c4-PREPARING FOR VENIPUNCTURE.docx

CHAPTER 4 ========= Routine Blood Collections ========================= OVERVIEW -------- As a phlebotomist, you perform venipuncture and capillary collections on patients to collect blood for a variety of tests. These blood collections are performed as venipunctures or dermal punctures. Venipunc...

CHAPTER 4 ========= Routine Blood Collections ========================= OVERVIEW -------- As a phlebotomist, you perform venipuncture and capillary collections on patients to collect blood for a variety of tests. These blood collections are performed as venipunctures or dermal punctures. Venipunctures refer to blood collection from a vein, usually in the antecubital area of the arm or the dorsal part of the hand. A dermal puncture, also known as a capillary collection or finger stick, refers to blood collected from capillaries in the finger or heel. Venipuncture and capillary collection tests help providers diagnose conditions, so take care to perform these collections properly to support accurate test results. To help ensure accurate blood test results are obtained, use the appropriate equipment, and follow the order of the draw. Check all equipment for expiration dates, for any manufacturers\' defects, and that the safety devices are intact. It is also important that all specimens are labeled correctly. A mislabeled specimen can result in inaccurate results and laboratory mistakes that could adversely affect the patient. Beyond test accuracy, another responsibility of phlebotomists is the safety of the patient. To ensure patient safety, dispose of used sharps properly and as soon as possible. Also observe the patient throughout the entire blood collection procedure and be prepared to respond to any complication. When a complication occurs, help reduce injury to the patient by providing prompt and appropriate action. After blood collection is complete, ensure that the patient has fully recovered from the collection before you leave their presence. Being observant of the patient throughout the blood collection, being aware of potential hazards in your surroundings, and using the proper equipment will keep both you and the patient safe. Objectives ---------- Upon completion of this chapter, you should be able to: - Determine the appropriate supplies and equipment needed for the requested collection. - Verify the quality of the supplies and equipment to be used for the collection. - Select the appropriate collection site based on the test ordered and patient condition. - Apply and remove the tourniquet to ensure patient safety and accurate test results. - Prepare the collection site prior to the procedure. - Demonstrate proper insertion and removal techniques for venipuncture. - Follow the order of the draw when performing venipuncture. - Invert evacuated tubes with additives after collection. - Ensure patient safety throughout the collection. - Identify and respond to any problematic patient signs and symptoms. - Recognize and respond to potential complications resulting from the procedure. - Perform capillary (dermal) collection method based on age and condition. - Perform capillary (dermal) puncture steps in order. - Follow the order of the draw when performing capillary collection. - Label all specimens. - Perform postprocedure care. PREPARING FOR VENIPUNCTURE ========================== Equipment selection ------------------- Many factors affect equipment choices for blood collection. Among these are the facility in which you work, the types of tests that are being performed, the needs and condition of the patients, and the setting in which the blood will be collected. In an outpatient setting (doctor\'s office, lab collection center) you most likely will have a phlebotomy station, where supplies and equipment are kept in a cabinet close to the phlebotomy chair. Patients come into the facility, and it is your responsibility to help make sure that they are safe throughout their visit. In the inpatient setting, you can have a phlebotomy tray or cart that you take with you to the inpatient floors. In either setting, assemble the equipment before the tourniquet is placed on the patient, and set up the supplies in a manner that keeps both you and the patient safe. Before the blood collection, review the requisition to know what supplies you need to collect the specimen. Gather all supplies necessary and double-check the requisition to make sure that you take all of the supplies with you. It gives the patient a feeling of confidence in you when all supplies are there, ready for the collection. When gathering supplies, check expiration dates and look for any manufacturer or packaging defects. Arrange equipment in a location that provides safety for the patient and for your convenience. When setting up for the blood collection, place all items within easy reach to help keep you and the patient safe. Because the patient eats on the overbed table in an inpatient setting, avoid placing the phlebotomy tray on this surface. Instead use a chair or put a towel or disposable drape under the phlebotomy tray. It is also important to keep needles capped until right before the blood collection. The evacuated tube system (ETS) is the most commonly used equipment for venipuncture. Equipment used for ETS includes the following: - **Gloves:** Use a new pair of well-fitting vinyl or nitrile gloves for each patient venipuncture. The reuse of gloves is prohibited. Consult the patient\'s chart for potential latex allergies. - **Isopropyl alcohol swabs or pads:** Use alcohol swabs or pads to cleanse the skin before inserting the needle. Discard them after each use. The reuse of swabs is prohibited. - **Gauze pads:** Use disposable gauze pads to provide pressure to aid in clotting