| Discussion A phlebotomist should never use an arm with restricted usage for the venipuncture. Even if no sign is posted, the patient may tell you not to use a particular arm for various reasons, i.e. previous mastectomy, history of phlebitis, active AV fistula, etc. Do not draw blood above an IV line. If blood is taken from a vein above an IV line it might be diluted by the IV fluid, which could cause incorrect test results. In this case, Bobby should choose a vein on the dorsum of Mrs. Grayson’s hand, below the IV. A butterfly needle would facilitate drawing blood from these small hand veins.Relevant topics:Alternate sites, Sites to avoid, Signs, Arms to avoid
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| Case Bobby Jones, a phlebotomist at Georgetown Hospital, entered the room of Mrs. Mary Grayson with a physician's order to draw some blood work. After properly greeting Mrs. Grayson, identifying himself and checking her armband, Bobby prepared for the venipuncture. He suddenly notice a sign posted above the bed that read: “Restricted left arm usage. Previous mastectomy - Do no use left arm for venipuncture.” Bobby set up his equipment to use her right arm and noticed an IV line in Mrs. Grayson’s right arm positioned in a vein slightly above her wrist on the dorsum (top) of her forearm. | View Page |
| Which site should Bobby choose for the venipuncture? | View Page |
| Case Julie Smith, a newly certified phlebotomist at Northlake Hospital, entered a patient’s room on the third floor for a routine blood draw. The patient was an elderly woman who had very small fragile veins. Julie therefore decided to use a safety butterfly needle attached to a Vacutainer tube in order to draw the blood. When Julie was finished with the venipuncture, she detached the butterfly needle from the Vacutainer, and approached the Biohazard needle disposal box. She noticed that the disposal box was full , but decided to try to fit the butterfly into the box anyway. Holding the butterfly by the tubing, she tried to push the butterfly into the box. The needle suddenly recoiled and stuck Julie’s finger. Julie left the patient’s room in a panic and headed back to the lab to report the needle stick injury. | View Page |
| Discussion Insufficient blood volume may cause erroneous test results, and specimen rejection. When blood flow stops, it can mean several things:The bevel of the needle may be pressed against the wall of the blood vessel. If this is the case, moving the needle slightly may cause blood to begin flowing again.The vein may have collapsed due to the vacuum of the tube. If moving the needle slightly does not re-establish blood flow, you will have to recollect the patient.The needle may have gone all the way through the vein. Pulling the needle back slightly may cause blood to resume flowing.
The tube you are using may have insufficient vacuum. Try another tube. Never vigorously probe the patient’s arm with a needle. At the first sign of discomfort the needle should be withdrawn. The patient may then be redrawn be yourself or another phlebotomist.Relevant topics: Insufficient volume, Partial collection tubes, What if no blood flows | View Page |
| Tourniquets Tourniquets wrap around the arm to increase venous pressure, and fill the veins, so that they are easier to see, feel, and puncture.
They can be made of latex, Velcro, or other material.
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| Multiple draw needles with built-in safety features. You will be required to use multiple draw needles with built-in Safety features.
One example is the Puncture-Guard™ (BioPlexus) needle, which uses an internal blunt needle (detail above) that is activated with forward pressure on the final blood tube prior to withdrawal of the needle from the vein.
Refer to your institution’s and the manufacturer’s procedure manuals before using these devices.
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| Choosing a site The median cubital vein is most commonly used. It is the middle of the bend of the arm (antecubital region).
