Transcript Chapter 8x

CHAPTER 8
Venipuncture Procedures
Blood Collection Process
• Essential steps common to all procedures
• Each step must be evaluated carefully and in a detailed manner.
• Take care not to omit any of the essential components.
– Cleanse hands and review laboratory test orders.
– Approach, identify, and position the patient.
– Assess physical disposition (diet, allergies, etc.).
– Select and prepare equipment/supplies.
– Find and prepare/cleanse puncture site.
– Choose a venipuncture method.
– Collect samples in the correct order.
– Discard contaminated supplies.
– Label the samples and confirm identity.
– Assess patient to assure bleeding has stopped.
– Perform hand hygiene after the procedure.
– Manage and document special circumstances.
Using Standard Precautions
• Overview of the Blood Collection Process
– Hand hygiene and the use of gloves should be routine procedures & practiced for each
patient.
– Vital for well-being of the patient &health care worker
– Perform hand hygiene/gloving when in visual contact with each patient, before beginning,
then glove removal plush and hygiene after the procedure.
– A clean, pressed uniform or "scrubs“ with a lab coat is comfortable & instills professionalism
and hygiene.
Mentally Preparing for the Patient Encounter
• Prepare & assemble PPE, supplies, test requests/labels, pen, and appropriate patient
information.
• Identify the patient properly.
• Wash or sanitize hands with an alcohol-based hand gel, then put on gloves.
• Present a positive, professional appearance and temperament.
• Take a deep, cleansing breath.
• Check phlebotomy supplies, test requests/labels, pen, and patient information.
• If patient information is incomplete, the health care worker may not be able to identify the
patient correctly, or may not know which tubes to use to collect the blood.
• In such cases, obtain assistance from a laboratory supervisor or a nurse before collecting
the sample.
Assessing, Identifying, and Approaching the Patient
• Test Requisitions
– Transmitted electronically or on paper
– If the test ordered is not understood, consult a supervisor, laboratory technologist, or nurse
before the phlebotomy procedure.
• Knowing which tests are requested helps to prepare the patient appropriately & collect
the specimen in the appropriate tubes & in the correct order.
Patient Identification Process
• The Joint Commission National Patient Safety Goal
• Use “at least 2 patient identifiers(neither to be the patient’s room number) whenever
taking blood samples or administering medications or blood products.”
The Basics of Patient Identification
• 3-step Process
1.
Ask the patient to state and spell his/her full name and identification number or date of
birth.
For example: “Hello, sir, could you please verify your name and identification
number? Could you please spell your name for me?”
2. Compare the information stated with the laboratory request/labels.
3. Confirm the information with another verifiable source, e.g., hospital identification
armband, driver’s license, nurse, or parent).
• If all 3 steps indicate the same identity, proceed with the rest of the specimen collection
procedure.
Patient Identification Process
• Inpatient Identification
– Hospitalized patients (except those just entering an emergency room) must wear an
identification arm band indicating the first & last names and a unique hospital number.
• Inpatient Identification
– For inpatients, a three-way match should always be made with the ID armband, the test
request/labels, and the patient’s statement of his/her name, date of birth, ID number, and/or
address.
• Identification of Patients Who Are Sleeping
– A patient who is sleeping should be awakened to have the patient identity verified before
blood is collected.
– Verbal information should be compared with the information on the requisition and the
identification bracelet.
• Identification of Patients Who are Unconscious, Cognitively Impaired, Too Young to Identify
Themselves, Do Not Speak the Language, or Have Sensory Impairments
– For those patients who are unconscious, mentally incompetent, comatose, or cannot
speak the health care worker's language, a nurse, relative, or friend my identify them by
providing the patient's name, address, and identification number and/or date of birth.
Patient Identification Process
• Identification of Patients Who are Unconscious, Cognitively Impaired, Too Young to Identify
Themselves, Do Not Speak the Language, or Have Sensory Impairments
– This information should be compared with the information on the armband and the
request/label to confirm identity.
– The name of the individual who makes the positive identification should be documented.
• Emergency Room Patient Identification
– Patients often come to the emergency room (ER) unconscious and/or unidentified.
– A temporary master identification is assigned (hospital number attached to the patient’s
body by wristband or other suitable device) until a positive identification can be made.
– All blood sample tube labels must contain the master ID number so they can be cross
referenced.
Patient Identification Process
• Identification of Neonates and Babies
– A nurse or relative may confirm identify.
– ID band is often placed on the ankle
– Newborns may remain unnamed for a period of time so their ID bands containthe birth
mother’s name
– Use caution in cases of multiple births(twins, triplets, etc.)
– Confirm the following elements:
Name of baby if designated
Date of birth
Gender
Unique ID number
Mother’s last name
• Outpatient/Ambulatory Patient
Identification
– Ambulatory patients are normally called to a blood collection area from a waiting room.
