Phlebotomy Ch 8: Venipuncture Procedures

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 177

EMERGENCY ROOM PATIENT ID ~Typically , a temporary master ID number (unique hospital number attached to the patients body by wristband or other suitable slice) may be provided until a positive ID can be made. ~When in the ER the phlebotomist must often complete a requisition or sample labels, either electronically or handwritten, and it is imperative that all requisions and sample labels can be cross-referenced to the ER patien's master ID Number.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Venipuncture Method P. 203

ORDER OF DRAW FOR BLOOD COLLECTION TUBES: CLSI recommends the following specific order (order of draw) When collecting blood in multiple tube (either glass or plastic) via the evacuated method or the syringe transfer method. 1. Yellow: or (Blood Culture Vials)...8-10 times 2. Light blue: (Sodium Citrate) coagulation tube....Glass tubes preferred because plastic may interfere w/coagulation...3-4 times 3. Red or speckled: (without clot activator)...5 times 4. Green: (heparin) w/or w/out gel plasma separator...8-10 times 5. Purple/Lavender: (EDTA used for routine hematology test) 8-10 times 6. Gray: Glycolytic inhibition tube (Potassium oxalate/sodium fluoride or lithium iodoacetate/heparin) ....8-10 times

~Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 179

OUTPATIENT/AMBULATORY PATIENT ID (I.E., Clinic or Physicians Office) ~Do not have arm bands ~Similar procedure as in hospital but no arm band to identify with Ask for some form of ID, License, Health Care Card, government issued ID) ~Use 3 way match: Verbal, ID & Requisition ~Out patient surgery, receiving sedation, or blood products must have an ID wristband issued at registration, name and medical record number & positive ID is essentially the same as for inpatients

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 179

PHYSICAL CLUES FOR ASSESSMENT OF THE PATIENT APPROACHING THE PATIENT: ~BOX 8-2 (Pg. 180): Typical Health care worker-pateint interaction ~Do not place phlebotomy supply tray on the patients bed or eating tray not stable enough. ~Also Avoiding microorganisms is a key factor in preventing hospital acquired infections. ~If a physician, clergy or nurse is consulting with the patient, the species collection procedure should be delayed until consultation is complete. ~Physician-patient relationship has priority over a phlebotomy procedure unless the request is for timed or STAT specimen & if either of these is the case as permission to proceed.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Equipment Selection and preparation: P. 183

POSITION OF THE PATIENT : Patient needs to be comfortable and choose least hazardous site for blood collection by skin puncture or venipuncture VENIPUNCTURE SITE SELECTION: ~The most common site for venipuncture are in the ante-cubital area of the arm just below the bend of the elbow, because this is where the median cubital , cephalic, and basilic veins lie close to the surface of the skin are most prominent. ~To reduce the risks of puncturing an artery or injuring a nerve, CLSI recommends that vein selection be considered in the following order.... 1. Median cubital (sometimes called the median vein) used because easiest to obtain reported to be less painful & less prone to injury. Check both arms for suitable median cubial vein prior to using the other choices. 2. Cephlic Vein on the outer edge (thumb side) 3. Basilic Vein (side of the pinkie finger)....This is close proximity to the median nerve and the bracial artery so the other choices are preferable.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection Process: P. 169

1. Prepare yourself by cleansing hands & review the orders 2. Approach, identify and position the patient comfortably and safely. 3. Assess the patient's physical disposition, including diet/and ask patient if sensitive to latex or skin cleansing products 4. Select and prepare equipment and supplies 5. Find a suitable puncture site 6. Prepare/decontaminate the puncture site 7. Choose venipuncture method 8. Collect the samples in the appropriate tubes and in the correct order 9. Discard contaminated supplies in designated containers 10. Label Samples 11. Assess the patient to ensure bleeding has stopped 12. Decontaminate hands 13. Manage an document any special circumstances that occurred during the phlebotomy procedure.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Equipment Selection and Preparation: P. 187-190