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| Patient clenches fist After applying the tourniquet, you may ask the patient to make a fist to further distend the arm veins. | View Page |
| Applying the tourniquet Tie the tourniquet just above the elbow.The tourniquet should be tight enough to stop venous blood flow in the superficial arm veins. | View Page |
| Choosing a site continued If the median cubital vein is not accessible, try the: Cephalic vein, or the Basilic vein. | View Page |
| Alternate Sites If no veins are accessible on the arm, you may try the veins on the back of the hand.Use a much smaller needle for these hand veins. | View Page |
| Hold vein in place You may now hold the patients arm below the venipuncture site.Pull the skin below the vein to anchor it and keep it from rolling. | View Page |
| Insert needle With the needle bevel up, insert the needle into the vein. | View Page |
| Blood won't flow If you do not see blood flow, the tip of the needle:May not yet be within the vein.May have already passed through the vein.May have missed the vein entirely.May be pushed up against the inside wall of the vein. | View Page |
| Butterfly needle - Butterfly needle collections Butterfly needles (also known as a winged infusion set), are available in smaller gauges, and are used to draw venous blood from children, and adults with difficult veins.
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| Butterfly needle - Angel WingTM safety butterfly The Angel Wing™ (Monoject), is activated by sliding a stainless steel safety shield over the needle after withdrawal from the vein.The Angel Wing™ (Monoject), is activated by sliding a stainless steel safety shield over the needle after withdrawal from the vein. | View Page |
| Syringe - Syringe blood collections Syringes may be used to collect blood from patients having small or delicate veins that might be collapsed by the vacuum of the evacuated tube system.Syringes may also be used to collect blood culture specimens. | View Page |
| Heelstick - Pediatric collection procedures: Introduction Veins of small children and infants are too small for venipuncture;Safety Lancets are used to puncture the skin and collect capillary blood.Butterfly needles may be used to collect venous blood in older children.
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| Bleeding time Select a site on the inside of the forearm with no visible veins, scars or bruises, about 5 cm below the bend of the elbowNicking a vein will invalidate the result. | View Page |
| Feel the vein If you need to feel for a vein again, you must first prep your gloved finger tip with iodine to prevent contamination. | View Page |
| Hematosis A hematoma is a blood clot which forms within the body. It is caused by leakage of blood into the tissues from an injured vein . It will resolve spontaneously.Hematomas are caused by excessive needle trauma to a vein, for example, by a needle which passed entirely through a vein and came out the other side.Apply compression to help stabilize a hematoma.
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| Blood should not be drawn from arms with IVs Blood drawn from veins with intravenous lines (IVs) may be diluted by the IV fluids. Arms containing IVs should therefore not be used to draw blood specimens.
If an arm with an IV line in place must be used for venipuncture, be sure to choose a site below the location of the IV, so that the specimen will not be diluted with IV fluids. | View Page |
| What if no blood flows when the needle is in place? The needle may not be in a vein. Try slightly manipulating the needle. If no blood flows, withdraw the needle and repeat the venipuncture. Never probe the patient’s arm with the needle. The bevel of the needle may be compressed against the inside of the vein wall. Slightly manipulating the needle should result in blood flow.
The needle may have passed entirely through the vein. Pull it back slightly, and blood should flow. | View Page |
| Insufficient volume Insufficient blood volume (short draws) within a collection tube containing anticoagulant will result in an incorrect ratio of blood to anticoagulant, and yield incorrect test results.Short draws can be caused by: A vein collapsing during phlebotomy.The needle coming out of the vein before the collection tube is full.Loss of collection tube vacuum before the tube is full. (Always keep extra tubes on hand.) | View Page |
| What is phlebotomy? Phlebotomy, also known as venipuncture, means collecting blood from veins.Phlebotomists, by definition, collect venous blood, but perform a variety of other important medical tasks as well. | View Page |
| Circulation: venous portion Deoxygenated (venous) blood flows from tiny capillary blood vessels within the tissues via progressively larger veins to the right side of the heart.Blood is routinely drawn from veins, but may also be drawn from arteries, or capillaries.
Illustration this screen from LifeArt Collection 2000, with permission. © Lippincott Williams & Wilkins.
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| Circulation: capillary portion In the capillaries, oxygen and nutrients diffuse from the blood cells into the tissues.