and to cover the venipuncture site. Reuse of the pads is prohibited. Do not use cotton balls, because they can leave fibers on the patient\'s collection site and can remove a clot when removed. - **Tape, self-adhering bandages, or adhesive bandages:** Apply these to the puncture site to promote clotting. - **Tourniquet:** These come in pliable straps (latex or latex-free) or hook-and-loop fastener forms. Tourniquets can be reused but discard them if they become soiled or obviously contaminated. If a tourniquet is not available, a blood pressure cuff pumped up to 40 mm Hg can be used. - **Needles:** Use 21- to 23-gauge hollow needles with a beveled edge for routine venipuncture. The needle used is 1 to 1.5 inches long. They are sterile and must be disposed of after each use. Needles must have a safety device that completely covers the needle after use. The 21-gauge needle is the most common size. Never reuse needles. ETS needles are double-sided-one side is inserted into the patient, and the other side is covered with a sheath that punctures into the evacuated tube and helps prevent the blood from dripping when tubes are changed. Before and after use, be equally careful with each side of the needle. - **Hub, adapter, or needle holder:** These are attached to the needle and used to guide the tubes toward the needle to initiate blood flow into the evacuated tube. - **Blood collection tubes:** Blood collection tubes used for adults are about 3 inches long and ½ to ¼ inches wide. The vacuum inside adult blood collection tubes is higher than the pressure inside the blood vessels of a child, so an adult collection tube can collapse a child\'s vein. Pediatric blood collection tubes are identical to adult tubes in color, but they are about half as big and have less vacuum. Evacuated tube system method ---------------------------- When using the ETS method, blood is collected into glass or plastic tubes. The inside of a blood collection tube is sterile, but the outside is not. The tubes have an opening at one end that is sealed with a rubber stopper. During manufacturing, the air in the tubes is removed, and rubber stoppers are placed over the openings. The tubes have a vacuum (negative pressure) that-when the tubes are attached to a needle within a vein-aids in the flow of blood into the collection tubes. The vacuum in each type of tube is designed to collect the appropriate amount of blood required for the tests to be performed from each tube. Because of this vacuum, it is important to never remove the stopper of a tube before a blood collection. Colored stoppers identify each tube and indicate which additive is contained inside. The label indicates which additive is in the tube, the expiration date, and the amount of blood that the tube will hold. Check the label to confirm that the additive is the correct one for the test being performed. Do not trust the color of the stopper alone. The most common additives in tubes are either anticoagulants or clot activators. The additives are chosen for each tube by how well it preserves the blood to help ensure test accuracy. The anticoagulant tubes (also called plasma tubes) are used when the blood test requires the blood not to clot. These most commonly include blood culture, light yellow, light blue, green, purple, royal blue, and gray tubes. - **Blood culture** tubes contain sodium polyanethole sulfonate (SPS) and are used for bacterial studies. - **Light blue tubes** contain sodium citrate and are used for coagulation blood tests. - ***(Red goes here in OOD)*** - **Green tubes** contain sodium, lithium, or ammonia heparin and are used to test chemical levels in the blood. - **Purple /lavender/Pink tubes** contain ethylenediaminetetraacetic acid (EDTA) and are used for whole blood hematology determinations. - **Gray tubes** contain potassium oxalate/sodium fluoride and are used for glucose determinations. - **Royal blue tubes** contain either a clot activator or EDTA and are used for trace element testing. - **Light yellow tubes** contain acid citrate dextrose (ACD) and are used for blood bank studies and DNA testing. Serum tubes are used for blood tests that require the blood to clot. - **Red, gold, or orange tubes** are serum tubes, which can have no additives if they are glass. (The silica in the glass or silicone blown into the tubes helps the blood clot.) Plastic red and gold tubes contain a clot activator and are used for chemistry determinations of the blood. Orange tubes contain a thrombin-based clot activator and are used when the chemistry determination is for a stat blood collection. The additives are specific to blood tests, and phlebotomy technicians must know the appropriate tubes to use for each test. Using the incorrect tube can alter the test results. It can also result in the clotting of blood that should not be clotted. Evacuated tubes can also contain a gel separator, which doesn't affect the condition or quality of the blood sample but assists in the processing of the blood after the tube is centrifuged. When the gel separator is in a serum tube, the tube is called a serum separator tube (SST). If the gel separator is contained in a plasma tube, the tube is called a plasma separator tube (PST). Syringe method -------------- The syringe method is used for patients who have fragile veins that collapse easily. ETS tubes, which contain a vacuum, collect the blood from the patient at a rapid rate that you cannot determine or control. The syringe is different; the plunger on the barrel of the syringe allows you to manually adjust the rate that the blood is withdrawn from the patient, and therefore helps prevent the collapsing of fragile veins. Many of the supplies used for a syringe collection are like those used in an ETS