ALTERNATIVE PUNCTURE SITES: ~Alternative sites for blood collection when the ante-cubial area cannot be used are hand veins and in, some cases with proper training and physician approval, foot veins. HANDS: Veins on the dorsals side of the hands or wrists (back of the hand) are acceptable venipuncture sites if the median, cephalic, or basilic veins are inaccessible on both arms. ~Veins in the wrist and ankle tend to move or roll aside as the needle is inserted: therefore it may be helpful to have the patient extend the hand (or foot) into a position that helps hold the vein taut. ~Venipuncture in small veins is facilitated by the use of a 21-to-23 gauge safety butterfly needle. CLINICAL ALERT: PG. 189 ~SERIOUS patient injury can occur due to excessive probing, poor sit selection, deep needle penetration to the nerve or if patient suddenly moves or jerks ~IF PATIENT complains of sever pain remove needle immediately and procedure discontinued. ~ONLY A physician can evaluated if nerve damage has occurred but document the incident ~Arteries do not feel like veins and should not be confused. Arteries pulsate, are elastic, and have thick walls. ~Accidental arterial puncture can lead to excessive bleeding, and hematoma. ~If artery has been punctured removed immediately and put pressure on for 5 minutes to stop bleeding. ~Notify a supervisor or nurse immediately.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Equipment Selection and Preparation: P. 190

ALTERNATIVE PUNCTURE SITES: CONTINUED ANKLE OR FEET: ~Should not be used with patients for cardiac or diabetic patients. ~Because coagulation and vascular complications tend to be more troublesome in the lower extremities. ~If this procedure it allowed by physician then use small needle. ~Simply performing a venipuncture on a nontraditional vein because "It Looks Good" is hazardous, increases the risk of injury to the patient, and will likely result in legal liability to the phlebotomist and health care facility.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Prioritizing Patients P. 208

BOX 8-5 P. 208: IDEAS OR IMPROVING VENIPUNCTURE PRACTICES 1. Coordinate lab request w/all staff 2. Modify test menu and better education so aware of all tests available. 3. Lab could be notified when many timed test are ordered 4. Reassessment of STAT test orders to make sure that they are clinically necessary. 5. THERAPEUTIC DRUG MONITORING (TDM): (timed laboratory analysis of serum drug levels to determine adequate therapeutic dosing) should be coordinated among all staff 6. Lab should be aware of patient transfers 7. Number of times a patient can be punctured should be monitored. (usually not more than twice before calling for a second opinion) 8. Number of times a patient can be punctured in one day should be minimized. 9. The volume of blood especially in infants and children and critically ill patients should be monitored. 10. Restrict info to clinical info, just basic facts and emphasize to that Dr. can answer questions in more detail. 11. Document refusal to take blood from patient. 12. Guidelines for Specimen rejection(criteria that relate to the suitability of a specimen for testing or when it may not be used) Should be reviewed and include a. inaccurate ID b. collection on the wrong tubes. inadequate bolume of blood in the tube c. hemolyzed or clotted specimens when they should not be d. improper transpiration or storage e. use of outdated/expired supplies f. contaminated samples g. patient did not comply w/diet restriction h. timed sample collected at the wrong time. ~ In all cases the HCW should learn how to prceed w/corrective actions and error documentation based on SOP for each facility. 13. Communication, honesty and ethical professional behavior are the keys to an efficient and reliable HC environment.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 173

Clinical Alert: ~Remember that the use of gloves does not eliminate the need for hand hygiene. ~All Specimens should be treated as if they are hazardous and infectious.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Venipuncture Method P. 199

EVACUATED TUBE SYSTEM AND WINGED INFUSION SYSTEM, 0R BUTTERFLY METHOD: Special consideration of the winged infusion/Butterfly Method: A safety winged infusion system, butterfly needles assembly needle assembly or scalp needle set can be used for certain patient populations or for particularly difficult veni-punctures. 1. Patients with small vein 2. Pediatric or geriatric patients 3. patients having numerous needle sticks (cancer Patients) 4. Pin restrictive positions (Traction and sever arthritis) 5. Patients who are severely burned 6. patients with fragile skin and veins 7. patients who specifically request it because they feel it is less painful 8. Short-term infusion therapy ~Winged or butterfly systems have been reported by patients to be less painful than other methods. ~the only difference in using the winged system is that there is air in the tubing so a non-additive tube should be filled first then the order of draw can follow.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Venipuncture Method P. 195

