KMB 001

Institute of Health Science

Baptist Hospital Kediri

Type of Skill : Venous Blood Sampling Test

Revision number :0
Student name : Maria Natalia Ponga
Study program / Student ID Number : S1/01.2.17.00614
Level / Semester : Three (3)/Six (6)
Day / The date : ________________/_________________
Place of practice : _________________________________

*Scale
NO COMPONENT
(0,1,2,3)
I Tools preparation :
1 Vacuntainer and needle
2 Blood vessel
3 Alcohol swab
4 Dry gauze
5 Clean gloves
6 Tray
7 Crooked / safety box
8 Tourniquet
II Pre-interaction stage :
1 Order verification
2 Nurse’s self preparation
3 Prepare a tool
4 Prepare the environment : Protect client privacy and close the blinds
III Orientation Stage :
1 Bring the tools and do identifying patients (calling names, asking names, reading bed cards,
reading patient bracelets)
2 Give a therapeutic greeting
3 Clarification os contracts when awarding positions
4 Explain the purpose and procedure for positioning
5 Give clients the opportunity to ask questions
6 Prepare the tool and then brought to the client
IV Work Stage :
1 Check the doctor’s order or instructions on the type of laboratory examination needed and prepare
the laboratory request form
2 Washing hand
3 Prepare equipment
4 Set the patient’s position
5 Wear clean gloves
6 Place the base on the area of the hand where the blood sample is taken
7 Select the distal side of the vein used
8 First place the patient’s arm in a comfortable position so that officers are free when taking action
9 Instal the torniquet 5-15 cm above the venous puncture site
10 Select the dilated vein, instruct the patient to grasp
11 Disinfect the venous puncture side with an alcohol swab from the inside outward approximately 5
cm in diameter
12 Remove the needle cap from the syringe and inform the patient that the patient will feel pain
13 Place the thumb or index finger of the non-dominant hand 2,5 cm below the insertion place and
pull the skin towards the officer
14 Hold the syringe or needle at an angle of 15-30 degrees from the patient’s arm with the base or
pinhole facing up
15 Gently insert the needle into venous
16 Attach the specimen tube into the needle holder
17 Watch for blood flow into the syringe or tube
18 Take the blood sample as determined
19 Release the torniquet
 *Scale
NO COMPONENT
(0,1,2,3)
20 Remove the needle from the vein and apply dry gauze over the side of the venous puncture
without applying pressure using the other on dominant hand, pull the needle by pulling straight
back from the side of venous puncture
21 Apply pressure by using dried gauze at the insertion site ± 1 minute
22 Throw the needle in the safety box
23 Take off your gloves
24 Cover the former location of the stab with plester
25 Stick it the patient’s identity label to each blood tube and confirm to the patient to make sure in
accordance with the patient identity
26 Tell the patient the the action has been completed
27 Tidy up the equipment
28 Washing hand
29 Send blood samples to the laboratory
V Termination Stage :
1 Evaluation of patient responses
2 Summarize the result of the activity
3 Giving a message
4 Contract time, place, topic or further activities
VI Documentation :
1 Blood test
2 Clinical state
3 Client response
VII Attitude :
1 Therapeutic communication
2 Maintain work principles
3 Work with the carefully
4 Work systematically
VIII Cognitive
1 The purpose of taking venous blood
2 Indication of changes in patient position
3 Nurses vigilance

1. Assessment Table
Stage stage Final Value
Value sub
Weight Score Total value x 100
(Weight x Score)
Maximal Score (30)
I Equipment and
1
environmental preparation
II Pre-interaction Stage 1
III Orientation Stage 1
IV Work Stage 3
V Termination Stage 1
VI Documentation 1
VII Attitude 1
VIII Cognitive 1
Total value
2. Value Conversion
A : > 80
AB : 75-79,9
B : 70-74,9
BC : 65-69,9
C : 55-64,9
Result : Pass / Not pass
* Cross the unnecessary ones
Supervisor note :
Kediri, …………………………….
Supervisor/Examiner

( ________________________)