. Sodium heparin (dark green top)
3. PST (light green top). Contains lithium heparin anticoagulant and a
gel separator.
4. EDTA (lavender top)
5. ACDA or ACDB (pale yellow top). Contains acid citrate dextrose.
6. Oxalate/fluoride (light gray top)

NOTE:Tubes with additives must be thoroughly mixed. Erroneous test results


may be obtained when the blood is not thoroughly mixed with the additive.

PROCEDURAL ISSUES

PATIENT RELATIONS AND IDENTIFICATION:

The phlebotomist's role requires a professional, courteous, and understanding


manner in all contacts with the patient. Greet the patient and identify yourself and
indicate the procedure that will take place. Effective communication - both verbal
and nonverbal - is essential.
Proper patient identification MANDATORY. If an inpatient is able to respond,
ask for a full name and always check the armband for confirmation. DO NOT
DRAW BLOOD IF THE ARMBAND IS MISSING. An outpatient must
provide identification other than the verbal statement of a name. Using the
requisition for reference, ask a patient to provide additional information such as a
surname or birthdate.

If possible, speak with the patient during the process. The patient who is at ease
will be less focused on the procedure. Always thank the patient and excuse
yourself courteously when finished.

PATIENT'S BILL OF RIGHTS:

The Patient's Bill of Rights has been adopted by many hospitals as declared by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The
basic patient rights endorsed by the JCAHO follow in condensed form are given
below.

The patient has the right to:

o Impartial access to treatment or accommodations that are available or


medically indicated, regardless of race, creed, sex, national origin, or
sources of payment for care.
o Considerate, respectful care.
o Confidentiality of all communications and other records pertaining to the
patient's care.
o Expect that any discussion or consultation involving the patient's case will
be conducted discretely and that individuals not directly involved in the
case will not be present without patient permission.
o Expect reasonable safety congruent with the hospital practices and
environment.
o Know the identity and professional status of individuals providing service
and to know which physician or other practitioner is primarily responsible
for his or her care.
o Obtain from the practitioner complete and current information about
diagnosis, treatment, and any known prognosis, in terms the patient can
reasonably be expected to understand.
o Reasonable informed participation in decisions involving the patient's
health care. The patient shall be informed if the hospital proposes to
engage in or perform human experimentation or other research/educational
profits affecting his or her care or treatment. The patient has the right to
refuse participation in such activity.
o Consult a specialist at the patient's own request and expense.
o Refuse treatment to the extent permitted by law.
o Regardless of the source of payment, request and receive an itemized and
detailed explanation of the total bill for services rendered in the hospital.
o Be informed of the hospital rules and regulations regarding patient
conduct.

VENIPUNCTURE SITE SELECTION:

Although the larger and fuller median cubital and cephalic veins of the arm are
used most frequently, the basilic vein on the dorsum of the arm or dorsal hand
veins are also acceptable for venipuncture. Foot veins are a last resort because of
the higher probability of complications.

Certain areas are to be avoided when choosing a site:

o Extensive scars from burns and surgery - it is difficult to puncture the scar
tissue and obtain a specimen.
o The upper extremity on the side of a previous mastectomy - test results
may be affected because of lymphedema.
o Hematoma - may cause erroneous test results. If another site is not
available, collect the specimen distal to the hematoma.
o Intravenous therapy (IV) / blood transfusions - fluid may dilute the
specimen, so collect from the opposite arm if possible. Otherwise,
satisfactory samples may be drawn below the IV by following these
procedures:

 Turn off the IV for at least 2 minutes before venipuncture.


 Apply the tourniquet below the IV site. Select a vein other than the
one with the IV.
 Perform the venipuncture. Draw 5 ml of blood and discard before
drawing the specimen tubes for testing.
o Cannula/fistula/heparin lock - hospitals have special policies regarding
these devices. In general, blood should not be drawn from an arm with a
fistula or cannula without consulting the attending physician.
o Edematous extremities - tissue fluid accumulation alters test results.

PROCEDURE FOR VEIN SELECTION:

o Palpate and trace the path of veins with the index finger. Arteries pulsate,
are most elastic, and have a thick wall. Thrombosed veins lack resilience,
feel cord-like, and roll easily.
o If superficial veins are not readily apparent, you can force blood into the
vein by massaging the arm from wrist to elbow, tap the site with index and
second finger, apply a warm, damp washcloth to the site for 5 minutes, or
lower the extremity over the bedside to allow the veins to fill.

