Proper identifiers include full name binomial name and numeric identifier. The selection of a vein site must be done properly. Veins provide an avenue of entry for various therapeutic agents as well as blood transfusions. Therefore, it is important to select the vein site carefully to preserve vein viability. Wrist veins: proceed with caution when drawing from this area. Use this site only as one alternative when recommended venipuncture sites are unavailable.
Possible nerve damage can occur when drawing at wrist; symptoms include: shooting pain, severe or unusual pain, tingling or numbness, onset of tremor.
Cleanse the venipuncture site —Determine antiseptic to be used and prep area by cleansing the site with a circular motion beginning at the center and working to the periphery. After cleansing, the site should be allowed to air dry completely. Never blot with gauze or tissue and never fan or blow on the area. The needle should form a 15 — 30 degree angle with the surface of the arm with the beveled side up. Swiftly insert the needle through the skin and into the lumen of the vein.
Avoid trauma and excessive probing. The phlebotomist should be alert to excessive bleeding. If bleeding persists longer than 5 minutes, immediately notify supervisor or provider. Label all tubes immediately at blood drawing station in the presence of the patient using two patient identifier protocol. Place tech code, time, and date on tubes. Place on requisition form, if applicable. Clean work area. Discard tourniquet, paper, extra cotton balls, and other items in the regular trash.
Remove gloves and wash hands with foam antiseptic hand-rub or antiseptic soap. For an inpatient the nursing staff can be contacted to aid in identification prior to proceeding. An outpatient must provide identification other than the verbal statement of a name.
Using the requisition for reference, ask a patient to provide additional information such as a surname or birthdate. A government issued photo identification card such as a driver's license can aid in resolving identification issues. If possible, speak with the patient during the process. The patient who is at ease will be less focused on the procedure.
Always thank the patient and excuse yourself courteously when finished. Impartial access to treatment or accommodations that are available or medically indicated, regardless of race, creed, sex, national origin, or sources of payment for care. Expect that any discussion or consultation involving the patient's case will be conducted discretely and that individuals not directly involved in the case will not be present without patient permission.
Know the identity and professional status of individuals providing service and to know which physician or other practitioner is primarily responsible for his or her care. Obtain from the practitioner complete and current information about diagnosis, treatment, and any known prognosis, in terms the patient can reasonably be expected to understand.
Reasonable informed participation in decisions involving the patient's health care. The patient has the right to refuse participation in such activity. Regardless of the source of payment, request and receive an itemized and detailed explanation of the total bill for services rendered in the hospital.
Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a last resort because of the higher probability of complications. Extensive scars from burns and surgery - it is difficult to puncture the scar tissue and obtain a specimen.
The upper extremity on the side of a previous mastectomy - test results may be affected because of lymphedema. Hematoma - may cause erroneous test results. If another site is not available, collect the specimen distal to the hematoma. Otherwise, satisfactory samples may be drawn below the IV by following these procedures:. Perform the venipuncture.
Draw 5 ml of blood and discard before drawing the specimen tubes for testing. Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. The line must be flushed first. When using a syringe inserted into the line, blood must be withdrawn slowly to avoid hemolysis. In general, blood should not be drawn from an arm with a fistula or cannula without consulting the attending physician. Palpate and trace the path of veins with the index finger.
Arteries pulsate, are most elastic, and have a thick wall. Thrombosed veins lack resilience, feel cord-like, and roll easily. If superficial veins are not readily apparent, you can force blood into the vein by massaging the arm from wrist to elbow, tap the site with index and second finger, apply a warm, damp washcloth to the site for 5 minutes, or lower the extremity over the bedside to allow the veins to fill.
Approach the patient in a friendly, calm manner. Provide for their comfort as much as possible, and gain the patient's cooperation. Verify the patient's condition. Fasting, dietary restrictions, medications, timing, and medical treatment are all of concern and should be noted on the lab requisition. Position the patient. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm. Apply the tourniquet inches above the selected puncture site.
Do not place too tightly or leave on more than 2 minutes and no more than a minute to avoid increasing risk for hemoconcentration. Wait 2 minutes before reapplying the tourniquet. Prepare the patient's arm using an alcohol prep. Cleanse in a circular fashion, beginning at the site and working outward. Allow to air dry. Grasp the patient's arm firmly using your thumb to draw the skin taut and anchor the vein. The needle should form a 15 to 30 degree angle with the surface of the arm.
Swiftly insert the needle through the skin and into the lumen of the vein. Avoid trauma and excessive probing. Press down on the gauze once the needle is out of the arm, applying adequate pressure to avoid formation of a hematoma. Follow the procedure as outlined above for greeting and identifying the patient. As always, properly fill out appropriate requisition forms, indicating the test s ordered.
The best locations for fingersticks are the 3rd middle and 4th ring fingers of the non-dominant hand. Do not use the tip of the finger or the center of the finger. Avoid the side of the finger where there is less soft tissue, where vessels and nerves are located, and where the bone is closer to the surface.
The 2nd index finger tends to have thicker, callused skin. The fifth finger tends to have less soft tissue overlying the bone. Avoid puncturing a finger that is cold or cyanotic, swollen, scarred, or covered with a rash.
Using a sterile lancet, make a skin puncture just off the center of the finger pad. The puncture should be made perpendicular to the ridges of the fingerprint so that the drop of blood does not run down the ridges. Collect drops of blood into the collection device by gently massaging the finger. Avoid excessive pressure that may squeeze tissue fluid into the drop of blood. Have the patient hold a small gauze pad over the puncture site for a couple of minutes to stop the bleeding.
Make sure the needle fully penetrates the upper most wall of the vein. Partial penetration may allow blood to leak into the soft tissue surrounding the vein by way of the needle bevel. Avoid drawing the plunger back too forcefully, if using a needle and syringe, or too small a needle, and avoid frothing of the sample. Discard a sample at least three times the volume of the line before a specimen is obtained for analysis.
Hemoconcentration: An increased concentration of larger molecules and formed elements in the blood may be due to several factors:. Primary effect is hemoconcentration of non-filterable elements i. The hydrostatic pressure causes some water and filterable elements to leave the extracellular space. Significant increases can be found in total protein, aspartate aminotransferase AST , total lipids, cholesterol, iron.
Therapeutic Drug Monitoring: different pharmacologic agents have patterns of administration, body distribution, metabolism, and elimination that affect the drug concentration as measured in the blood.
Many drugs will have "peak" and "trough" levels that vary according to dosage levels and intervals. Check for timing instructions for drawing the appropriate samples. Effects of Exercise: Muscular activity has both transient and longer lasting effects. Stress: May cause transient elevation in white blood cells WBC's and elevated adrenal hormone values cortisol and catecholamines. Anxiety that results in hyperventilation may cause acid-base imbalances, and increased lactate.
Diurnal Rhythms: Diurnal rhythms are body fluid and analyte fluctuations during the day. For example, serum cortisol levels are highest in early morning but are decreased in the afternoon. Serum iron levels tend to drop during the day. You must check the timing of these variations for the desired collection point. Posture: Postural changes supine to sitting etc. Certain larger molecules are not filterable into the tissue, therefore they are more concentrated in the blood.
Enzymes, proteins, lipids, iron, and calcium are significantly increased with changes in position. Other Factors: Age, gender, and pregnancy have an influence on laboratory testing.
Normal reference ranges are often noted according to age. A test that has been ordered may be cancelled due to problems unrelated to drawing the specimen, and these are the most common causes for cancellations:.
Because of contacts with sick patients and their specimens, it is important to follow safety and infection control procedures. Dispose of needles immediately upon removal from the patient's vein.
Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or splashing of contents.
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.
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