c3-PATIENT PREPARATION.docx

PATIENT PREPARATION =================== Positioning the patient ----------------------- Your priorities and goals during blood collection are to keep the patient safe, provide comfort, and obtain necessary specimens efficiently and successfully. Properly positioning the patient helps achieve these...

PATIENT PREPARATION =================== Positioning the patient ----------------------- Your priorities and goals during blood collection are to keep the patient safe, provide comfort, and obtain necessary specimens efficiently and successfully. Properly positioning the patient helps achieve these goals. In inpatient settings, you can perform the procedure with the patient in a comfortable position in bed. This adds an extra component of safety in case of fainting. In outpatient settings, have the patient sit in a venipuncture chair with comfortable, adjustable armrests and a padded locking bar to prevent falls. Chairs with adjustable height make specimen collection easier and reduce back strain. Some chairs also recline for added safety and comfort. Never perform venipunctures with patients standing or sitting on a high stool or the edge of an examination table. Some facilities provide extra-wide venipuncture chairs and wheelchair stations. You will need to adjust arm positioning based on individual nuances of each patient. However, the optimal position is a full extension of the arm with the palm of the hand facing upward. Slight rotation of the arm can help you visualize the vein and keep it from rolling when inserting the needle. A pillow or an armrest device can improve comfort for some patients. Another technique is to have the patient support their arm under the elbow with their free hand. Specimen collection ------------------- Blood vessels consist of arteries, capillaries, and veins. When performing venipuncture, you access a vein. The three veins accessible in the antecubital fossa most often used for venipuncture are the following. - **Median cubital vein:** This vein is the first choice. It lies at or near the center of the antecubital fossa. It is a large vein and does not usually move when punctured. It is less prone to injury, and accessing it is less painful for the patient than other veins. In some patients (especially those who are obese), this vein might not be visible but can often be found with palpation. - **Cephalic vein:** This vein is usually the second choice. It lies in the antecubital fossa on the lateral aspect of the forearm. It is a large vein that can be easily palpated, but it is not usually visible. It tends to roll and can be difficult to stabilize. - **Basilic vein:** This vein should be the last choice when selecting a site in the antecubital fossa. It lies in the medial aspect of the forearm. It is a large vein, but it lies very close to the brachial artery. The median nerve runs very close to this vein, in some patients, the nerve crosses over the vein. If you use this site for a venipuncture and miss the target, stop the procedure and use another site instead of readjusting the needle. A readjustment can result in damage to the median nerve. Some patients have medical conditions (cellulitis or hematoma near the collection site, vascular shunt or graft) that are contraindications for venipuncture. Other patients have laboratory tests ordered where only small amounts of blood are needed, so venipuncture is not necessary. For those patients, a dermal puncture (finger or heel stick) can provide an adequate blood sample. These procedures are not considered venipunctures because blood is obtained from capillaries, not veins. When performing a capillary puncture on an adult, use the patient\'s middle or ring finger as the puncture site. The little finger is too small, with the bone too close to the surface. The index finger and thumb are likely to be sensitive or have thick calluses. It is preferable to use the side of the finger for the puncture. The tip of the finger is sensitive, has fewer capillaries, and can have calluses. If the fingertip puncture site is tender afterward, the patient would continue to feel it during activities such as typing on a keyboard. Do not perform a finger stick on a finger that is cold, cyanotic (blue), scarred, swollen, or covered in a rash. You are responsible for choosing the most appropriate location and determining whether a finger is suitable for specimen collection. If in doubt, consult a laboratory supervisor or the provider. When unsure whether to perform a capillary specimen collection, seek advice from a colleague or supervisor. If the laboratory requisition states \"capillary specimen\" for infants younger than 12 months, use a heel stick to obtain capillary blood. The veins of infants are too small for a standard venipuncture, and infants do not have sufficient tissue on their fingers for a finger stick. To choose a suitable vein, it is important to know the acceptable locations on the body from which to collect blood. The preferred location for venipuncture is the antecubital fossa. It is visible when the patient extends the arm with the palm of the hand facing upward. The antecubital fossa is a good site for venipuncture because several large veins here are close to the surface and are relatively easy to see and palpate. Other veins you could use when the antecubital veins are not optimal for venipuncture are the following. - **Hand veins:** Veins on the dorsal side of the hand are the next choice after the antecubital fossa. However, these veins are more fragile than the veins in the antecubital fossa, often roll, and are small in circumference. Venipuncture of the veins on the dorsal side of the hand tends to be more painful than of veins in the antecubital fossa. These veins are relatively short and thin, so it is difficult to achieve a good angle for a venipuncture. It is relatively easy to push the needle completely through the vein in this area. When collecting blood from a hand vein, it is best to use a butterfly needle because it is easier to guide, and the wings give you more control. Never collect blood from the wrist with the palm of the hand facing upward because tendons and nerves are close to the surface in this area. - **Ankle and foot veins:** These veins should be the last choice for a venipuncture. They are difficult to access, easy to injure, and often painful. If there are no other choices, use a butterfly needle for collection. Never collect blood from the ankle or foot vein of a patient who has diabetes mellitus or peripheral vascular disease