PERFORMANCE OF A VENIPUNCTURE:
o Approach the patient in a friendly, calm manner. Provide for their comfort
as much as possible, and gain the patient's cooperation.
o Identify the patient correctly.
o Properly fill out appropriate requisition forms, indicating the test(s)
ordered.
o Verify the patient's condition. Fasting, dietary restrictions, medications,
timing, and medical treatment are all of concern and should be noted on
the lab requisition.
o Check for any allergies to antiseptics, adhesives, or latex by observing for
armbands and/or by asking the patient.
o Position the patient. The patient should either sit in a chair, lie down or sit
up in bed. Hyperextend the patient's arm.
o Apply the tourniquet 3-4 inches above the selected puncture site. Do not
place too tightly or leave on more than 2 minutes.
o The patient should make a fist without pumping the hand.
o Select the venipuncture site.
o Prepare the patient's arm using an alcohol prep. Cleanse in a circular
fashion, beginning at the site and working outward. Allow to air dry.
o Grasp the patient's arm firmly using your thumb to draw the skin taut and
anchor the vein. The needle should form a 15 to 30 degree angle with the
surface of the arm. Swiftly insert the needle through the skin and into the
lumen of the vein. Avoid trauma and excessive probing.

o When the last tube to be drawn is filling, remove the tourniquet.


o Remove the needle from the patient's arm using a swift backward motion.
o Press down on the gauze once the needle is out of the arm, applying
adequate pressure to avoid formation of a hematoma.
o Dispose of contaminated materials/supplies in designated containers.
o Mix and label all appropriate tubes at the patient bedside.
o Deliver specimens promptly to the laboratory.

PHLEBOTOMY PROCEDURE ILLUSTRATED:

o Patient identification
o Filling out the requisition
o Equipment
o Apply tourniquet and palpate for vein
o Sterilize the site
o Insert needle
o Drawing the specimen
o Drawing the specimen
o Releasing the tourniquet
o Applying pressure over the vein
o Applying bandage
o Disposing needle into sharps
o labeling the specimens

PERFORMANCE OF A FINGERSTICK:

o Follow the procedure as outlined above for greeting and identifying the
patient. As always, properly fill out appropriate requisition forms,
indicating the test(s) ordered.
o Verify the patient's condition. Fasting, dietary restrictions, medications,
timing, and medical treatment are all of concern and should be noted on
the lab requisition.
o Position the patient. The patient should either sit in a chair, lie down or sit
up in bed. Hyperextend the patient's arm.
o The best locations for fingersticks are the 3rd (middle) and 4th (ring)
fingers of the non-dominant hand. Do not use the tip of the finger or the
center of the finger. Avoid the side of the finger where there is less soft
tissue, where vessels and nerves are located, and where the bone is closer
to the surface. The 2nd (index) finger tends to have thicker, callused skin.
The fifth finger tends to have less soft tissue overlying the bone. Avoid
puncturing a finger that is cold or cyanotic, swollen, scarred, or covered
with a rash.
o Using a sterile lancet, make a skin puncture just off the center of the finger
pad. The puncture should be made perpendicular to the ridges of the
fingerprint so that the drop of blood does not run down the ridges.
o Wipe away the first drop of blood, which tends to contain excess tissue
fluid.
o Collect drops of blood into the collection device by gently massaging the
finger. Avoid excessive pressure that may squeeze tissue fluid into the
drop of blood.
o Cap, rotate and invert the collection device to mix the blood collected.
o Have the patient hold a small gauze pad over the puncture site for a couple
of minutes to stop the bleeding.
o Dispose of contaminated materials/supplies in designated containers.
o Label all appropriate tubes at the patient bedside.
o Deliver specimens promptly to the laboratory.