The deoxygenated blood then returns to the veins, completing the circulatory pathway.
Illustration this screen from LifeArt Collection 2000, with permission. © Lippincott Williams & Wilkins.
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| Anatomy & physiology: essential to phlebotomy Since phlebotomy involves puncture of the skin (integumentary system) and veins,
(A component of the cardiovascular system), a basic knowledge of the anatomy and physiology of these systems is essential.
Knowledge of blood and its components is also important.
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| What is Venipuncture? Venipuncture is the collection of blood from a vein. The person having the responsibility for the performance of the venipuncture may be a phlebotomist who is a part of the laboratory staff, or he/she may be another healthcare professional that has been trained to perform this duty. In this course, we will refer to the person performing the venipuncture as the phlebotomist. | View Page |
| Give Yourself a Chance A key element for successful venipuncture is choosing the best vein. To determine the best vein, use both sight and touch. Remember -- the first vein found is not always the best vein. Take enough time to assess the vein before beginning the venipuncture procedure. | View Page |
| Explore the Possibilities! The antecubital area of the arm is usually the first choice for routine venipuncture. This area contains the three vessels primarily used by the phlebotomist to obtain venous blood specimens: the median cubital, the cephalic and the basilic veins.Although the veins located in the antecubital area should be considered first for vein selection, there are alternate sites available for venipuncture. These include the top of the hand, the side of the wrist, and the forearm. These sites should only be considered after determining that the veins of the antecubital area cannot be accessed or cannot be used. Vein Location Reason for Choice Placement Direction Median Cubital Mid antecubital fossa Vertical to diagonal Musculature assists in stabilizing vein; very often largest; ease of access Cephalic Thumb side of antecubital fossa Vertical Ease of access; few nerves and tendons in area Basilic Body side of antecubital fossa Vertical to diagonal More difficult to access; proximity of artery, nerves and tendons. Use this vein only as the final alternative. | View Page |
| Which of the veins in the antecubital area should be considered only as a final alternative due to its proximity to an artery, nerves, and tendons? | View Page |
| Pre-analytical Errors Preanalytical Error What is it? How does it happen? What is the result? Hemolysis Red blood cells (RBCs) break and release contents of cell into plasma. Needle incorrectly positioned in vein; cells forced to squeeze through opening. Needle gauge too small; slow blood return into tube. Vigorous mixing or shaking of tube. Alcohol on skin that has not had sufficient time to dry. Some test results may be falsely elevated. (Potassium is especially affected by hemolysis.) Patient may have to be re-drawn. Clotted specimen Clumped or clotted cells in specimen that requires anticoagulated or whole blood Insufficient mixing of blood with anticoagulant in tube. Delay in mixing tube. Slow filling tube. Inaccurate test results for cell counts and clotting studies. Patient may have to be re-drawn. Tube filled to incorrect volume Too little or too much blood in tube. Tube removed from needle too quickly. Vacuum in tube has been compromised due to use of tube past the expiration date (Results in a short fill). Manual fill of tube may lead to over-fill. Test results may be unreliable due to dilution errors. Patient may have to be re-drawn. | View Page |
| Avoid Prolonged Tourniquet Time A prolonged tourniquet time may lead to blood pooling at the venipuncture site, a condition called hemoconcentration. Hemoconcentration can cause falsely elevated results for glucose, potassium, and protein-based analytes such as cholesterol.Ideally, the tourniquet should be in place no longer than one minute to prevent hemoconcentration. If the phlebotomist takes longer than one minute to assess and locate vein of choice for venipuncture, it is best practice to release the tourniquet, assemble supplies and reapply tourniquet immediately before needle insertion. | View Page |
| Ideally, a tourniquet should remain tightened for no longer than what amount of time before releasing it? | View Page |
