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BLOOD COLLECTION: ROUTINE VENIPUNCTURE AND SPECIMEN HANDLING

Objectives for the tutorial:

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Describe and perform the venipuncture process including: 1. Proper patient identification procedures. 2. Proper equipment selection and use. 3. Proper labeling procedures and completion of laboratory requisitions. 4. Order of draw for multiple tube phlebotomy. 5. Preferred venous access sites, and factors to consider in site selection, and ability to differentiate between the feel of a vein, tendon and artery. 6. Patient care following completion of venipuncture. 7. Safety and infection control procedures. 8. Quality assurance issues. Identify the additive, additive function, volume, and specimen considerations to be followed for each of the various color coded tubes. List six areas to be avoided when performing venipuncture and the reasons for the restrictions. Summarize the problems that may be encountered in accessing a vein, including the procedure to follow when a specimen is not obtained. List several effects of exercise, posture, and tourniquet application upon laboratory values.

VENIPUNCTURE PROCEDURE
The venipuncture procedure is complex, requiring both knowledge and skill to perform. Each phlebotomist generally establishes a routine that is comfortable for her or him. Several essential steps are required for every successful collection procedure: 1. Identify the patient. 2. Assess the patient's physical disposition (i.e. diet, exercise, stress, basal state). 3. Check the requisition form for requested tests, patient information, and any special requirements. 4. Select a suitable site for venipuncture. 5. Prepare the equipment, the patient and the puncture site. 6. Perform the venipuncture.

7. Collect the sample in the appropriate container. 8. Recognize complications associated with the phlebotomy procedure. 9. Assess the need for sample recollection and/or rejection. 10. Label the collection tubes at the bedside or drawing area. 11. Promptly send the specimens with the requisition to the laboratory.

ORDER FORM / REQUISITION
A requisition form must accompany each sample submitted to the laboratory. This requisition form must contain the proper information in order to process the specimen. The essential elements of the requisition form are:
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Patient's surname, first name, and middle initial. Patient's ID number. Patient's date of birth and sex. Requesting physician's complete name. Source of specimen. This information must be given when requesting microbiology, cytology, fluid analysis, or other testing where analysis and reporting is site specific. Date and time of collection. Initials of phlebotomist. Indicating the test(s) requested. An example of a simple requisition form with the essential elements is shown below:

Date. Examples of labeled collection tubes are shown below: EQUIPMENT: THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE: o o o o o o o o Evacuated Collection Tubes . The rubber stoppers are color coded according to the additive that the tube contains.LABELING THE SAMPLE A properly labeled sample is essential so that the results of the test match the patient. NOTE: Both of the above MUST match the same on the requisition form.for application on the site from which the needle is withdrawn.The gauge number indicates the bore size: the larger the gauge number. Various sizes are available. Tourniquet . the smaller the needle bore. Patient's ID number. The key elements in labeling are: o o o o Patient's surname.70% isopropyl alcohol. time and initials of the phlebotomist must be on the label of EACH tube.use with the evacuated collection system.Wipe off with alcohol and replace frequently. Needles are available for evacuated systems and for use with a syringe. Holder/Adapter . Needles .Used if blood culture is to be drawn. Adhesive bandages / tape . Automated systems may include labels with bar codes.The tubes are designed to fill with a predetermined volume of blood by vacuum. single draw or butterfly system. . Blood should NEVER be poured from one tube to another since the tubes can have different additives or coatings (see illustrations at end). Gauze sponges . Alcohol Wipes .protects the venipuncture site after collection. first and middle. Povidone-iodine wipes/swabs .