FINGERSTICK PROCEDURE ILLUSTRATED:


o Equipment
o Proper location on finger
o Puncture with lancet
o Drop of blood
o Wipe first drop
o Collecting the specimen
o Specimen container

ADDITIONAL CONSIDERATIONS:

To prevent a hematoma:

o Puncture only the uppermost wall of the vein


o Remove the tourniquet before removing the needle
o Use the major superficial veins
o Make sure the needle fully penetrates the upper most wall of the vein.
(Partial penetration may allow blood to leak into the soft tissue
surrounding the vein by way of the needle bevel)
o Apply pressure to the venipuncture site

To prevent hemolysis (which can interfere with many tests):

o Mix tubes with anticoagulant additives gently 5-10 times


o Avoid drawing blood from a hematoma
o Avoid drawing the plunger back too forcefully, if using a needle and
syringe, and avoid frothing of the sample
o Make sure the venipuncture site is dry
o Avoid a probing, traumatic venipuncture

Indwelling Lines or Catheters:

o Potential source of test error


o Most lines are flushed with a solution of heparin to reduce the risk of
thrombosis
o Discard a sample at least three times the volume of the line before a
specimen is obtained for analysis

Hemoconcentration: An increased concentration of larger molecules and formed


elements in the blood may be due to several factors:

o Prolonged tourniquet application (no more than 2 minutes)


o Massaging, squeezing, or probing a site
o Long-term IV therapy
o Sclerosed or occluded veins

Prolonged Tourniquet Application:


o Primary effect is hemoconcentration of non-filterable elements (i.e.
proteins). The hydrostatic pressure causes some water and filterable
elements to leave the extracellular space.
o Significant increases can be found in total protein, aspartate
aminotransferase (AST), total lipids, cholesterol, iron
o Affects packed cell volume and other cellular elements

Patient Preparation Factors:

o Therapeutic Drug Monitoring: different pharmacologic agents have


patterns of administration, body distribution, metabolism, and elimination
that affect the drug concentration as measured in the blood. Many drugs
will have "peak" and "trough" levels that vary according to dosage levels
and intervals. Check for timing instructions for drawing the appropriate
samples.
o Effects of Exercise: Muscular activity has both transient and longer lasting
effects. The creatine kinase (CK), aspartate aminotransferase (AST),
lactate dehydrogenase (LDH), and platelet count may increase.
o Stress: May cause transient elevation in white blood cells (WBC's) and
elevated adrenal hormone values (cortisol and catecholamines). Anxiety
that results in hyperventilation may cause acid-base imbalances, and
increased lactate.
o Diurnal Rhythms: Diurnal rhythms are body fluid and analyte fluctuations
during the day. For example, serum cortisol levels are highest in early
morning but are decreased in the afternoon. Serum iron levels tend to drop
during the day. You must check the timing of these variations for the
desired collection point.
o Posture: Postural changes (supine to sitting etc.) are known to vary lab
results of some analytes. Certain larger molecules are not filterable into
the tissue, therefore they are more concentrated in the blood. Enzymes,
proteins, lipids, iron, and calcium are significantly increased with changes
in position.
o Other Factors: Age, gender, and pregnancy have an influence on
laboratory testing. Normal reference ranges are often noted according to
age.

SAFETY AND INFECTION CONTROL

Because of contacts with sick patients and their specimens, it is important to


follow safety and infection control procedures.

PROTECT YOURSELF

o Practice universal precautions:


 Wear gloves and a lab coat or gown when handling blood/body
fluids.
 Change gloves after each patient or when contaminated.
 Wash hands frequently.
 Dispose of items in appropriate containers.
o Dispose of needles immediately upon removal from the patient's vein. Do
not bend, break, recap, or resheath needles to avoid accidental needle
puncture or splashing of contents.
o Clean up any blood spills with a disinfectant such as freshly made 10%
bleach.
o If you stick yourself with a contaminated needle:
 Remove your gloves and dispose of them properly.
 Squeeze puncture site to promote bleeding.
 Wash the area well with soap and water.
 Record the patient's name and ID number.
 Follow institution's guidelines regarding treatment and follow-up.
 NOTE: The use of prophylactic zidovudine following blood
exposure to HIV has shown effectiveness (about 79%) in
preventing seroconversion

PROTECT THE PATIENT

o Place blood collection equipment away from patients, especially children


and psychiatric patients.
o Practice hygiene for the patient's protection. When wearing gloves, change
them between each patient and wash your hands frequently. Always wear
a clean lab coat or gown.

TROUBLESHOOTING GUIDELINES:

IF AN INCOMPLETE COLLECTION OR NO BLOOD IS OBTAINED:

o Change the position of the needle. Move it forward (it may not be in the
lumen)
o or move it backward (it may have penetrated too far).

o Adjust the angle (the bevel may be against the vein wall).

o Loosen the tourniquet. It may be obstructing blood flow.


o Try another tube. There may be no vacuum in the one being used.
o Re-anchor the vein. Veins sometimes roll away from the point of the
needle and puncture site.