| Needles - What's the Point? Needles that are used for venipuncture are available in a variety of lengths and diameters. The diameter of the needle is referred to as the needle gauge; the larger the diameter of the needle, the smaller the gauge number. The image on this page illustrates the relative gauges of needles that are available for venipuncture. Needles that are routinely used for venipuncture are available in 3/4 inch, 1 inch and 1 1/2 inch lengths. The phlebotomist determines the gauge and length of the needle to use for a venipuncture after assessing the vein. | View Page |
| Needles and Patient Safety All needles are single use. That is, every needle is immediately discarded in a sharps container after one insertion. If you suspect that you inadvertently touched anything with the needle prior to inserting the needle into the patient's vein, the needle cannot be used; the safety device must be activated and the needle discarded.NEVER remove a needle from a patient and reinsert into another vein; this could put the patient at risk for infection. | View Page |
| Blood Collection Systems and Devices The phlebotomist has a choice of several blood collection systems. Three that are commonly used are discussed on the following pages. Evacuated Tube SystemThe primary choice for a routine venipuncture that will be performed on an adult or an older child is a blood collection system that consists of a holder (or adapter), a needle that is pointed on both ends, and evacuated blood collection tubes. One end of the needle will pierce the vein and the other end will pierce the stopper of the evacuated tube so that blood will flow into the tube to fill the vacuum. A safety device is required on either the holder or the needle to comply with current standards for needle safety. Two examples of needle holders equipped with safety devices are shown on this page. | View Page |
| Syringe The syringe and needle combination should be the last equipment option that is considered; it is not as safe a choice as the self-contained blood collection systems because it involves more manipulation. However, the phlebotomist may choose to use a syringe to prevent vein collapse if the phlebotomist thinks that the vein is too fragile to withstand the pressure exerted by the vacuum as it pulls blood into the collection tube. A transfer device aids in the safe transfer of blood from the syringe into blood collection tubes. During blood transfer, do not manually push plunger as this may cause hemolysis of the specimen. | View Page |
| Winged Device The winged device is another popular choice for the phlebotomist. This may be chosen for pediatric venipuncture, small delicate veins on adults (particularly geriatric patients), or hand veins. The device can be used with a needle holder and evacuated tube or a syringe. A needle safety device is incorporated into the design of the winged device to prevent needlestick injury. | View Page |
| Tourniquets, Alcohol, and Gauze A tourniquet is used by the phlebotomist to assess and determine the location of a suitable vein for venipuncture. Single-use, latex-free tourniquets are preferred but reusable tourniquets are acceptable. However, if the reusable tourniquet becomes contaminated with blood or body fluid, it must be discarded immediately to avoid the spread of harmful contaminants to other patients. Follow the guidelines established by your facility for cleaning reusable tourniquets.Proper application of a tourniquet will partially impede venous blood flow back toward the heart and cause the blood to temporarily pool in the vein so the vein is more prominent and the blood is more easily obtained. The tourniquet is applied three to four inches above the needle insertion point and should remain in place no longer than one minute to prevent hemoconcentration. If the tourniquet is used during preliminary vein selection, it is best to release the tourniquet after assessing the vein and while you are assembling your supplies. Reapply the tourniquet just before starting the venipuncture; it should then be released soon after the needle has been inserted into the vein and the blood flows into the first tube. If collecting multiple tubes, the tourniquet may remain in place until blood enters the last tube. | View Page |
| Vein Palpation Before attempting a venipuncture, the phlebotomist should assess a vein by palpation. Palpating the vein increases the chance of a successful venipuncture. Use the index or middle finger to palpate the vein following this procedure: Align your finger in the direction of the vein Press on top of the vein with enough pressure to depress the skin Keep your finger in contact with the skin so that you may feel the "bounce back" of a resilient, healthy vein. The phlebotomist uses palpation to assess the depth, width, direction and health (resilience) of a vein. When determining a vein suitable for venipuncture, the skilled phlebotomist relies more on touch or feel than on sight. Looking away from the vein while palpating will help the phlebotomist perfect the skill of palpation leading to good vein assessment. The image on the following page illustrates the considerations for vein assessment. | View Page |