EVACUATED TUBE SYSTEM AND WINGED INFUSION SYSTEM, 0R BUTTERFLY METHOD: ~CLSI recommends that venipuncture specimens be collected with a system that enables blood flow directly into the tubes. ~Evacuated tube systems and winged infusion systems (butterfly) are widely available , equipped with safety devices.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Using Standard Precautions P. 169

HAND HYGIENE: ~Hand Hygiene and gloving procedures are most commonly done as soon as the health care worker is in visual contact with each patient, before beginning the actual procedure. ~Hand hygiene techniques (hand washing or use of alcohol-bases hand rubs) has been shown to significantly reduce outbreaks ~Flow chart of the Venipuncture Process: Pg. 171 figure 8-1

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 176

INPATIENT IDENTIFICATION: ~Hospital identification: 1. First name 2. Last name 3. Designated hospital number and/or Unit number ID might also include patients 1. Room number 2. Bed assignment 3. Physicians name A three way match should be made w/ the patient's statement and spelling of his or her name, birthday, or address, the ID wrist band, and the test requisition. ~Burn or isolated patients identification may be attached to bed rather than arm. These are the only circumstances in which a HCW may use a bed labeled ID tag to confirm identity.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Equipment Selection and Preparation:P. 191

HARD TO FIND VEINS: ~Use heat to increase arterial blood flow ~Dangle arm by patients side in a downward position for 1-2 minutes. This allows the blood to fill the arm to capacity, the the tourniquet maybe reapplied and the area re-palpated. ~DO NOT USE DORASL/BACK SIDE OF HAND: RING SIDE.....because nerves are easily injured by needle probing in this area. TOURNIQUET APPLICATION AND CLEANSING THE PUNCTURE SITE: ~Less experienced health care workers are encouraged to take their time in finding a suitable puncture site, so it may be necessary to apply the tourniquets while palpating the ante-cubical area, then release the tourniquet for a short period of time while the supplies are readied, then reapply it before the needle puncture. ~ A tourniquet should not be left on for more then one minute . ~If HCW can can not find a vein after tourniquet application, efforts should be made to increase blood flow to the area (warming or lower arm) the re-palpate the are to feel again. It is better to defer the patient to someone else who can search for a palpable vein than take a blind chance. ~Never touch patients cleansed skin with any non-sterile object. The alcohol should be allowed to dry (30-60 Seconds), or it should be wiped off with sterile gauze after the sit is prepared; otherwise the puncture site will sting, and the alcohol may cause hemolysis and/or interfere with test results, such as blood alcohol levels. Blowing on the site to hasten the drying process is not advised, because doing so may re-contaminate the site.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 178

ID OF NEONATES AND BABIES ~CLSI Recommends ask A Nurse , Guardian, Family Member OR Relative to State The Bayb's Name And Date Of Birth. The following elements should be confirm so that it may be compared with ID Band AND with the requisition. 1. name of baby if designated 2. Date of Birth 3. Baby gender 4. Medical recored number or unique ID 5. Mother's last name, or the last named used at registration ~Document who gave the info and the relationship to the patient. ~extra care needs to be taken with twins.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 177

ID OF PATIENTS WHO ARE UNCONSCIOUS, COGNITIVELY IMPAIRED, TOO YOUNG TO IDENTIFY THEMSELVES, DO NOT SPEAK THE LANGUAGE, OR HAVE SENSORY IMPAIRMENTS ~There are also special cases in which health care workers must deviate from the standard ID procedure. A nurse, relative, or friend may ID patients in the following circumstances. Make note of who gave information. 1. Unconscious or comatose 2. Cognitively impaired 3. Too young to ID self i.e., peds patients 4. Cannot speak the HCW's language & interpreter can't be found 5. Have sensory impairment such as deafness