due to poor circulation in the lower extremities. The tendency to develop infection, phlebitis, or hematoma is increased when drawing blood from the ankles or feet. Some facilities prohibit the use of these veins or require provider approval for venipuncture. You should know the facility's policy on alternative sites for venipuncture before attempting specimen collection from a site other than an arm or hand. When in doubt, seek advice from a supervisor or provider. Use both inspection and palpation when selecting the appropriate vein. The purpose of palpating a vein is to determine whether there is any condition that would make the vein unsuitable for a venipuncture. A vein that is suitable for venipuncture should be soft, flexible, and feel spongy or bouncy. Pulsation when palpating indicates that the vessel is an artery (not a vein) and should not be used. Once you feel the vein, you should be able to trace its path with your finger. Palpate it for depth, direction, and dimension. Knowing the depth will assist in deciding the angle of insertion. Knowing the direction of the vein will ensure that the needle will be in the lumen of the vessel and not pierce through the vein. Knowing the size of a vein assists in choosing the right needle for the venipuncture. Sometimes you cannot visually identify or palpate a vein that seems suitable for a venipuncture. In this case, place the patient's arm below the level of the heart for several minutes to decrease the return of blood to the heart and allow the veins to fill. In addition, a warm compress dilates the veins, making them easier to palpate. Follow the facility\'s protocol for applying heat and confirm with the provider or supervisor that a compress is safe. Never slap a patient\'s hand to make veins more accessible. This could cause injury, and the patient can perceive it as threatening or abusive. Transilluminating and laser devices, as well as ultrasound technology, can also be used to locate veins if other attempts have been unsuccessful. The following locations **[should not be used]** for venipuncture. - Above an IV catheter\'s insertion site in an arm, because IV fluids can mix with the blood sample and affect the results. - An arm that has an arteriovenous fistula or shunt for hemodialysis, because it can compromise the circulation in that arm and possibly damage the shunt. - An arm that has a central venous access device, because venipuncture can damage the device. - Antecubital fossa on the same side as a recent mastectomy, because it can cause swelling, injury, or infection. - Site that has edema, because excess fluid that accumulates in the area can alter test results. It can also be painful for the patient. - Site that has scarring, because blood collection is likely to be difficult and painful for the patient. - Site that has a hematoma, because it can alter the test results. It can also be painful for the patient, increase the risk of nerve damage by making the hematoma larger, or cause permanent damage to circulation in the limb. Some veins are large and easily visible but not good choices for venipuncture. Performing venipuncture on these veins can lead to vascular or neurological damage. Blood supply through these veins can also be poor, resulting in poor collection success rates. Examples include the following: - **Sclerotic veins:** As people age, veins tend to become sclerotic (hard, inflexible, and narrow). These veins can be difficult to puncture and painful for the patient. A patient who has had repeated blood draws from one site will tend to develop sclerotic veins as well. - **Tortuous veins:** Also referred to as varicose veins, tortuous veins are twisted, dilated, and lack elasticity. They do not run in a straight line, so it would be easy to push the needle completely through the wall of these veins. - **Thrombotic veins:** A vein with a thrombus (blood clot) can feel hard and inflexible. The patient might report tenderness when the vein is touched. - **Fragile veins:** Common in older adult, newborn, and pediatric patients, these veins are quite thin, weak, and difficult to puncture. With palpation, they collapse easily and do not refill quickly. Attempting to draw blood from these veins can be painful for the patient and often requires multiple sticks to collect enough blood for the testing. - **Phlebitic veins:** These veins are tender and warm with a red area around them. Phlebitic veins also can have clots and be difficult to puncture and painful for the patient. Factors such as age and mental status can alter the patient\'s ability to understand the venipuncture procedure. Objectively assess the patient to determine understanding, as this can affect tolerance of the procedure. The assessment doesn\'t need to take long; you can perform it in less than a minute while identifying the patient. Important information can be obtained through observation and active listening. To determine potential tolerance of the procedure, follow these guidelines: - Ask patients whether they have had any problems during or after a venipuncture. If yes, find out what the issue was. Was there excessive pain, significant bruising, prolonged bleeding, chest pain, dizziness, fainting, nausea, or another problem? - Look and listen. Do patients seem anxious? Is there anything about their body language or tone of voice that indicates fear? If yes, ask them directly if they are afraid and why. - Don\'t make assumptions about a patient\'s veins, regardless of age. With children, evaluate the location and type of blood collection suitable for the child\'s age. Infants younger than 12 months should have blood collections from the heel. Never use a lancet that punctures deeper than 2 mm when performing an infant heel stick. Do not perform a dermal puncture on the finger of a child younger than 1 year old due to the size of the finger and the increased risk of injury. - When performing a venipuncture on older adult patients, do not assume their veins are difficult to access. Some older adult patients have easily accessible veins. Examine and palpate the veins in the antecubital fossa in both arms to determine whether the patient has any veins suitable for blood collection. If the extremities are cool to the touch, warming the area might help locate a vein. If there are no accessible veins of the arms and hands, a dermal puncture might need to be considered. Skin changes with age, often becoming thinner and more prone to injury. Muscles diminish in size, so a shallower angle between the needle and the skin can be needed.