blood culture bottle or tube (yellow or yellow-black top) Second .can be made of latex.needles should NEVER be broken. 3. rubber. PROCEDURAL ISSUES PATIENT RELATIONS AND IDENTIFICATION: The phlebotomist's role requires a professional. If there is a concern regarding contamination by tissue fluids or thromboplastins. then one may draw a non-additive tube first. etc. and then the light blue top tube.non-additive tube (red top) 4. ORDER OF DRAW: Blood collection tubes must be drawn in a specific order to avoid crosscontamination of additives between tubes. 6. EDTA (lavender top) 5. Third . Syringes . .both verbal and nonverbal . PST (light green top). worn to protect the patient and the phlebotomist. Contains a gel separator and clot activator. Oxalate/fluoride (light gray top) 1.. Sodium heparin (dark green top) 3. NOTE:Tubes with additives must be thoroughly mixed. Needles should be placed in a proper disposal unit IMMEDIATELY after their use. Last draw .is essential. courteous. 2. The recommended order of draw for plastic vacutainer tubes is: First . Effective communication . Greet the patient and identify yourself and indicate the procedure that will take place. Contains lithium heparin anticoagulant and a gel separator.o o o Needle disposal unit . Contains acid citrate dextrose.coagulation tube (light blue top). If just a routine coagulation assay is the only test ordered. then a single light blue top tube may be drawn. ACDA or ACDB (pale yellow top). 4. bent.additive tubes in this order: 1. and understanding manner in all contacts with the patient. Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive. or recapped.may be used in place of the evacuated collection tube for special circumstances. SST (red-gray or gold top). Gloves . vinyl. 2.

and any known prognosis. If possible. Reasonable informed participation in decisions involving the patient's health care. creed. Expect reasonable safety congruent with the hospital practices and environment. Using the requisition for reference. or sources of payment for care. Always thank the patient and excuse yourself courteously when finished. ask a patient to provide additional information such as a surname or birthdate. Regardless of the source of payment. Considerate. ask for a full name and always check the armband for confirmation. If an inpatient is able to respond. The patient shall be informed if the hospital proposes to engage in or perform human experimentation or other research/educational profits affecting his or her care or treatment. Confidentiality of all communications and other records pertaining to the patient's care. 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. An outpatient must provide identification other than the verbal statement of a name. treatment. sex. respectful care. PATIENT'S BILL OF RIGHTS: The Patient's Bill of Rights has been adopted by many hospitals as declared by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). 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. The patient has the right to refuse participation in such activity. regardless of race. speak with the patient during the process. DO NOT DRAW BLOOD IF THE ARMBAND IS MISSING. The patient has the right to: o o o o o o o o o o o Impartial access to treatment or accommodations that are available or medically indicated. Consult a specialist at the patient's own request and expense. . request and receive an itemized and detailed explanation of the total bill for services rendered in the hospital. national origin. The basic patient rights endorsed by the JCAHO follow in condensed form are given below. The patient who is at ease will be less focused on the procedure. Refuse treatment to the extent permitted by law.Proper patient identification MANDATORY. Obtain from the practitioner complete and current information about diagnosis. in terms the patient can reasonably be expected to understand.

Foot veins are a last resort because of the higher probability of complications. so collect from the opposite arm if possible. Arteries pulsate.may cause erroneous test results. you can force blood into the vein by massaging the arm from wrist to elbow. VENIPUNCTURE SITE SELECTION: Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently. The upper extremity on the side of a previous mastectomy . or lower the extremity over the bedside to allow the veins to fill. satisfactory samples may be drawn below the IV by following these procedures:  Turn off the IV for at least 2 minutes before venipuncture. tap the site with index and second finger.tissue fluid accumulation alters test results.fluid may dilute the specimen. and roll easily.test results may be affected because of lymphedema. the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. and have a thick wall. If another site is not available. o Cannula/fistula/heparin lock .it is difficult to puncture the scar tissue and obtain a specimen. Intravenous therapy (IV) / blood transfusions .  Perform the venipuncture.o Be informed of the hospital rules and regulations regarding patient conduct. PROCEDURE FOR VEIN SELECTION: Palpate and trace the path of veins with the index finger. apply a warm. collect the specimen distal to the hematoma. o PERFORMANCE OF A VENIPUNCTURE: . Thrombosed veins lack resilience. Select a vein other than the one with the IV. Certain areas are to be avoided when choosing a site: o o o o Extensive scars from burns and surgery . feel cord-like. In general.  Apply the tourniquet below the IV site. o Edematous extremities . Hematoma . o If superficial veins are not readily apparent. damp washcloth to the site for 5 minutes. Otherwise.hospitals have special policies regarding these devices. Draw 5 ml of blood and discard before drawing the specimen tubes for testing. blood should not be drawn from an arm with a fistula or cannula without consulting the attending physician. are most elastic.