| Assessing the Vein | View Page |
| If a vein cannot be located in the antecubital area of the arm, the next best alternative for venipuncture is a vein in the ankle. | View Page |
| Performing a Venipuncture on an Arm Containing an Intravenous Line Blood that is drawn from a vein that has an intravenous (IV) line may be diluted by the IV fluid. This can ultimately affect the accuracy of the blood test results. Therefore, an arm containing an IV should not be used to draw blood specimens if it can be avoided. However, if there is no alternative and an arm with an IV line in place must be used for venipuncture, try to choose a site away from and below the location of the IV. Document that the venipuncture was performed distal to (below) an infusion site. If the only vein available is proximal to (above and near) the IV, these steps should be followed: Ask the patient's caregiver if the IV can be turned off for a short period of time. The IV should be discontinued for at least two minutes before the venipuncture. Apply the tourniquet between the IV site and the area of the venipuncture. Perform the venipuncture. Document that the venipuncture was performed proximal to an IV site and that the IV was discontinued for two minutes prior to specimen collection. Notify the patient's caregiver when the procedure is completed and be certain that she/he restarts the IV. | View Page |
| When to Use Hand Veins to Obtain Blood Sometimes the phlebotomist may decide that the antecubital area is not the best site for venipuncture. Reasons for this decision may include: Extensive bruising (hematomas) in the antecubital area Inability to "feel" a vein suitable for puncture Presence of an intravascular line (IV) or vascular access device Physical condition of the patientWhen the veins in the antecubital area cannot be used, the phlebotomist may choose to use a vein on the top of a hand. The veins in the hand are very near the surface and often very small and thin so the procedure must be performed carefully and cautiously. . | View Page |
| Handle With Care Equipment: To successfully enter a hand vein, the phlebotomist must choose equipment that will allow needle entry at a very small angle. A winged device with a small gauged needle of 3/4 inch length is most often used to obtain blood from a hand vein. A syringe is usually attached to the end of the tubing of this device. By using a syringe, the phlebotomist can control the amount of pressure on the vein and avoid vein collapse. Evacuated tubes may collapse a vein by exerting too much pressure on the delicate vein. If available, smaller tubes containing less vacuum may be used.Insertion angle: The angle at which the needle is inserted into a hand vein is smaller compared to the angle of needle insertion into veins of the antecubital area. When drawing from a hand, the needle should be inserted into the vein at approximately a 15 degree angle to allow easier access of the surface hand veins. By inserting the needle at this angle, the risk of the needle going "through" the vein and puncturing the bony structures underneath are reduced. | View Page |
| Tips for Successful Venipuncture When Using Hand Veins Hand position: It is best practice to position the patient's hand slightly downward with the top of the hand facing the phlebotomist. The fingers of the patient's hand should be rolled underneath and wrapped around the fingers of the phlebotomist's "anchoring" hand forming a loose fist. The phlebotomist should use his or her thumb to pull back gently on the surface of the skin, making the skin taut. The vein should be anchored adequately to proceed with venipuncture. The phlebotomist may have the patient roll his/her fingers over a pillow or a rolled up washcloth to make the hand vein more prominent.Tourniquet Position: The tourniquet should always be applied 3 - 4 inches above the needle insertion point. Therefore, when assessing for a usable vein in a hand, apply the tourniquet 1 - 2 inches above the wrist. If the tourniquet is on longer than one minute, release and reapply prior to venipuncture to avoid hemoconcentration.Cautions: Choose a straight section of the hand vein-- avoid the "intersection" or "V" where a vein branches into another vein. This juncture may contain a valve and could be damaged if punctured. Only use the top of a hand or thumb-side of the wrist for puncture. Avoid the fingers or the underside of the wrist. This will prevent the inadvertent puncture of hidden arteries, tendons or nerves in the area. | View Page |