collection: gloves, alcohol, gauze pads, and bandages. Evacuated tubes are used, but not in the blood collection process itself. The blood is first collected into the syringe and then transferred into the tubes. The supplies that differ from the ETS method include the following: - **Syringe:** Used instead of an adapter, the syringe attaches to the needle and holds the blood during collection. The syringe has a plunger, which is used to slowly withdraw blood from the vein into the barrel of the syringe. The side of the syringe has printed numbers that indicate the amount of blood that can be collected into the barrel. Syringes can be many sizes, but 10 mL and 20 mL are most commonly used. - **Needles:** Like the ETS method, needles are hollow with a beveled end. The needles range from 21- to 23-gauge and are 1 to 1½ inches long. OSHA requires a safety device that completely covers the used needle. Unlike the ETS method, the needles are single-sided. - **Transfer device:** This is a plastic device, similar in appearance to an adapter/hub, containing a needle on the end and covered in a sheath. The transfer device is constructed to screw onto a syringe, where the needle was originally attached. The barrel of the transfer device is large enough to allow an evacuated tube to slide in and snap onto the needle to allow the blood to be collected into the tube by its vacuum. Winged infusion (butterfly) method ---------------------------------- A winged infusion device is used when a patient has veins that are small or difficult to access. The winged infusion set is also known as a butterfly, because the holders on either side of the needle look like wings. The supplies used to perform a venipuncture via the butterfly method are very similar to those used for the ETS method: gloves, gauze, alcohol pads, adapter/hub, and bandages. The difference is how the butterfly attaches to the adapter and how it is used to puncture the patient\'s skin. The winged infusion set consists of a 21- to 23-gauge, hollow, ¾-inch-long sterile needle with a beveled edge, a short length of flexible plastic tubing, and another sterile needle at the other end of the plastic tubing covered with a rubber sheath. The second needle attaches to the adapter similar to the ETS method. Instead of holding the entire device in one hand like the ETS system, one hand holds only the needle (not the adapter) during insertion. Once the first needle has been inserted into the vein, the tube is inserted into the adapter and the second needle is used to puncture the rubber collection tube. As the second needle punctures the stopper, the rubber sheath slides back, allowing the needle to pierce the tube and blood to flow from the vein into the collection tube. Equipment quality ----------------- Check all blood collection equipment before each procedure to determine that it meets quality control standards and supports safe blood collection for you and the patient. Check the equipment that is on the phlebotomy tray or in storage on a routine basis for expiration dates and any corruption of the equipment (missing labels, defects, cracks, breaks). Perform these checks prior to every blood collection. Before performing a blood collection, visually inspect the needle before and after removing the cap. If the needle is in a package, there must be no rips, tears, or other signs that the sterility of the needle has been compromised. If there is a rip or tear in the package, discard the needle into a sharps container. Before removing the cap, examine needles for the following: - **Expiration date:** Even though a needle itself cannot expire, the date refers to the sterility of the needle, which is only guaranteed for a specific amount of time. Verify that the date is within range, and do not use if expired. - **Label seal:** The label on the side of the needle that extends over the needle cover is a safety seal. The seal indicates that the needle has never been used or opened. When the seal is broken (even new out of the box), treat it as a used needle and dispose into a sharps container. After removing the cap and before insertion into the patient, examine the needle for the following: **Safety device:** The safety device should be attached firmly to the needle or adapter and cover the needle completely. If the safety device is missing, damaged, or excessively loose, do not use; discard the needle into a sharps container. **Bevel:** Inspect the end of the needle before every blood collection for an intact bevel. The bevel should not be bent, broken, or have any burrs or other flaws. If any of these conditions are discovered, activate the safety and dispose of the needle into the sharps container. A broken or bent bevel can tear the skin instead of puncturing it, causing pain to the patient. Needles must be used only once, even on the same patient. If you miss the vein and withdraw the needle from the patient, it must not be reinserted. A new needle must be used. All safety devices must always be deployed as soon as possible after the needle is removed from the vein. Place them in a sharps container as soon as possible; do not lay a used needle on a patient\'s bed or a phlebotomy tray. Other venipuncture supplies must be examined to determine if they are safe for use on patients. Evacuated tubes also have expiration dates and must not be used beyond that date. Additives in expired tubes might not work correctly and can alter test results. Also, the vacuum in an expired tube can be insufficient to guarantee a complete blood collection. Do not use tubes missing a label, as the label contains information such as the expiration date, additive information, and size of the tube. Using a tube without a label can adversely alter test results. Inspect all