dietary restrictions. Identify the patient correctly. indicating the test(s) ordered. Position the patient. Press down on the gauze once the needle is out of the arm. Prepare the patient's arm using an alcohol prep. and gain the patient's cooperation. o o o PHLEBOTOMY PROCEDURE ILLUSTRATED: o o o Patient identification Filling out the requisition Equipment . Check for any allergies to antiseptics. Cleanse in a circular fashion. calm manner. Do not place too tightly or leave on more than 2 minutes. Remove the needle from the patient's arm using a swift backward motion. Swiftly insert the needle through the skin and into the lumen of the vein. applying adequate pressure to avoid formation of a hematoma. or latex by observing for armbands and/or by asking the patient. The patient should either sit in a chair. lie down or sit up in bed. Avoid trauma and excessive probing. The needle should form a 15 to 30 degree angle with the surface of the arm. The patient should make a fist without pumping the hand. Select the venipuncture site. Hyperextend the patient's arm. o Mix and label all appropriate tubes at the patient bedside. remove the tourniquet. Properly fill out appropriate requisition forms. Apply the tourniquet 3-4 inches above the selected puncture site. Grasp the patient's arm firmly using your thumb to draw the skin taut and anchor the vein. Allow to air dry. and medical treatment are all of concern and should be noted on the lab requisition. medications. Verify the patient's condition. Provide for their comfort as much as possible. Fasting. When the last tube to be drawn is filling. o Dispose of contaminated materials/supplies in designated containers. o Deliver specimens promptly to the laboratory.o o o o o o o o o o o Approach the patient in a friendly. beginning at the site and working outward. adhesives. timing.

dietary restrictions. swollen. and medical treatment are all of concern and should be noted on the lab requisition. Cap. Label all appropriate tubes at the patient bedside. indicating the test(s) ordered. Avoid the side of the finger where there is less soft tissue. rotate and invert the collection device to mix the blood collected. Fasting. Wipe away the first drop of blood. Have the patient hold a small gauze pad over the puncture site for a couple of minutes to stop the bleeding. lie down or sit up in bed.o o o o o o o o o o Apply tourniquet and palpate for vein Sterilize the site Insert needle Drawing the specimen Drawing the specimen Releasing the tourniquet Applying pressure over the vein Applying bandage Disposing needle into sharps labeling the specimens PERFORMANCE OF A FINGERSTICK: o o o o o o o o o o o o Follow the procedure as outlined above for greeting and identifying the patient. callused skin. properly fill out appropriate requisition forms. Position the patient. The fifth finger tends to have less soft tissue overlying the bone. where vessels and nerves are located. The 2nd (index) finger tends to have thicker. or covered with a rash. Dispose of contaminated materials/supplies in designated containers. Avoid puncturing a finger that is cold or cyanotic. make a skin puncture just off the center of the finger pad. Hyperextend the patient's arm. Verify the patient's condition. As always. and where the bone is closer to the surface. FINGERSTICK PROCEDURE ILLUSTRATED: . which tends to contain excess tissue fluid. Using a sterile lancet. The patient should either sit in a chair. The puncture should be made perpendicular to the ridges of the fingerprint so that the drop of blood does not run down the ridges. Avoid excessive pressure that may squeeze tissue fluid into the drop of blood. Collect drops of blood into the collection device by gently massaging the finger. scarred. Deliver specimens promptly to the laboratory. timing. medications. 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.