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 176

IDENTIFICATION OF PATIENTS WHO ARE SLEEPING: ~Wake them to Identify before blood collection. Verbal info. should be compared with info. on the ID bracelet & the requisition/labels. ~Always ask open ended questions... 1. What is your name 2. please state your name Never yes no questions

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Venipuncture Method P. 205-206

SPECIMEN IDENTIFICATION AND LABELING: ~Completed labels should be firmly attached to the patient's specimen in the presence of the patient. ~Labels must accompany all blood specimens. ~NEVER pre-label because they may be erroneously picked up and used fro another patient which could cause significant errors. ~Blood sample labels should consistently include the following information. 1. Patients name 2. Patient's ID Number 3. Date of Collection 4. Time of collection 5. ID of person who collected the sample (Initials) 6. Patient's room number, bed assignment, or outpatient status (optional). ~Before leaving patient, be cognizant of the following issues 1. Make sure all steps are done: bleeding stopped, labels are correctly on tubes,identified and placed in secure location for transport, supplies that were used are disposed of, hands cleaned, patient feel good and not faint, thank patient. 2. date & time the collection 3. Initial specimen 4. remove all equipment from patients bedside ~Note bandages for infants and very young children are not recommended.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Equipment Selection and preparation P. 181-182

SUPPLIES FOR VENIPUNCTURE: Three types of venipuncture: 1. Evacuated tube system 2. Butterfly System 3. Syringe Method Supplies needed: 1. Written, printed, or electronic lab requisitions and/or labels 2. Markin Pens 3. Gloves 4. Non-latex tourniquets 5. Alcohol pads/skin disinfectants 6. Disinfectant swab sticks for blood culture skin prep 7. Safety needles w/ single use, evacuated tube holders and winged infusion sets 8. Safety syringes and syringe transfer devices 9. Blood collection tube 10. Plastic capillary tubes with tube sealer 11. Non-latex bandages and sterile gause pads 12. Glass microscope slides 13. Puncture-proof sharps containers Supplies should be readily available and selected just prior to the procedure

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 173 Assessing, Identifying, and Approaching, the Patients

TEST REQUISITIONS: ~Lab test requests are usually transmitted electronically or as a paper requisition ~Each facility should have specific instructions for health care workers and their level of authority in making decisions about lab requests.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 186-187

VENIPUNCTURE SITE SELECTION: CONTINUED ~Palpating the entire antebucial area enable the health care worker to get an idea of the size, angle and depth of the vein. ~The patient can assist in the process by holding his or her arm straight or slightly bent at the elbow. ~It is not recommend that "make a fist" an/or "Pump up the vein" pumping can lead to *HEMOCONCENTRATION. ~However in some cases, making a fist once and and keeping it closed for a short period of time (not pumping the fist) can facilitate the veinipunctrue until blood flows into the tube. When blood begins to flow let fist go. *HEMOCONCENTRATION= increased localized blood concentration of lg. molecules such as proteins, cells, and coagulation factors. This can be caused by excessive application of a tourniquet.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Prioritizing Patients P. 208

~TIMED SPECIMENS: HCW is responsible for for drawing the blood as near to the requested time as possible. ~STAT, OR EMERGENCY, SPECIMENS-STAT: Blood samples must be collected and delivered to the lab for testing as quickly as possible.

Phlebotomy Ch 8: Venipuncture Procedures Pg. 169 Blood Collection: P. 174 Patient Identification Process

~Use at least two ways to identify patients can include: 1. name 2. date of birth 3. government issued ID w/photograph Not Acceptable items to use in identification: 1. Hospital room number 2. Bed tags 3. charts in holders near patient 4. Tags in IV equipment ~High risk situations the following: 1. If patient does not understand language, find an interpreter 2. Siblings or twins are being cared for at he same time 3. patients with similar sounding names are being treated 4. patients have common names (Rodriguez, Smith, Jones) 5. Patients have similarly spelled names