IF BLOOD STOPS FLOWING INTO THE TUBE:

o The vein may have collapsed; resecure the tourniquet to increase venous
filling. If this is not successful, remove the needle, take care of the
puncture site, and redraw.
o The needle may have pulled out of the vein when switching tubes. Hold
equipment firmly and place fingers against patient's arm, using the flange
for leverage when withdrawing and inserting tubes.

PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:

o A hematoma forms under the skin adjacent to the puncture site - release
the tourniquet immediately and withdraw the needle. Apply firm pressure.

Hematoma formation is a problem in older patients.

o The blood is bright red (arterial) rather than venous. Apply firm pressure
for more than 5 minutes.

BLOOD COLLECTION ON BABIES:

o The recommended location for blood collection on a newborn baby or


infant is the heel. The diagram below indicates in green the proper area to
use for heel punctures for blood collection:
o Prewarming the infant's heel (42 C for 3 to 5 minutes) is important to
obtain capillary blood gas samples and warming also greatly increases the
flow of blood for collection of other specimens. However, do not use too
high a temperature warmer, because baby's skin is thin and susceptible to
thermal injury.
o Clean the site to be punctured with an alcohol sponge. Dry the cleaned
area with a dry cotton sponge. Hold the baby's foot firmly to avoid sudden
movement.
o Using a sterile blood lancet, puncture the side of the heel in the
appropriate regions shown above in green. Do not use the central portion
of the heel because you might injure the underlying bone, which is close to
the skin surface. Do not use a previous puncture site. Make the cut across
the heelprint lines so that a drop of blood can well up and not run down
along the lines.
o Wipe away the first drop of blood with a piece of clean, dry cotton. Since
newborns do not often bleed immediately, use gentle pressure to produce a
rounded drop of blood. Do not use excessive pressure or heavy massaging
because the blood may become diluted with tissue fluid.
o Fill the capillary tube(s) or micro collection device(s) as needed.
o When finished, elevate the heel, place a piece of clean, dry cotton on the
puncture site, and hold it in place until the bleeding has stopped.
o Be sure to dispose of the lancet in the appropriate sharps container.
Dispose of contaminated materials in appropriate waste receptacles.
Remove your gloves and wash your hands.

HEELSTICK PROCEDURE ILLUSTRATED:

o Heelstick on baby
COLLECTION TUBES FOR PHLEBOTOMY

Red Top

ADDITIVE None
MODE OF Blood clots, and the serum is separated by
ACTION centrifugation
Chemistries, Immunology and Serology,
USES
Blood Bank (Crossmatch)

Gold Top

ADDITIVE None
Serum separator tube (SST) contains a gel
MODE OF
at the bottom to separate blood from serum
ACTION
on centrifugation
USES Chemistries, Immunology and Serology

Light
Green Top

Plasma Separating Tube (PST) with


ADDITIVE
Lithium heparin
Anticoagulates with lithium heparin;
MODE OF
Plasma is separated with PST gel at the
ACTION
bottom of the tube
USES Chemistries

Purple Top

ADDITIVE EDTA
MODE OF
Forms calcium salts to remove calcium
ACTION
Hematology (CBC) and Blood Bank
(Crossmatch); requires full draw - invert 8
USES
times to prevent clotting and platelet
clumping

Light Blue
Top

ADDITIVE Sodium citrate


MODE OF
Forms calcium salts to remove calcium
ACTION
Coagulation tests (protime and prothrombin
USES
time), full draw required

Green Top

ADDITIVE Sodium heparin or lithium heparin


MODE OF
Inactivates thrombin and thromboplastin
ACTION
For lithium level, use sodium heparin
USES For ammonia level, use sodium or lithium
heparin

Dark Blue
Top

ADDITIVE EDTA-
MODE OF Tube is designed to contain no
ACTION contaminating metals
Trace element testing (zinc, copper, lead,
USES
mercury) and toxicology
Light Gray
Top

ADDITIVE Sodium fluoride and potassium oxalate


MODE OF Antiglycolytic agent preserves glucose up
ACTION to 5 days
Glucoses, requires full draw (may cause
USES
hemolysis if short draw)

Yellow Top

ADDITIVE ACD (acid-citrate-dextrose)