traumatic venipuncture o o o Indwelling Lines or Catheters: Potential source of test error Most lines are flushed with a solution of heparin to reduce the risk of thrombosis o Discard a sample at least three times the volume of the line before a specimen is obtained for analysis o o Hemoconcentration: An increased concentration of larger molecules and formed elements in the blood may be due to several factors: o o o o Prolonged tourniquet application (no more than 2 minutes) Massaging. and avoid frothing of the sample o Make sure the venipuncture site is dry o Avoid a probing. squeezing. (Partial penetration may allow blood to leak into the soft tissue surrounding the vein by way of the needle bevel) o Apply pressure to the venipuncture site o o o o To prevent hemolysis (which can interfere with many tests): Mix tubes with anticoagulant additives gently 5-10 times Avoid drawing blood from a hematoma Avoid drawing the plunger back too forcefully.o o o o o o o Equipment Proper location on finger Puncture with lancet Drop of blood Wipe first drop Collecting the specimen Specimen container ADDITIONAL CONSIDERATIONS: To prevent a hematoma: Puncture only the uppermost wall of the vein Remove the tourniquet before removing the needle Use the major superficial veins Make sure the needle fully penetrates the upper most wall of the vein. if using a needle and syringe. or probing a site Long-term IV therapy Sclerosed or occluded veins Prolonged Tourniquet Application: .

serum cortisol levels are highest in early morning but are decreased in the afternoon. Many drugs will have "peak" and "trough" levels that vary according to dosage levels and intervals. o Significant increases can be found in total protein. proteins). SAFETY AND INFECTION CONTROL Because of contacts with sick patients and their specimens. cholesterol. and platelet count may increase. Check for timing instructions for drawing the appropriate samples. Enzymes. aspartate aminotransferase (AST). iron o Affects packed cell volume and other cellular elements o Patient Preparation Factors: o o o o o o Therapeutic Drug Monitoring: different pharmacologic agents have patterns of administration. Certain larger molecules are not filterable into the tissue. and pregnancy have an influence on laboratory testing. For example. Posture: Postural changes (supine to sitting etc. aspartate aminotransferase (AST). therefore they are more concentrated in the blood. metabolism. total lipids. Diurnal Rhythms: Diurnal rhythms are body fluid and analyte fluctuations during the day. Effects of Exercise: Muscular activity has both transient and longer lasting effects.Primary effect is hemoconcentration of non-filterable elements (i. iron. Serum iron levels tend to drop during the day. Stress: May cause transient elevation in white blood cells (WBC's) and elevated adrenal hormone values (cortisol and catecholamines). and increased lactate. You must check the timing of these variations for the desired collection point. Other Factors: Age. it is important to follow safety and infection control procedures. The hydrostatic pressure causes some water and filterable elements to leave the extracellular space. PROTECT YOURSELF o Practice universal precautions: . proteins.) are known to vary lab results of some analytes. body distribution. and elimination that affect the drug concentration as measured in the blood.e. and calcium are significantly increased with changes in position. Anxiety that results in hyperventilation may cause acid-base imbalances. Normal reference ranges are often noted according to age. lactate dehydrogenase (LDH). gender. lipids. The creatine kinase (CK).

change them between each patient and wash your hands frequently. When wearing gloves. Wear gloves and a lab coat or gown when handling blood/body fluids.  Wash hands frequently. Move it forward (it may not be in the lumen) . break. recap. o Dispose of needles immediately upon removal from the patient's vein. o TROUBLESHOOTING GUIDELINES: IF AN INCOMPLETE COLLECTION OR NO BLOOD IS OBTAINED: o Change the position of the needle.  Record the patient's name and ID number.  NOTE: The use of prophylactic zidovudine following blood exposure to HIV has shown effectiveness (about 79%) in preventing seroconversion PROTECT THE PATIENT Place blood collection equipment away from patients. especially children and psychiatric patients.  Change gloves after each patient or when contaminated. o Practice hygiene for the patient's protection.  Squeeze puncture site to promote bleeding. o If you stick yourself with a contaminated needle:  Remove your gloves and dispose of them properly. or resheath needles to avoid accidental needle puncture or splashing of contents.  Dispose of items in appropriate containers. o Clean up any blood spills with a disinfectant such as freshly made 10% bleach.  Wash the area well with soap and water. Do not bend.  Follow institution's guidelines regarding treatment and follow-up. Always wear a clean lab coat or gown.

