1. Venipuncture

2. Objectives: List basic concepts and guidelines for venipuncture.
List the supplies needed to perform venipuncture.
Define common complications of venipuncture.
List documentation requirements for venipuncture.
Perform venipuncture to collect a laboratory specimen.

3. Describe and perform the venipuncture process including:
Proper patient identification procedures.
Proper equipment selection and use.
Proper labeling procedures and completion of laboratory requisitions.
Order of draw for multiple tube phlebotomy.
Preferred venous access sites, and factors to consider in site selection, and ability to differentiate between the feel of a vein, tendon and artery.
Patient care following completion of venipuncture.

4. Safety and infection control procedures.
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.

5. 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.
Infection control procedures

6. Purpose of venipuncture
To obtain blood for a specimen
To infuse fluids and blood
To administer medication
Diagnostic tests

7. What is the Venifuncture procedure?
Venipuncture, venopuncture or venepuncture is the process of obtaining intravenous access for the purpose of intravenous therapy or for blood sampling of venous blood.
This procedure is performed by medical laboratory scientists, medical practitioners, some MTs, paramedics,phlebotomists, dialysis technicians and other nursing staff.

8. PROCEDURE
1.    Identify the patient.  Outpatients are called into the phlebotomy area and asked their name and date of birth.  This information must match the requisition.  Inpatients are identified by their arm band.        If it has been removed, a nurse must install a new one before the patient can be drawn.
2.    Reassure the patient that the minimum amount of blood required for testing will be drawn.
3.    Assemble the necessary equipment appropriate to the patient's physical characteristics. 4.    Wash hands and put on gloves. 5.    Position the patient with the arm extended to form a straight-line form shoulder to wrist.
6.    Do not attempt a venipuncture more than twice.  Notify your supervisor or patient's physician if unsuccessful.

9. 7. Select the appropriate vein for venipuncture
7.    Select the appropriate vein for venipuncture.          The larger median cubital, basilic and cephalic veins are most frequently used, but other may be necessary        and will become more prominent if the patient closes his fist tightly.  At no time may phlebotomist perform venipuncture on an artery.  At no time will blood be drawn from the feet.        Factors to consider in site selection:             * Extensive scarring or healed burn areas should be avoided             * Specimens should not be obtained from the arm on the same side as a mastectomy.             * Avoid areas of hematoma.             * If an IV is in place, samples may be obtained below but NEVER above the IV site.               * Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.             * Allow minutes after a transfusion is completed before obtaining a blood sample. 8.     Apply the tourniquet 3-4 inches above the collection site.  

10. Never leave the tourniquet on for over 1 minute
Never leave the tourniquet on for over 1 minute.         If a tourniquet is used for preliminary vein selection, release it and reapply after two minutes.
9.   Clean the puncture site by making a smooth circular pass over the site with the 70% alcohol pad,moving in an outward spiral from the zone of penetration.  Allow the skin to dry before proceeding.  Do not touch the puncture site after cleaning.
10.    Perform the venipuncture         A.    Attach the appropriate needle to the hub by removing the plastic cap over the small end of the                 needle and inserting into the hub, twisting it tight.         B.    Remove plastic cap over needle and hold bevel up.         C.    Pull the skin tight with your thumb or index finger just below the puncture site.           D.    Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and                  enter the vein in one smooth motion.         E.    Holding the hub securely, insert the first vacutainer tube following proper order of draw into                 the large end of the hub penetrating the stopper.  Blood should flow into the evacuated tube.             

11. After blood starts to flow, release the tourniquet and ask the patient to open his or her hand.         G.   When blood flow stops, remove the tube by holding the hub securely and pulling the tube off the needle.  If multiple tubes are needed, the proper order of draw to avoid cross contamination and erroneous results is as follows: 
  1.     Blood culture vials or bottles, sterile tubes                 2.     Coagulation tube (light blue top)                         (Routine PT/PTT may be performed if blue top is first tube collected.  It may be desirable to                         collect a second tube for other coagulation assays.)                 3.     Serum tube with or without clot activator or silica gel (Red or Gold)                 4.     Heparin tube (Green top)                 5.     EDTA (Lavender top)                 6.     Glycolytic inhibitor (Gray top)

12. H.    Each coagulation tube (light blue top) should be gently inverted 4 times after being removed from the hub.  Red and gold tops should be inverted 5 times.  All other tubes containing an additive should be gently inverted 8-10 times.  DO NOT SHAKE OR MIX VIGOROUSLY.                     I.    Place a gauze pad over the puncture site and remove the needle.                   Immediately apply slight pressure.  Ask the patient to apply pressure for at least 2 minutes.                   When bleeding stops, apply a fresh bandage, gauze or tape.         J.     Properly dispose of hub with needle attached  into a sharps container.  Label all tubes with                  patient labels, initials, date and time.
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:

13. 11. Venipuncture procedure using a syringe: A
11.    Venipuncture procedure using a syringe:         A.    Place a sheathed needle or butterfly on the syringe.           B.    Remove the cap and turn the bevel up.         C.    Pull the skin tight with your thumb or index finger just below the puncture site.           D.    Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and                 vein in one motion.         E.    Draw the desired amount of blood by pulling back slowly on the syringe stopper.         F.    Release the tourniquet.         G.    Place a gauze pad over the puncture site and quickly remove the needle.                  Immediately apply pressure.  Ask the patient to apply pressure to the gauze for at least 2 minutes.                  When bleeding stops, apply a fresh bandage, gauze or tape.         H.    Transfer blood drawn into the appropriate tubes as soon as possible using a needleless BD                Vacutainer Blood Transfer Device, as a delay could cause improper coagulation.                Gently invert tubes containing an additive 5-8 times.         I.    Dispose of the syringe and needle as a unit into an appropriate sharps container

14. Infant/Child Phlebotomy A. Confirm the patient's identification B
Infant/Child Phlebotomy         A.    Confirm the patient's identification         B.    Secure patient to Papoose apparatus for stabilization if child is unable to sit upright                on their own.         C.    Assemble the required supplies         D.    Select the collection site and proceed as routine phlebotomy.  If the child is old enough,collect blood as in an adult. 