MODE OF
Complement inactivation
ACTION
HLA tissue typing, paternity testing, DNA
USES
studies

Yellow -
Black Top

ADDITIVE Broth mixture


MODE OF
Preserves viability of microorganisms
ACTION
USES Microbiology - aerobes, anaerobes, fungi

Black Top

ADDITIVE Sodium citrate (buffered)


MODE OF
Forms calcium salts to remove calcium
ACTION
Westergren Sedimentation Rate; requires
USES
full draw
Orange
Top

ADDITIVE Thrombin
MODE OF
Quickly clots blood
ACTION
USES STAT serum chemistries

Light
Brown Top

ADDITIVE Sodium heparin


MODE OF Inactivates thrombin and thromboplastin;
ACTION contains virtually no lead
USES Serum lead determination

Pink Top

ADDITIVE Potassium EDTA


MODE OF
Forms calcium salts
ACTION
USES Immunohematology

White Top

ADDITIVE Potassium EDTA


MODE OF
Forms calcium salts
ACTION
USES Molecular/PCR and bDNA testing
BLOOD CULTURE COLLECTION PROCEDURE
PRINCIPLE: To outline procedure for the proper collection of blood cultures by
venipuncture.
SPECIMEN:
1. Factors to Consider in Site Selection:
A. Scarring - Avoid areas with extensive scarring.
B. Bruising - Specimens collected from a hematoma area may cause erroneous
results.
C. IV Therapy - Do not collect specimen from a site above an IV site. Preferably,
use
opposite arm.
D. Mastectomy - Specimens should not be taken from the side on which a
mastectomy was performed.
E. Cannulas, Fistulas, or Vascular Grafts - Use arm only after consultation with
the
physician.
F. Feet - Feet should not be used unless approved by a physician. Consult with
the
nurse manager/supervisor before drawing a patient with a foot order.
G. Blood cultures are not to be drawn from indwelling intravenous or intraarterial
catheter unless specifically ordered by a physician.
H. Blood cultures are not to be drawn by heelstick.
2. Specimen Type and handling conditions:
Two full yellow vacutainer tubes are required for adults. One pediatric yellow
vacutainer tube is required for neonates and pediatric patients.
Proper skin disinfection is an essential requirement to reduce the incidence of
contamination.
EQUIPMENT AND MATERIALS:
Blood Culture Collection Kit containing:
-70% isopropyl alcohol swabs Tourniquet
-Yellow top vacutainer collection tubes 2x2 gauze pads
-10% Povidone-Iodine Swabstick Needles: 20, 21, 22, or 23 gauge
-Specimen bag Tape
-Instructions Sharps container
Clean Gloves
Vacutainer holder
ST. PETER’S BENDER LABORATORY
St. Peter’s Hospital
SPECIMEN COLLECTION
Blood Culture Procedure
2/09 2
PROCEDURE:
1. Ascertain the physician order and refer to SPH Laboratory Resource Manual
or laboratory
collection list for test requirements.
2. Identify and explain the procedure to the patient. No patient should be drawn
without a
wristband or proper identification.
3. Wash hands and put on gloves.
4. Assemble all equipment needed to perform the procedure.
5. Position the patient for procedure. The patient should be lying down or seated
with their
arm supported.
6. Disinfect the tops of two yellow blood culture vacutainer tubes with separate
povidone
iodine swabsticks. Disinfect one pediatric yellow blood culture vacutainer tube for
use
with neonates and pediatric patients.
7. Apply tourniquet 3 - 4 inches above intended site.
8 Have patient make a fist.
9. Palpate for a vein and select site, preferably in the antecubital fossa.
10. Site preparation.
a. Vigorously cleanse the venipuncture site with 70% isopropyl alcohol swabs
and allow
to dry.
b. Starting at the center of the site, swab concentrically with 10% povidone iodine
swabsticks for 1 minute.
c. Allow the site to dry.
d. Do not touch the venipuncture site after preparation and prior to phlebotomy.
e. The skin of patients with known hypersensitivity to iodine can be prepared with
a
double application of 70% isopropyl alcohol by performing step 9. a. twice.
11. Have patient release fist.
12. Using thumb and index finger, anchor the vein.
13. With needle bevel up, puncture the vein.
14. Push tube onto the needle. Blood should flow into the tube.
If a blood sample cannot be obtained:
a. Change position of the needle.
1) Withdraw the needle a small distance.
2) Insert the needle deeper a small distance.
3) Rotate needle half a turn.
b. Try another tube.
c. Loosen the tourniquet.
d. Excessive probing is not recommended and should be avoided as this is
painful to the patient.
e. Do not attempt a venipuncture more than twice.