resecure the tourniquet to increase venous filling. remove the needle. and redraw. . IF BLOOD STOPS FLOWING INTO THE TUBE: o The vein may have collapsed. take care of the puncture site.o or move it backward (it may have penetrated too far). Veins sometimes roll away from the point of the needle and puncture site. Re-anchor the vein. o Adjust the angle (the bevel may be against the vein wall). There may be no vacuum in the one being used. Try another tube. If this is not successful. It may be obstructing blood flow. o o o Loosen the tourniquet.

Hematoma formation is a problem in older patients.o The needle may have pulled out of the vein when switching tubes. PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION: o A hematoma forms under the skin adjacent to the puncture site . Apply firm pressure for more than 5 minutes. The diagram below indicates in green the proper area to use for heel punctures for blood collection: . o The blood is bright red (arterial) rather than venous. BLOOD COLLECTION ON BABIES: o The recommended location for blood collection on a newborn baby or infant is the heel.release the tourniquet immediately and withdraw the needle. using the flange for leverage when withdrawing and inserting tubes. Apply firm pressure. Hold equipment firmly and place fingers against patient's arm.

which is close to the skin surface. When finished. Do not use the central portion of the heel because you might injure the underlying bone. and hold it in place until the bleeding has stopped. Wipe away the first drop of blood with a piece of clean. puncture the side of the heel in the appropriate regions shown above in green. place a piece of clean. Do not use a previous puncture site. Using a sterile blood lancet. HEELSTICK PROCEDURE ILLUSTRATED: o Heelstick on baby . dry cotton on the puncture site. dry cotton. do not use too high a temperature warmer.o o o o o o o Prewarming the infant's heel (42 C for 3 to 5 minutes) is important to obtain capillary blood gas samples and warming also greatly increases the flow of blood for collection of other specimens. Since newborns do not often bleed immediately. However. Dispose of contaminated materials in appropriate waste receptacles. because baby's skin is thin and susceptible to thermal injury. elevate the heel. Clean the site to be punctured with an alcohol sponge. Make the cut across the heelprint lines so that a drop of blood can well up and not run down along the lines. Be sure to dispose of the lancet in the appropriate sharps container. Dry the cleaned area with a dry cotton sponge. Do not use excessive pressure or heavy massaging because the blood may become diluted with tissue fluid. use gentle pressure to produce a rounded drop of blood. Fill the capillary tube(s) or micro collection device(s) as needed. Remove your gloves and wash your hands. Hold the baby's foot firmly to avoid sudden movement.

Immunology and Serology Light Green Top ADDITIVE Plasma Separating Tube (PST) with Lithium heparin Anticoagulates with lithium heparin. MODE OF Plasma is separated with PST gel at the ACTION bottom of the tube USES Chemistries Purple Top ADDITIVE EDTA . and the serum is separated by ACTION centrifugation USES Chemistries.COLLECTION TUBES FOR PHLEBOTOMY Red Top ADDITIVE None MODE OF Blood clots. Immunology and Serology. Blood Bank (Crossmatch) Gold Top ADDITIVE None Serum separator tube (SST) contains a gel MODE OF at the bottom to separate blood from serum ACTION on centrifugation USES Chemistries.

use sodium or lithium heparin Dark Blue Top ADDITIVE EDTAMODE OF Tube is designed to contain no ACTION contaminating metals USES Trace element testing (zinc. copper. requires full draw . mercury) and toxicology . use sodium heparin For ammonia level.invert 8 times to prevent clotting and platelet clumping Light Blue Top ADDITIVE Sodium citrate MODE OF Forms calcium salts to remove calcium ACTION USES Coagulation tests (protime and prothrombin time). lead. full draw required Green Top ADDITIVE Sodium heparin or lithium heparin MODE OF Inactivates thrombin and thromboplastin ACTION USES For lithium level.MODE OF Forms calcium salts to remove calcium ACTION USES Hematology (CBC) and Blood Bank (Crossmatch).