– Identification process involves verbally asking for name, address, and/or birthdate.
– The verbal information is compared with the requisition and a form of identity.
• Physical Clues for Assessment of the Patient
– Observe clues about the patient’s disposition by being alert and listening carefully.
– A clue about something unusual may come after talking to the patient or after the
identification process has taken place and it should be noted.
Patient Identification Process
• Approaching the Patient
– Politely knock on the patient’s door.
– Introduce yourself and state which department you are from and that you have come to
collect a blood sample.
– Turn lights on gradually if patient was asleep.
– Explain that the physician ordered laboratory tests.
– Explain the procedure as supplies are being set up or as gloves are put on.
Equipment Selection and Preparation
• Positioning of the Patient and Venipuncture Site Selection
– Make the patient comfortable and safe and choose the least hazardous site for blood collection by
skin puncture or venipuncture.
– Know about useful devices and the positions and locations of veins.
• Venipuncture Site Selection
– The most common sites for venipuncture are in the antecubital area of the arm just below the bend
of the elbow.
– The median cubital vein, sometimes called the median vein, is preferred for venipuncture because it
is the easiest to obtain blood from, is reported to be less painful, and is less prone to injury.
• Venipuncture Site Selection
– The second choice of vein is the cephalic vein which lies on the outer edge of the arm.
– The third choice should be the basilic vein which lies on the inside edge of the antecubital fossa
area.
– Accidental arterial puncture may result in excessive bleeding and hematoma formation.
– Accidental nerve damage may also occur; if the patient experiences sharpshooting pain during the
venipuncture, discontinue the process immediately.
• Alternative Puncture Sites
– Arm veins cannot be used for venipunctures if:
Intravenous (IV) lines in both arms
Burned or scarred areas
Areas with a hematoma
Cast(s) on arm(s)
Thrombosed veins
Edematous arms
Mastectomy on one side only
Mastectomy on both sides
– Veins on the dorsal side (e.g., backside) of the hands or wrists are acceptable venipuncture sites if the median cubital, cephalic,
or basilic veins are inaccessible.
– Ankle and foot veins (on the dorsal or upper side) should be used only if arm veins have been determined to be unsuitable and
after proper training.
• Hard-to-Find Veins
–Warming the Puncture Site
Facilitates phlebotomy by increasing arterial blood flow to the area
Commercially available warming devices
A clean towel or a washcloth heated to about 42°C
– Position Arm in Downward Position & Hang arm with fingers pointed downward(1–2 minutes)
Uses gravity to fill veins to capacity
Use of a Tourniquet
• A tourniquet or blood pressure cuff makes veins more prominent and easier to puncture by causing
venous filling.
• A non-latex, single-use tourniquet about 1 inch (2.5 cm) wide and about15 to 18 inches (45 cm) long is
most comfortable for patients, affordable, and easy to use.
• After identifying the patient, performing hand hygiene, & donning gloves, select a clean latex-free
tourniquet.
• Wrap the ends of the tourniquet around the patient’s arm about 3 inches (7.6cm) above the venipuncture
area(antecubital area).
• Hold both ends of the tourniquet in one hand and use the other hand to tuck in a section next to the skin
and make a partial loop with the tourniquet
.• The tourniquet should be tight but not painful to the patient. Do not leave it on for more than a minute.
• Do not place it over sores or burned skin, but, depending on the policies of each health care facility, it
may be placed over a hospital gown sleeve or apiece of gauze.
• Palpate the antecubital area to locate the safest vein.
• Once a vein is selected, cleanse the area.• Release the tourniquet after the needle puncture, when
blood has begun to flow into the collection tubes.
• During the venipuncture, release the tourniquet with one hand, because the other hand will be holding
the needle and tubes.
• The partially looped tourniquet should allow for easy release by the healthcare worker.
• Once released, it can remain loosely on the arm or surface of the work area(e.g., bed or blood collection
chair)until the procedure is completed.
Cleansing the Puncture Site
• After patient ID, hand hygiene, donning gloves, & site selection, then clean the
antecubital area.
• Cleanse thoroughly with a 70% isopropanol (isopropyl alcohol) pad.
• Rub the site with the alcohol pad, working in concentric circles from the inside out.
• If the skin is particularly dirty, repeat the process with a new alcohol pad.
• Allow it to air-dry.
• Don’t blow or fan the area to dry it.
Venipuncture Methods
• Evacuated Tube System and Winged Infusion System, or Butterfly Method
– CLSI recommends that venipuncture specimens be collected with a system that enables
blood to flow directly into the tubes.
– Evacuated tube systems and winged infusion systems are widely available, equipped with
safety devices, and comply with CLSI recommendation.
