Venipuncture Information and Courses from MediaLab, Inc.

Some global specimen collection and handling issues to consider include: Specimens that contain nucleated cells will be of interest in DNA methodologies while specimens lacking nucleated cells are more useful in RNA methodologies. rRNA is more stable than mRNA, which is labile and sensitive to contamination. DNA is relatively stable and can be obtained from nonviable sources. Serum or plasma obtained by standard routine venipuncture procedures can be used as long as proper site selection and decontamination occur. Standard anticoagulants such as Ethylenediaminetetraacetic Acid (EDTA) and Acid Citrate Dextrose (ACD) can be used; however avoid the use of heparin as an anticoagulant as it interferes with some polymerase chain reaction (PCR) methodologies. When using fluorescence, fasting serum or whole blood specimens should be used to decrease the interference by lipids.

Standardized systems should be used in virtually every circumstance to reduce errors. For example, medical errors can be avoided by using the standardizing procedure for preparing a venipunture site before drawing a blood alcohol specimen. A standardized system for this procedure is developed, published, trained, and posted. Everyone learns one protocol. Encouraging them to review and use the procedure for drawing blood alcohol tests avoids the error of using alcohol wipes to prepare the venipuncture site.

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

A phlebotomist at Monroe Medical Center will be collecting a lavender top tube, a green top tube, a light-blue top tube, and a serum separator tube from a patient. For safety reasons, the laboratory has transitioned to using all plastic tubes.

A phlebotomist at an outpatient drawing station prepares to collect blood from a patient who is scheduled for surgery the next day. The patient tells the phlebotomist that she is afraid of needles. The phlebotomist assures the patient that everything will be fine. He seats the patient in a phlebotomy chair. He talks the patient through the beginning of the venipuncture and she seemed to be doing fine. As the second of four tubes is being drawn, the patient suddenly blurts out that she fells very dizzy and is going to faint.

You will be required to use appropriate safety devices with your needle holder. Various options are available. The Needle-Pro™ Needle protection device (Sims Portex) shown here is an example of a needle holder with a built-in safety device. It is activated after venipuncture by pressing the orange protection device against any flat surface so as to engage the sheath firmly on the needle.

Basic equipment includes: Alcohol swab, Bandage, Tube(s), Needle, Needle holderDo not remove the needle cover until you are ready to perform the venipuncture.

Before Venipuncture: Wash hands and apply new gloves

Allow the alcohol to dry prior to performing the venipunctureDrying gives the alcohol time to disinfect the site.It also tends to prevent a burning sensation from occurring during venipuncture.

Treat all blood & body fluids as if they were infectious.Always wear gloves during vascular access procedures.

Assemble the proper equipment, and place it in a convenient location.Apply the tourniquet, then choose a venipuncture site.

Clean blood culture bottles while the iodine on the venipuncture site is drying. Wipe the tops of the blood culture bottles, first with a new iodine swab, then with a clean alcohol pad.

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.

Poor and unsatisfactory specimens pose significant problems : They can cause misleading laboratory results.Unsatisfactory specimens must be rejected by the laboratory. The patient must then undergo another venipuncture to get a better specimen. It costs time & money to redraw the specimen.The credibility of the laboratory is reduced if too many unsatisfactory specimens are drawn.

Long hair should be arranged so that it does not touch the patient or venipuncture site during collection. Long necklaces should be avoided for the same reason. Excessively large rings should not be worn since they may damage gloves.

A variety of tools are available to ensure a safe and successful venipuncture. It is important to know which tools to choose and how to use them correctly so that an adequate specimen is collected for laboratory testing.

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.

Hidden errors are those that cannot be detected or corrected by the laboratory analyst prior to testing. Most often these errors can be prevented by the phlebotomist following correct venipuncture procedure for every procedure, every time.Hidden errors include hemoconcentration, incorrect order of draw, and (the most serious of all errors) misidentification of patient or specimens. Because these errors often are unknown, the analyst may inadvertently report erroneous patient results which could be harmful to the safety and well-being of the patient. Condition What is it? How does it happen? What is the Result? Hemoconcentration Blood pools at site of venipuncture Tourniquet is applied for a prolonged period of time Test results may be inaccurate because blood components move between blood and tissues Pouring Blood between tubes Mixing contents of two or more tubes Removing top of tube to combine contents of one tube with another Inaccurate test results due to over or under dilution or incorrect anticoagulant Clots form due to lack of mixing Patient may have to be redrawn Incorrect patient identification and incorrect specimen labeling Using the wrong name to label a specimen Failure to positively identify EVERY patient using 2 unique identifiers BEFORE beginning venipuncture Failure to label EVERY specimen in the presence of the patient Failure to concentrate fully on the task Results reported to caregiver for wrong patient Compromises patient care; may be life-threatening

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.

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.

The product used most often to cleanse and disinfect the site prior to venipuncture is 70% isopropyl alcohol in towelette form. Alternative cleansing agents available are chlorhexadine gluconate (chloraprep) and povidone-iodine which are used mainly for collection of blood cultures, blood alcohol specimens, or when the patient is sensitive to alcohol.The alcohol should be applied using a circular target motion, as demonstrated in the image. This technique pushes the bacteria away from the inside of the venipuncture site to the outside. The alcohol must be allowed to air dry for approximately one minute prior to venipuncture to properly disinfect site, prevent hemolysis of the specimen, and avoid discomfort for the patient. Gauze should be used when applying pressure to the venipuncture site immediately after the needle is withdrawn. Adequate pressure to stop bleeding is crucial to avoid formation of a hematoma or bruise. Cotton balls should not be used to apply pressure to stop bleeding because the clot formed may be dislodged by residual cotton fibers as the cotton ball is pulled away from the site.Paper tape or a bandage is used to cover the wound after bleeding has stopped to prevent disruption of the clot.

If the antecubital area of the patient's arm is compromised or inaccessible, an alternate site must be chosen for venipuncture such as the top of the hand or the thumb-side of the wrist. However, some sites must be avoided due to the risk of complications and/or unnecessary pain to the patient.

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.

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.

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.

An important element of safety is personal protective equipment (PPE). This must be provided to phlebotomists by their facility and may include gloves, lab coats and protective eyewear. An N95 respirator (shown in the lower image) or other respiratory protection may be required to protect the phlebotomist from Mycobacterium tuberculosis or other airborne infectious agents. Phlebotomists and other healthcare workers must be medically cleared and fit-tested to wear N95 respirators. For the phlebotomist, gloves are required during every procedure. The gloves must remain totally intact. The gloves cannot be altered in any way as to expose the hand or fingers to potential bloodborne pathogens. Never remove all or part of the finger tip of the glove while performing venipuncture.