tubes and stoppers for cracks or breaks. Any tubes that are expired, cracked, without a label, or have any other defects cannot be used and must be discarded. OSHA requires that all adapters be single-use items. Before use, inspect the adaptor for any manufacturer\'s defects, cracks, or breaks. Dispose of any adapters that are cracked, broken, or contaminated. Depending on the facility, tourniquets are either single- or multiple-use items. All tourniquets should be inspected for any tears or rips. A multiple-use tourniquet should be inspected for dirt, hair, blood, or any other contamination. If there are any tears or significant signs of wear or contamination, dispose of the tourniquet into a waste basket. Check individual packages of alcohol pads for any rips or tears. A rip or a tear could cause the alcohol to dry out and lose its antiseptic properties. Do not reuse any alcohol pad and dispose of any ripped packages or dry alcohol pads. Select and prepare the site --------------------------- Observe the patient\'s arm for any factors that can affect the blood collection (tattoos, scarring, hematoma). Many patients prefer a specific arm to be used for a collection. Some patients have a reason why one arm cannot be used. Ask the patient which arm they prefer prior to the collection preparation. Start your palpation on the arm that the patient prefers. If you cannot locate a vein on that arm, ask for permission to palpate the other arm. Both arms can be checked to find the best vein for the blood collection. When selecting the arm to use for a blood collection, there are several factors that determine which side should be assessed first. Due to the increased risk of infection or pain to the patient, avoid using the arm on the affected side of a patient who has a history of a mastectomy. Avoid performing a collection in any area of the body covered with a tattoo. Do not obtain a specimen through a hematoma because the collected blood in the area can affect test results and could also cause more pain to the patient. If a patient has edema, avoid the area due to the possibility of the blood collected being altered with the extra fluid in that area. It can also cause increased pain to the patient because the skin becomes very tight in the areas of edema. Do not collect from an area that is scarred due to pain and potential difficulty finding a vein. Do not collect from a sclerosed vein; the scarring in the vein can be difficult to collect from and increases the risk of pain to the patient. When a patient has an IV in their arm, first try to find a vein in the other arm. If not possible, follow the facility\'s procedure for the blood collection. Sometimes the IV will be turned off for several minutes prior to blood collection. In all cases (IV on or off), the collection must take place below the IV to help prevent contamination of the specimen with infused fluids. It is especially important to collect from the opposite arm or below the IV when a patient is receiving a blood transfusion. Collecting above the IV could mean that the blood being tested is from the donor, which can yield inaccurate blood test results. When performing a venipuncture on a child or an adult, first palpate the veins in the antecubital area. The first choice for a vein is usually the median cubital. The median cubital is firmly anchored in the middle of the arm on the anterior surface and is most often the least painful to access for the patient. The second choice is often the cephalic vein, which is found toward the outside (lateral) surface of the arm. Accessing the cephalic vein might be a little more painful for the patient but is the next best choice after the median cubital. In patients who are obese, the cephalic vein tends to be the easiest vessel to locate for a venipuncture. If you cannot locate the cephalic or median cubital vein in a patient, the next choice is to check for an accessible hand vein. If a vein cannot be found in any of the previous choices, the basilic vein can be attempted. The basilic vein-very prominent in some patient\'s arms-should be the last choice for a blood collection. The radial nerve and brachial artery are very close to the basilic vein; the risk of accidentally disrupting the nerve or artery increases with this vessel choice. If an attempt to collect blood from the basilic vein is not successful, never reposition the needle. The ideal vein to choose is well anchored, feels spongy and bouncy to the touch, is straight, and is easy to access with a needle. When performing a blood collection from an infant, the first choice is the heel. Infants up until 12 months of age have blood collection obtained from the heel. Do not perform a heel blood collection on an area that has a hematoma, has recently been accessed for another collection, or has any cuts or scratches. When performing a dermal puncture on a child or adult, the middle and ring fingers on the nondominant hand are the best choices. The nondominant hand is preferred because the patient uses it less than their dominant hand. Observe the finger for any factors that can affect the blood collection (scarring, cuts, extreme calluses). Avoid these areas because they will make the blood collection difficult and can increase pain to the patient. Choose a site on the finger that is the least callused and away from the bone and nail bed. Tourniquet application and removal ---------------------------------- Tourniquets can be for single or multiple use. If using a multiple-use tourniquet, check for contamination, cracks, or excessive wear before each patient. The tourniquet should be placed approximately 3 to 4 inches above the antecubital area for collections in that region, or above the wrist bone for dorsal hand collections. When