Performing a Venipuncture
• After greeting, identifying, and assessing the patient, cleanse hands and don gloves.
• Assemble equipment in the presence of the patient.
• Double check expiration dates & the integrity of all supplies. Offer to answer any questions.
• Prepare equipment according to manufacturer’s instructions.
• For a winged infusion or butterfly apparatus, the smaller needle (1⁄2 to3⁄4 inch in length and
21- to 23-gaugein diameter) comes attached to thin tubing with a Luer adapter that, in turn,
must be attached to a tube holder.
• Position the patient’s arm straight or slightly bent, in a downward but comfortable manner.
• Apply the tourniquet and check for potential sites by palpating the vein.
• Recleanse the site as needed.
• Feel for the median cubital vein first; if it does not feel suitable, remove the tourniquet and
try the other arm.
• The cephalic vein is the next choice followed by the basilic vein.
Performing a Venipuncture
• Choose a vein that feels the fullest.
• If necessary, warm the site or lower the arm further in a downward position to pool venous blood.
• Select the site and cleanse the patient’s skin with an alcohol pad in a circular motion outward.
• Allow it to air-dry and do not blow on it.
• Do not allow the patient to vigorously clench their fist or “pump” their fist because it can affect lab values.
• However, the patient may close his/her fist around a ball or other item temporarily until the puncture has been done and blood
begins to flow. Simply ask the patient to “Please relax your hand.”
• Caution the patient that he/she will “feel a stick” and ask the patient to remain still while you begin the procedure.
• Remove the needle cap carefully (it cannot touch anything that would contaminate it).
• Position the needle so that it is parallel or running in the same direction as the vein.
• Insert the needle quickly, with the bevel side up and at a 15- to 30-degreeangle with the skin.
• A slight “pop” should be felt as the needle enters the vein.
• Press the evacuated tube gently on to the sheathed needle.
• Blood should begin to flow.
• If blood does not flow, palpate gently above the puncture to feel for the vein and possibly reorient the needle very slightly.
• Do not probe!
• Release the tourniquet.
• Using the correct order of draw, carefully push each evacuated tube into the holder so that the tube closure is punctured by
the inside needle and blood can enter.
• Allow the blood to flow into the tube until it stops so that the proper dilution of blood to additive can occur.
• If multiple sample tubes are to be collected, remove each tube from the holder with a gentle twist-and-pull motion and replace
it with the next tube.
Performing a Venipuncture
• During Tube Transfer, be Mindful to:
– Hold the needle apparatus firmly and motionlessly so that the needle remains comfortably in the vein during tube changes.
– Follow the correct order of draw.
– Remember that blood stops flowing between tube changes because of the inner needle design, which allows a sleeve to block flow if it is not in use.
• Experienced health care workers can gently mix/invert a full tube in one hand while holding the needle apparatus in the other hand waiting for another tube to
fill.
• Some phlebotomists switch hands to use a dominant hand for stability during tube exchange.
• Use the method recommended by your health facility supervisors, or instructors.
• Find the approach that is most reliable, safe, and comfortable for both patient and you.
• When all tubes have been filled and removed from the holder, withdraw the needle, move it away from the patient, and hold a gauze pad over the site.
• Immediately activate the safety device according to manufacturer’s instructions.
• This may involve resheathing/covering the needle once it has been with drawnor rotating a device that renders the needle blunt.
• Instruct the patient to apply pressure to the site using the gauze.
• If necessary, continue gentle inversion of the specimen tubes for complete mixing of additives with the blood.
• Remember: do not shake the tubes.
• Dispose of the entire needle/holderapparatus.
• Apply pressure until the bleeding has stopped.
• Keep an eye on the patient for signs of syncope.
• Label specimens appropriately. Ask the patient to confirm that the labels are correct on his/her specimen.
• Dispose of contaminated supplies andequipment.
• Double-check to make sure that the bleeding has stopped and apply a bandage, if appropriate.
• Wash or sanitize your hands.
• Thank the patient for cooperating and depart with all specimens and all remaining supplies. Do not leave anything at the patient's bedside.
• Deliver the sample immediately to the laboratory.
Winged Infusion or Butterfly Method
• Most helpful in following patients:
– Those having small veins
– Pediatric or geriatric patients
– Patients who may many needle sticks
– Those patients in restrictive positions(traction, arthritis)
• Most helpful in following patients:
– Those with severe burns
– Those with fragile skin or veins
– Those with short term infusion therapy
– Those patients who have specifically requested it due to less pain
• Requires training and practice because of tubing attached to the needle.
• Tubing contains air which enters the1st tube, thus it will under-fill by 0.5mL. Because this would affect the additive-toblood ratio in some tubes, an on-additive tube should be filled prior to any other tube with additives.