requires full draw . paternity testing. anaerobes. fungi Black Top ADDITIVE Sodium citrate (buffered) MODE OF Forms calcium salts to remove calcium ACTION USES Westergren Sedimentation Rate.aerobes. requires full draw (may cause hemolysis if short draw) Yellow Top ADDITIVE ACD (acid-citrate-dextrose) MODE OF Complement inactivation ACTION USES HLA tissue typing.Light Gray Top ADDITIVE Sodium fluoride and potassium oxalate MODE OF Antiglycolytic agent preserves glucose up ACTION to 5 days USES Glucoses. DNA studies Yellow Black Top ADDITIVE Broth mixture MODE OF Preserves viability of microorganisms ACTION USES Microbiology .

ACTION contains virtually no lead USES Serum lead determination Pink Top ADDITIVE Potassium EDTA MODE OF Forms calcium salts ACTION USES Immunohematology White Top ADDITIVE Potassium EDTA MODE OF Forms calcium salts ACTION USES Molecular/PCR and bDNA testing .Orange Top ADDITIVE Thrombin MODE OF Quickly clots blood ACTION USES STAT serum chemistries Light Brown Top ADDITIVE Sodium heparin MODE OF Inactivates thrombin and thromboplastin.

Bruising . 2. Preferably. E. use opposite arm. PETER’S BENDER LABORATORY St. Peter’s Hospital SPECIMEN COLLECTION Blood Culture Procedure 2/09 2 PROCEDURE: 1. Identify and explain the procedure to the patient.Use arm only after consultation with the physician. Feet . Specimen Type and handling conditions: Two full yellow vacutainer tubes are required for adults. Fistulas. Factors to Consider in Site Selection: A. No patient should be drawn without a . Cannulas. or Vascular Grafts . C.Do not collect specimen from a site above an IV site. Consult with the nurse manager/supervisor before drawing a patient with a foot order. 2. Blood cultures are not to be drawn from indwelling intravenous or intraarterial catheter unless specifically ordered by a physician.Avoid areas with extensive scarring. SPECIMEN: 1. EQUIPMENT AND MATERIALS: Blood Culture Collection Kit containing: -70% isopropyl alcohol swabs Tourniquet -Yellow top vacutainer collection tubes 2x2 gauze pads -10% Povidone-Iodine Swabstick Needles: 20.BLOOD CULTURE COLLECTION PROCEDURE PRINCIPLE: To outline procedure for the proper collection of blood cultures by venipuncture.Feet should not be used unless approved by a physician.Specimens collected from a hematoma area may cause erroneous results. F. Blood cultures are not to be drawn by heelstick. 22. One pediatric yellow vacutainer tube is required for neonates and pediatric patients.Specimens should not be taken from the side on which a mastectomy was performed. G. 21. Mastectomy . Proper skin disinfection is an essential requirement to reduce the incidence of contamination. B. Scarring . or 23 gauge -Specimen bag Tape -Instructions Sharps container Clean Gloves Vacutainer holder ST. Ascertain the physician order and refer to SPH Laboratory Resource Manual or laboratory collection list for test requirements. D. H. IV Therapy .