the tourniquet is too far from the desired venipuncture site, the tourniquet might not provide enough tension. If the tourniquet is too close to the site, the vein can collapse. Tourniquets should be applied gently, yet tight enough to assist with finding the vein. Too loose of a tourniquet can make it difficult to find the vein. A tourniquet that is too tight can slow or stop blood flow and can also hurt the patient. Apply the tourniquet so that the removal is quick and easy. It is also important that the tourniquet be removed once blood flow is established and no longer than 1 minute after being applied. After 1 minute, hemoconcentration begins. Hemoconcentration alters the blood and can yield inaccurate results. Remove the tourniquet gently, because the needle will still be in the vessel. Discard or reuse tourniquets as the facility requires. If a tourniquet is not available, a blood pressure cuff pumped to 40 mm/Hg can be used. Release once blood flow is established and within the 1-minute point, similar to the tourniquet. Observation and palpation ------------------------- Once the tourniquet is applied, begin to palpate, starting from the middle of the antecubital region and moving toward the outside of the arm. Palpation should begin with light pressure, the finger bouncing against the skin-up and down-without leaving the surface of the skin. Veins feel spongy and bouncy. Tendons feel hard (similar to bone) and should be avoided. Also, avoid veins that feel hard because they could be sclerosed or scarred. If no veins are felt with light pressure, increase pressure but avoid hurting the patient. Only one finger should be used, preferably the index or second finger of the nondominant hand. Palpate with the very tip of the finger, which can be the most sensitive, and avoid palpating with the thumb. Do not select a vein that you can see but not feel-it can be a superficial vessel, which will not be large enough to permit the needle to be entered and blood to be collected. Always palpate with the same finger and hand to train your brain to find veins easily. Palpating with the nondominant hand also allows you to re-palpate in the case of a miss without switching hands, which can disrupt the needle. Once a vein is found, travel your finger up and down the vessel to determine the direction. Palpate also for depth of the vein and the size of the vessel. This information will help you decide what equipment to choose and how to align the needle when entering the vein. When a vein is difficult to find, there are a few procedures that can help the vein become more prominent. Because veins will rise to the surface to help cool the body and blood, a warm cloth or an infant heel warmer can be used on the antecubital space, the dorsal part of the hand, or the heel of an infant. Just make sure that it isn\'t so hot that it could burn the patient. For arm or hand collections, hang the arm below the heart to allow gravity to help fill the veins with blood. Some rubbing of the area can help circulation, but avoid too much friction, which can affect blood test results. Do not slap or smack the area of the palpated veins. Not only could this hurt the patient, but it can also be considered an act of battery. Antiseptic application ---------------------- Always wear gloves when cleansing a patient's skin in preparation for blood collection. To cleanse the site prior to routine venipuncture use a new individually packaged 70% alcohol pad or swab. Open the package carefully to avoid wetting fingers and excessive touching of the pad. Cleanse the site with friction, using back-and-forth strokes. Refer to the study guide addendum on the NHA website for details on CLSI guidelines for venipuncture site preparation. Allow the alcohol to dry (preferably air-dry) so it can perform its antiseptic action. Performing the blood collection when the alcohol is wet can also cause the patient to feel a stinging sensation when the needle enters the skin. Do not blow on the site, which can contaminate the specimen. If the alcohol seems to stay wet a sterile gauze can be used to gently dab the site to remove the excess alcohol. An alcohol swab stick can also be used in the same method as the pad. Avoid touching the area after it has been cleansed. If a re-palpation is necessary, repeat the cleansing process. If a patient is allergic to alcohol, use the recommended alternative in your facility. Replacements include chlorhexidine gluconate and povidone-iodine. Do not use alcohol to cleanse the site if the blood collection requested is to test for alcohol in the patient's system. Use the recommended antiseptic in the facility for these procedures. When performing a blood culture collection, the site should have a different cleansing method. Instead of using only 70% isopropyl alcohol, the facility can require use of another antiseptic such as povidone-iodine\> chlorhexidine gluconate, or an alcohol and povidone combination. The cleansing should occur for at least 30 to 60 seconds to remove as many micro-organisms from the skin as possible. Careful cleansing of the area helps ensure better blood culture results and reduce the risk of accidental contamination of the test. When performing a dermal puncture (capillary puncture), cleansing the skin is also very important. When the location on the finger or heel has been chosen, rub the area vigorously with a new individually packaged 70% isopropyl alcohol pad or swab. The vigorous rubbing helps remove micro-organisms from the skin and increase blood flow to the area. Allow to air-dry prior to the puncture. Do not use povidone-iodine to cleanse a dermal puncture because it will have an adverse effect on the results of a bilirubin, uric acid, phosphorous, or potassium test.