• After the first tube, the order of the tube draw should be the same as other methods.
• Each tube should be held slightly downward.
• The safety device that is built into the system should be activated immediately after withdrawing the needle.
• If safety device is not activated, it can pose serious needle stick hazards for the health care worker because the tubing
with the exposed contaminated needle may recoil causing an accidental stick.
Syringe Method
• Syringes are not routinely used for venipuncture because of:
– Safety concerns
– Accidental cross-contamination of tube additives as blood is injected into multiple tubes
– Excessive/forceful withdrawal of blood such that lab values may be affected
– Potential clotting in the syringe
• Using blood transfer device minimizes some of these problems.
• Syringes, if properly used, are useful for veins that collapse easily because the pressure withdrawing the blood can be more gently controlled.
• Follow the same instructions for greeting, assessing, and identifying the patient, cleansing hands, and donning gloves.
• Assemble equipment in the presence of the patient. Offer to answer any questions.
• Prepare equipment according to the manufacturer’s instructions.
• Always use a syringe with a safety device that protects you from the contaminated needle after use.
• Before the needle is inserted, move the plunger back and forth to allow for free movement and to expel all air.
• Use the same approach to needle insertion as that used for the evacuated tube method.
• Try to orient the syringe so that the graduated markings are easily visible.
• Once the needle is in the vein, drawback the syringe plunger slowly until the required amount of blood is drawn.
• Take care not to accidentally with draw the needle while pulling back on the plunger, and do not pull hard enough to cause hemolysis (rupture of the cells)or collapse of the vein.
• After tourniquet release and collection of the appropriate amount of blood, withdraw the entire needle assembly quickly.
• Activate the safety device immediately, depending on the manufacturer’s specifications.
• Remove the needle or winged collection set and discard it appropriately.
• Immediately fill the evacuated tubes for testing using a blood transfer device.
• Fill the tubes until flow stops; there is no need to push the plunger to expel blood.
• Fill the tubes in the same order as that for the evacuated tube method.
• Apply a dry, sterile gauze pad with pressure to the puncture site for several minutes or until bleeding ceases.
• Follow the same directions for the rest of the procedure as in other venipuncture methods.
Order of Draw for Blood Collection Tubes
• Multiple blood assays are often ordered on patients.
• A specified “order of draw” reduces the effects of additive carry-over and cross-contamination from one tube to the
next.
• Carry over of additives can cause erroneous laboratory results.
Order of Tube Collection—CLSI Recommendations
• Blood culture tubes (yellow closure), or blood culture vials
• Coagulation tube (sodium citrate) (light blue closure)
• Serum tube—with or without clot activator, with or without gel (red of speckled closure)
• Heparin tube (green closure) with or without gel plasma separator
• EDTA tube (purple/lavender closure)
• Glycolytic inhibition tube (potassium oxalate/sodium fluoride or lithium iodoacetate/heparin) (gray closure)
Tip for the Order of Draw
• “Yellow light, red light, green light, go”• Blood cultures, serum tubes, heparin tubes
Other Issues Related to Filling Tubes
• Transfer of additives from one tube to next
• Fill rate & volume
• Closures/stoppers
• Coagulation tests
Specimen Identification and Labeling
• Completed labels should be firmly attached to the patient's specimens in
the presence of the patient.
• Specimen labels should include
1. Patient’s full name
2. Patient’s identification number
3. Date of collection
4. Time of collection
5. Health care worker’s initials
6. Patient’s room number, bed assignment, or outpatient status(optional)
Ideas for Improving Venipuncture Practices
• Number of times that a patient can be punctured by one health care worker(generally, not more than twice)
• Number of times that a patient can be punctured in a day
• The total volume of blood that can be drawn daily from a patient, especially for infants and children
• Restrict discussion about a patient's clinical information to very basic facts about the tests that have been ordered.
• Establish procedures for documenting a patient’s refusal to have blood collected.
• Review guidelines for specimen rejection.
Leaving the Patient
• Scan surfaces for extraneous supplies; discard appropriately.
• Cleanse hands with an alcohol hand gel or soap/water.
• Check the puncture site to assure bleeding has stopped completely & that the patient does not feel faint.
• Apply an adhesive bandage if appropriate.
• Ensure that tubes are appropriately labeled. Ask patient to confirm identity on specimen labels.
• Prepare the specimens for transportation.
• Thank the patient.
Prioritizing Patients
• Timed Specimens– If a test is ordered to be drawn at a particular time, the health care worker
is responsible for drawing the blood as near to the requested time as possible.
• STAT or Emergency Specimens– Should be acted on immediately because the patient has a medical condition that must be treated or
responded to as a medical emergency