6. The skin of patients with known hypersensitivity to iodine can be prepared with a double application of 70% isopropyl alcohol by performing step 9. 3. 12. 10. Starting at the center of the site. 5. Change position of the needle. Disinfect the tops of two yellow blood culture vacutainer tubes with separate povidone iodine swabsticks. 3) Rotate needle half a turn. Vigorously cleanse the venipuncture site with 70% isopropyl alcohol swabs and allow to dry. Push tube onto the needle. a. Disinfect one pediatric yellow blood culture vacutainer tube for use with neonates and pediatric patients. swab concentrically with 10% povidone iodine swabsticks for 1 minute. d. 2) Insert the needle deeper a small distance. Blood should flow into the tube. a. Do not attempt a venipuncture more than twice. 14. Position the patient for procedure. Remove tube when filled and continue with next tube if any. 11. 1) Withdraw the needle a small distance. 8 Have patient make a fist. puncture the vein. 9. SPECIMEN COLLECTION 15. Palpate for a vein and select site. Using thumb and index finger. Apply tourniquet 3 . b. e. 7. e.wristband or proper identification. 13. The order of draw for multiple tubes is: (1) Yellow top tube (Blood Culture) . twice. Allow the site to dry. anchor the vein. Do not touch the venipuncture site after preparation and prior to phlebotomy. Remove tourniquet within one minute of application. b. Excessive probing is not recommended and should be avoided as this is painful to the patient. c. Have patient release fist. c. Assemble all equipment needed to perform the procedure. Wash hands and put on gloves. preferably in the antecubital fossa. The patient should be lying down or seated with their arm supported. Site preparation. If a blood sample cannot be obtained: a.4 inches above intended site. With needle bevel up. 4. d. 16. Try another tube. Loosen the tourniquet.

cleanse the site with 70% isopropyl alcohol pad to remove remaining iodine. Deliver to the Laboratory.(2) Red top tube (Glass) No additive (3) Blue top tube (Coagulation) (4) Gold top tube (SST Gel Sep) (5) Red top tube (Plastic) With clot activator (6) Green top tube (Heparin) (7) Lavender top tube (EDTA) (8) Pink top tube (Blood bank tube) (9) Grey top tube (Glycolytic inhibitor) 17. which can cause irritation in some patients. Insert specimen in specimen bag (or specimen racks for 6:00 am draws). because preload is ↓ more precisely with nitroprusside. After phlebotomy. Tape gauze to puncture site. Continue applying pressure until patient stops bleeding to avoid unnecessary bruising. Use of the rotating tourniquet has declined with the development of vasodilating drugs and diuretics. Record the date and time of collection and the phlebotomist’s initials on the requisition slip or collection list. 24. Remove gloves and wash hands. 21. tourniquet. rotating tourniquet [rō′tāting] Etymology: L. Fr.10 times. Dispose of needle in sharps container and dispose of other waste in proper container. Description Provides instruction for performing a venipuncture on an adult . 19. the label must contain the patient’s name and date of birth. rotating tourniquet Cardiology A modality for ↓ preload in acute cardiogenic pulmonary edema. Avoid aggressive shaking of tubes. 20. Immediately apply pressure with a 2x2 gauze to stop bleeding. Central Receiving room 1249 within 2 hours of collection. 22. 18. to rotate. Gently invert all additive tubes 5 . garrote one of four constricting devices used in a rotating order to pool blood in the extremities. Remove needle from patient’s arm. in which the blood flow to the extremities is blocked by RTs. The purpose is to relieve congestion in the lungs in the treatment of acute pulmonary edema. rotare. Label all tubes with a hospital computer label. 23. If one is not available. RTs are rarely used I.

...... 1 IV....... middle/maiden initial.............. ............................................................................................... sex and race..................................... Policy................................................. Procedure These steps should be followed in order to perform a successful venipuncture........................... patient’s last name... 1............... Original Policy Date and Revisions .................. 3 II........... ............................... date of birth............... 1 III......... Reviewed/Approved by ......... Policy/Procedure ........................................................ Description .............. Rationale Accurate specimen collection and proper specimen handling are of the utmost importance because errors are more likely to occur in these areas than during the laboratory analysis itself....................... 4 VI......Table of Contents I....................... The request for blood collection must contain the Medical Record Number...................................... 1 II................................. ................................. Procedure............................................................. 1 A.............................................. It is important that each phlebotomist establish a routine for blood collection that incorporates these essential steps......... 4 Figure / Table List Table 1: Tube Draw Order ........................... Performing a venipuncture should be comfortable for the phlebotomist and should enable the phlebotomist to complete the procedure in a timely manner B.................................................................................. Policy/Procedure A....................................................................... ............................................................................. 1 B. III......................... Several steps in this process are an essential part of every successful collection..... References ............... ............ Rationale ..................................................... first name.............................. The information is .. Policy The blood collection procedure requires both skill and knowledge......................................................................... 4 V...................

