• List basic concepts and guidelines for
• List the supplies needed to perform
• Define common complications of
• List documentation requirements for
• Perform venipuncture to collect a laboratory
• Describe and perform the venipuncture process
– 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
– Patient care following completion of venipuncture.3
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
• List six areas to be avoided when performing
venipuncture and the reasons for the
• Summarize the problems that may be
encountered in accessing a vein, including the
procedure to follow when a specimen is not
• List several effects of exercise, posture, and
tourniquet application upon laboratory values.
• Infection control procedures
Purpose of venipuncture
To obtain blood for a specimen
To infuse fluids and blood
To administer medication
Diagnostic tests
What is the Venifuncture procedure?
• Venipuncture, venopuncture or venepunctur
e 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.
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.
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 10-15 minutes after a transfusion is completed before
obtaining a blood sample.
Apply the tourniquet 3-4 inches above the collection site.
• 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
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.
• 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:
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)
• 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
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:
• 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
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
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
Gently invert tubes containing an additive 5-8 times.
I. Dispose of the syringe and needle as a unit into an appropriate sharps
• 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
• 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.
• 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
• 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.
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.
• Povidone-iodine wipes/swabs - Used if blood culture is to be drawn.
• Gauze sponges - for application on the site from which the needle is
• Adhesive bandages / tape - protects the venipuncture site after
• 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.
1. 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
See Selecting the Appropriate Collection
Tube and Specimen Container Types.
5. Tourniquets. Latex-free tourniquets are available
6. Antiseptic. Individually packaged 70% isopropyl alcohol
7. 2x2 Gauze or cotton balls.
8. Sharps Disposal Container. An OSHA acceptable,
puncture proof container marked "Biohazardous".
9. Bandages or tape
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.
Characteristics of a suitable
• Large enough to receive the shaft
of the needle
• Visible and palpable
• Intact
• 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
Antecubital space contains the most common venipuncture sites
Use Universal Precautions!!!
Promote vein distension
Patient clench and unclench fist
Tap area lightly
Have patient lower arm
Apply warm compress
Specimen label
• Patient’s full name
• FMP and Social Security Number
• Rate or dependency status, branch
of service, and active duty or
Vacutainer holder and
• Clean holder with soap and water
• Vacutainer needle used for single
or multi-draw type
Vacutainer tube
Vacuum blood collection tube
Rubber stopper are color coded
Various sizes
3 sources to determine appropriate tube
to be used
• Order of Draw
– to avoid cross-contamination of additives between
• 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
• 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
»Glossary of terms
• PPE-Personal Protective equipment
• Wing-tipped needle set-Butterfly needle,
used on elderly female patients
Define common complications
of venipuncture.
• Needle has gone through the vein
• Bevel is only partially in the vein
• Insufficient pressure on a puncture
site after needle is removed
• May result from repeated puncture
of vein and/or improper technique
• Results from improper technique
• Results from using contaminated
• Usually caused by probing with the
• List documentation requirements
for venipuncture
Patient Profile
• Date lab was ordered
• Date sample was sent to lab
Nursing Notes
Date/time specimen drawn
Specific test
Patient’s tolerance
Location specimen was drawn from
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
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
Still Sticking
• If using a vacutainer: as soon as needle
enters vein, ease the tube forward into
• Release tourniquet before withdrawing
• Remove needle from vein, and place a
sterile 2X2 over site with direct pressure.
• Invert tube gently to mix additive.
• 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.
• Perform venipuncture to collect a
laboratory specimen.
What are the Universal Precautions
you follow during Venipuncture
Hand washing
Prevention of needle recaping

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