SPECIMEN COLLECTION
15. Remove tourniquet within one minute of application.
16. Remove tube when filled and continue with next tube if any.
The order of draw for multiple tubes is:
(1) Yellow top tube (Blood Culture)
(2) Red top tube (Glass) No additive
(3) Blue top tube (Coagulation)
(4) Gold top tube (SST Gel Sep)
(5) Red top tube (Plastic) With clot activator
(6) Green top tube (Heparin)
(7) Lavender top tube (EDTA)
(8) Pink top tube (Blood bank tube)
(9) Grey top tube (Glycolytic inhibitor)
17. Gently invert all additive tubes 5 - 10 times. Avoid aggressive shaking of
tubes.
18. Remove needle from patient’s arm. Immediately apply pressure with a 2x2
gauze to
stop bleeding. Continue applying pressure until patient stops bleeding to avoid
unnecessary bruising. Tape gauze to puncture site.
19. Dispose of needle in sharps container and dispose of other waste in proper
container.
20. Label all tubes with a hospital computer label. If one is not available, the label
must
contain the patient’s name and date of birth. Record the date and time of
collection
and the phlebotomist’s initials on the requisition slip or collection list.
21. Insert specimen in specimen bag (or specimen racks for 6:00 am draws).
22. Remove gloves and wash hands.
23. Deliver to the Laboratory, Central Receiving room 1249 within 2 hours of
collection.
24. After phlebotomy, cleanse the site with 70% isopropyl alcohol pad to remove
remaining iodine, which can cause irritation in some patients.