15. 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.
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.
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 heel print lines so that a drop of blood can well up and not run down along the lines.

16. Wipe away the first drop of blood with a piece of clean, dry cotton
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.
Fill the capillary tube(s) or micro collection device(s) as needed.
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.
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.

17. EQUIPMENT:
THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE:
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).
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.
Holder/Adapter - use with the evacuated collection system.
Tourniquet - Wipe off with alcohol and replace frequently.
Alcohol Wipes - 70% isopropyl alcohol.

18. Povidone-iodine wipes/swabs - Used if blood culture is to be drawn.
Gauze sponges - for application on the site from which the needle is withdrawn.
Adhesive bandages / tape - protects the venipuncture site after collection.
Needle disposal unit - needles should NEVER be broken, bent, or recapped. Needles should be placed in a proper disposal unit IMMEDIATELY after their use.
Gloves - can be made of latex, rubber, vinyl, etc.; worn to protect the patient and the phlebotomist.
Syringes - may be used in place of the evacuated collection tube for special circumstances.

19. Safety Needles, 22g or less 2. Butterfly needles. 21g or less 3
Safety Needles, 22g or less 2.    Butterfly needles. 21g or less 3.    Syringes 4.    Blood Collection Tubes.  The vacuum tubes are designed to draw a predetermined volume of blood.          Tubes with different additives are used for collecting blood specimens for specific types of tests.          The color of the rubber stopper is used to identify these additives.          See Selecting the Appropriate Collection Tube  and Specimen Container Types. 5.    Tourniquets.  Latex-free tourniquets are available 6.    Antiseptic.  Individually packaged 70% isopropyl alcohol wipes. 7.    2x2 Gauze or cotton balls.   8.    Sharps Disposal Container.  An OSHA acceptable, puncture proof container marked "Biohazardous". 9.    Bandages or tape

20. 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.

22. Characteristics of a suitable vein
Large enough to receive the shaft of the needle
Visible and palpable
Intact

23. Use veins in uninjured arm
Do NOT use veins if IV fluids are being administered
Do NOT use veins that are thrombosed, tortuous, or rolling

24. Use Universal Precautions!!!
Antecubital space contains the most common venipuncture sites
Use Universal Precautions!!!

25. Promote vein distension
Patient clench and unclench fist
Tap area lightly
Have patient lower arm
Apply warm compress

26. Specimen label Patient’s full name FMP and Social Security Number
Rate or dependency status, branch of service, and active duty or retired.

27. Vacutainer holder and needle
Clean holder with soap and water
Vacutainer needle used for single or multi-draw type

28. Vacutainer tube Vacuum blood collection tube
Rubber stopper are color coded
Various sizes
3 sources to determine appropriate tube to be used

29. TUBES, Tubes, TUBES Order of Draw
to avoid cross-contamination of additives between tubes
Yellow-Black top: Blood culture, this is always FIRST.
Red-top: non-additive. Use this before using tubes containing additives
EXCEPTION: When using SYRINGE, this tubes is last.
Light-Blue top: Coagulation, contains sodium citrate
Last draw -additive tubes in this order
Dark-Green top: Used for Heparin
Lavender top: CBC
Gray-top: Glucose

30. Vocabulary Glossary of terms PPE-Personal Protective equipment
Wing-tipped needle set-Butterfly needle, used on elderly female patients

31. Define common complications of venipuncture.

32. Hematoma Needle has gone through the vein
Bevel is only partially in the vein
Insufficient pressure on a puncture site after needle is removed

33. Phlebitis
May result from repeated puncture of vein and/or improper technique

34. Septicemia Results from improper technique
Results from using contaminated equipment

35. Trauma Usually caused by probing with the needle
List documentation requirements for venipuncture

36. Patient Profile
Date lab was ordered
Date sample was sent to lab

37. Nursing Notes Date/time specimen drawn Specific test Disposition
Patient’s tolerance
Location specimen was drawn from

39. The Stick Apply tourniquet 2-4 inches above proposed venipuncture site
Cleanse area with antiseptic wipe; circular motion from center out
Anchor vein with thumb about 2 inches below site

40. The Stick...continued
Enter skin with the needle bevel up at a 15 degree angle in line with the vein
Insert the needle smoothly and confidently, deep enough to enter the vein
If using a syringe: Pull back on barrel with slow, even tension as blood fills syringe

41. Still Sticking
If using a vacutainer: as soon as needle enters vein, ease the tube forward into holder.
Release tourniquet before withdrawing needle.
Remove needle from vein, and place a sterile 2X2 over site with direct pressure.
Invert tube gently to mix additive.

42. Reminders Specimen handling: zip-lock bag with blood specimen enclosed
Wear gloves
Sharps management: No recapping, bending of needles. Place all sharps in proper sharps container.

43. CLASSROOM DEMONSTRATIOIN
Perform venipuncture to collect a laboratory specimen.

44. What are the Universal Precautions you follow during Venipuncture
Gloving
Hand washing
Gowning
Goggle
Prevention of needle recaping

45. Summary
and
Evaluation