| When assessing a vein in the hand, where should the tourniquet be placed? | View Page |
| Venipuncture Procedure At a Glance Required Step Description Step #1 Wash your hands. Clean your hands with soap and water or gel cleanser. Step #2 Positively identify patient using unique identifiers. Ask the patient to state his/her first and last name; if the patient is unable to give you this information, ask the patient's caregiver to confirm the patient's name. A second unique identifier must also be used. Step #3 Special test requirements Determine if the test to be obtained has any special requirements. For example, should the patient be fasting? Is this a timed test? If any requirements are not met, consult with the caregiver to determine a course of action. Step #4 Prepare the patient Explain the procedure to the patient and obtain cooperation. Usually the patient will extend an arm. (This is a form of implied consent.) Position the arm for venipuncture; support the arm on a firm surface; the arm should be in a downward position. Step #5 Site determination The patient can make a fist, but should not pump the hand open and closed. Apply tourniquet Palpate the vein. Release the tourniquet and assemble appropriate equipment. Step #6 Aseptic technique Wear gloves that have not been altered in any way. Cleanse site with approved disinfectant. Allow the disinfectant to air-dry to avoid hemolysis of the specimen and discomfort to the patient. Step #7 Specimen collection Re-apply tourniquet about 3-4 inches above puncture site, insert needle, bevel-side up, at about a 30° angle, and collect specimens. Remove needle and immediately activate the safety device. Mix specimens by gentle inversion 5-10 times. Step #8 Patient care Apply direct pressure to stop bleeding at puncture site; do not have patient bend arm as this may cause a hematoma to form. After about 2 minutes, check the puncture site to verify that bleeding has stopped. Apply bandage if appropriate. Thank the patient for his/her cooperation. Step #9 Specimen labeling Label specimen(s) in the presence of the patient including all the information that is required by your facility. Check the labeled tubes a second time against the patient's wristband to verify labeling accuracy. A professional phlebotomist follows the procedure in the same way for every venipuncture. This ensures that none of the vital steps are omitted. The phlebotomist who is consistent in performance and who concentrates fully to obtain a quality specimen is an indispensable part of the healthcare team. | View Page |
| Specimen Collection Procedure Following the approved order of draw, connect the first blood collection tube onto the needle by pushing the tube into the holder so that the tube stopper is pierced by the exposed end of the needle. Use the flanges of the holder to stabilize the needle while connecting the tube. After tube is filled completely, remove the tube, again using the flanges of the holder to stabilize the needle. Replace with the next tube and mix the removed tube immediately if it contains an additive. Release the tourniquet when blood enters the final tube. When the last tube is filled, pull it back off the needle before removing the needle from the vein. Remember: Fill tubes in correct order and to correct volume. If you suspect that a tube did not adequately fill, try another tube. | View Page |
| Bobby Jones, a phlebotomist at Community Hospital, entered the room of Mrs. Mary Grayson with a physician's order to draw some blood work. After greeting Mrs. Grayson, identifying himself, and properly identifying the patient, Bobby prepared for the venipuncture.As he approached the patient's bed, he noticed a sign posted above the bed that read: “Restricted left arm usage. Previous mastectomy - Do no use left arm for venipuncture.” Bobby set up his equipment to use the patient's right arm and noticed an intravenous (IV) line in Mrs. Grayson’s right arm positioned in a vein slightly above her wrist on the dorsum (top) of her forearm.Which site should Bobby choose for the venipuncture? | View Page |
| A phlebotomist was collecting a STAT prothrombin time (PT) and complete blood count (CBC) on a patient when blood flow unexpectedly stopped. The lavender top tube being drawn at the time was less than one third full. The light-blue top tube had already been drawn for the prothrombin time.Before resorting to a second venipuncture, which of the following procedures should be attempted in order to adequately fill the lavender top tube? | View Page |