rotating tourniquet
[rō′tāting]
Etymology: L, rotare, to rotate; Fr, tourniquet, garrote
one of four constricting devices used in a rotating order to pool blood in the extremities.
The purpose is to relieve congestion in the lungs in the treatment of acute pulmonary
edema. Use of the rotating tourniquet has declined with the development of vasodilating
drugs and diuretics.
rotating tourniquet
Cardiology A modality for ↓ preload in acute cardiogenic pulmonary edema, in which the
blood flow to the extremities is blocked by RTs; because preload is ↓ more precisely with
nitroprusside, RTs are rarely used
I.
Description
Provides instruction for performing a venipuncture on an adult
Table of Contents
I.
Description ............................................................................................................................
............. 1
II.
Rationale ...............................................................................................................................
............. 1
III.
Policy/Procedure ...................................................................................................................
............. 1
A.
Policy.....................................................................................................................................
....... 1
B.
Procedure...............................................................................................................................
...... 1
IV.
References .............................................................................................................................
............ 4
V. Reviewed/Approved
by ....................................................................................................................... 4
VI. Original Policy Date and
Revisions ..................................................................................................... 4
Figure / Table List
Table 1: Tube Draw
Order ........................................................................................................................ 3
II.
Rationale
Accurate specimen collection and proper specimen handling are of the utmost importance
because errors are more likely to occur in these areas than during the laboratory analysis
itself.
III.
Policy/Procedure
A.
Policy
The blood collection procedure requires both skill and knowledge. Several steps in this
process are an essential part of every successful collection. It is important that each
phlebotomist establish a routine for blood collection that incorporates these essential
steps. Performing a venipuncture should be comfortable for the phlebotomist and should
enable the phlebotomist to complete the procedure in a timely manner
B.
Procedure
These steps should be followed in order to perform a successful venipuncture.
1.
The request for blood collection must contain the Medical Record Number, patient’s last
name, first name, middle/maiden initial, date of birth, sex and race. The information is
entered into the Laboratory Information System and an LIS order number is accessioned
and printed on the label. The outpatient requisition or computer generated patient label
will be used by the phlebotomist to identify the patient.
2.
Approach the patient in a calm, confident and professional manner. LAB 0025 Page 1 of
4
Adult Venipuncture
LAB 0025 Page 2 of 4
a.
The phlebotomist must gain the patient’s confidence assure the patient that, although the
venipuncture will be slightly painful, it will be short in duration and necessary for the
diagnosis and treatment of their health care problem.
b.
The phlebotomist may be able to help the patient feel more comfortable by giving as
much information as possible regarding the venipuncture procedure. Never, under any
circumstances, should the phlebotomist tell the patient what disease or condition a
specific blood test will detect.
3.
Identify the patient according to Inpatient or Outpatient Identification procedures.
4.
Determine the best site for venipuncture according to the Venipuncture Site Selection
Guidelines procedure.
5.
Select equipment and method of blood collection based on assessment of the patient’s
veins.
a.
The preferred procedure for venipuncture is the evacuated tube method. This procedure
should always be the first procedure of choice.
b.
In some instances the phlebotomist may need to use a procedure that allows more
flexibility and stability (i.e. small hand veins or veins in the back of the wrist.). In this
case the butterfly (winged infusion set) needle may be used.
6.
Prepare equipment and don gloves at any point prior to the actual venipuncture.
7.
Insure proper positioning of the patient’s arm. Position the arm so that it is resting on a
table or on the bed alongside the patient. The arm should be supported firmly and should
not be bent at the elbow. If necessary, place a pillow under the arm to provide additional
support. Lower bedrails, if necessary, but be sure to replace rails to the upright position.
8.
Apply the tourniquet.
a.
Under ideal conditions, the tourniquet should be applied to 3 to 4 inch clearance. Always
allow at least a 1 to 2 inch clearance between the IV or med lock and the tourniquet.
b.
Ideally, the tourniquet should not be applied for longer than one or two minutes at a time.
Leaving the tourniquet applied for an excessive period of time (>2 minutes) may cause
localized stasis, formation of a partial filtrate of blood and hemoconcentration. These
may result in erroneously high values for all protein-based analytes, packed cell volume,
and other cellular elements.
9.
Cleanse venipuncture site with alcohol using a circular motion form the center to the
pheriphery.
10.
Allow the area to dry before venipuncture.
11.
Alert the patient before venipuncture.
12.
Anchor the vein and smoothly insert needle with bevel up. Use the thumb to draw the
skin taut. This anchors the vein. The thumb should be 1 or 2 inches below the
venipuncture site.
a.
Each phlebotomist is permitted only two unsuccessful venipunctures per patient. If a third
attempt is needed, the phlebotomist must contact a lead tech for a decision regarding any
subsequent attempts.
b.
A clean, sterile needle must be used for each new collection attempt. NEVER restick a
patient using the same needle.
13.
Calmly make adjustments if blood does not flow.
Adult Venipuncture
LAB 0025 Page 3 of 4
a.
Change the position of the needle.
i.
If the needle has penetrated too far into the vein, pull it back a bit.
ii.
If the needle has not penetrated far enough, advance it further into the vein.
iii.
Carefully rotate the needle to assure that the bevel is up. (This step is particularly useful
when using a butterfly as they tend to turn over if not anchored properly.)
b.
Try another tube if you feel you are in the vein but the tube may lack vacuum.
c.
Loosen the tourniquet. This is particularly helpful with babies, less so with adults.
i.
The tourniquet may have been applied too tightly, thereby stopping the blood flow.
ii.
If blood flow is adequate after tourniquet removal it is not necessary to reapply the
tourniquet.
iii.
If blood flow is still not adequate, loosely reapply the tourniquet.
14.
Release the tourniquet as soon as the blood begins to flow.
15.
Collect the proper amount of blood for tests ordered.
Note:
Collect tubes in proper order according to the NCCLS guidelines. Suggested order of
draw is as follows.
Table 1: Tube Draw Order
a.
Blood Culture
b.
Royal Blue
c.
Red (No additive)
d.
Light Blue (Sodium Citrate)
e.
Serum Separation (Gold Top w/ gel in bottom)
f.
Green (Sodium Heparin)
g.
Yellow (ACD Solution)
h.
Pink (TMS)
i.
Pearl
j.
Lavender (EDTA)
16.
Gently invert anticoagulated tubes as they are collected in order to eliminate clotting.
17.
Apply pressure to site after withdrawing needle.
18.
Dispose of needle properly and carefully in the appropriate container.
19.
Check site to ascertain if bleeding has completely stopped.
20.
Apply a gauze bandage. Tape it down with medical tape. Paper tape is preferred.
21.
Clean up supplies and waste.
22.
Label tubes according to the Specimen Labeling procedure.
23.
Dismiss the patient in a courteous and professional manner