a. the tourniquet should be applied to 3 to 4 inch clearance. The phlebotomist must gain the patient’s confidence assure the patient that. 8. place a pillow under the arm to provide additional support. a.entered into the Laboratory Information System and an LIS order number is accessioned and printed on the label. . 6. Insure proper positioning of the patient’s arm. 7. The preferred procedure for venipuncture is the evacuated tube method. 3. small hand veins or veins in the back of the wrist. This procedure should always be the first procedure of choice. Always allow at least a 1 to 2 inch clearance between the IV or med lock and the tourniquet. under any circumstances. but be sure to replace rails to the upright position. 4.e. Identify the patient according to Inpatient or Outpatient Identification procedures. should the phlebotomist tell the patient what disease or condition a specific blood test will detect. Apply the tourniquet. confident and professional manner. b. if necessary. Determine the best site for venipuncture according to the Venipuncture Site Selection Guidelines procedure. LAB 0025 Page 1 of 4 Adult Venipuncture LAB 0025 Page 2 of 4 a. If necessary. Position the arm so that it is resting on a table or on the bed alongside the patient.). Approach the patient in a calm. Lower bedrails. The phlebotomist may be able to help the patient feel more comfortable by giving as much information as possible regarding the venipuncture procedure. Select equipment and method of blood collection based on assessment of the patient’s veins. it will be short in duration and necessary for the diagnosis and treatment of their health care problem. Never. Under ideal conditions. 5. 2. b. Prepare equipment and don gloves at any point prior to the actual venipuncture. In some instances the phlebotomist may need to use a procedure that allows more flexibility and stability (i. b. although the venipuncture will be slightly painful. In this case the butterfly (winged infusion set) needle may be used. The arm should be supported firmly and should not be bent at the elbow. The outpatient requisition or computer generated patient label will be used by the phlebotomist to identify the patient.

iii. Alert the patient before venipuncture. sterile needle must be used for each new collection attempt. Cleanse venipuncture site with alcohol using a circular motion form the center to the pheriphery. NEVER restick a patient using the same needle. iii. 13. i. This anchors the vein. Carefully rotate the needle to assure that the bevel is up. a. formation of a partial filtrate of blood and hemoconcentration. If the needle has penetrated too far into the vein. packed cell volume. ii. b. advance it further into the vein. A clean. Try another tube if you feel you are in the vein but the tube may lack vacuum. The thumb should be 1 or 2 inches below the venipuncture site.Ideally. Leaving the tourniquet applied for an excessive period of time (>2 minutes) may cause localized stasis.) b. If a third attempt is needed. (This step is particularly useful when using a butterfly as they tend to turn over if not anchored properly. The tourniquet may have been applied too tightly. pull it back a bit. and other cellular elements. Each phlebotomist is permitted only two unsuccessful venipunctures per patient. . Allow the area to dry before venipuncture. This is particularly helpful with babies. ii. 9. i. Calmly make adjustments if blood does not flow. 11. less so with adults. the tourniquet should not be applied for longer than one or two minutes at a time. Use the thumb to draw the skin taut. Loosen the tourniquet. If the needle has not penetrated far enough. Change the position of the needle. 10. Adult Venipuncture LAB 0025 Page 3 of 4 a. 12. c. the phlebotomist must contact a lead tech for a decision regarding any subsequent attempts. thereby stopping the blood flow. These may result in erroneously high values for all protein-based analytes. Anchor the vein and smoothly insert needle with bevel up. If blood flow is adequate after tourniquet removal it is not necessary to reapply the tourniquet.

19. Yellow (ACD Solution) h. Note: Collect tubes in proper order according to the NCCLS guidelines. 21. Table 1: Tube Draw Order a. Apply pressure to site after withdrawing needle. Release the tourniquet as soon as the blood begins to flow. Collect the proper amount of blood for tests ordered. Clean up supplies and waste. Check site to ascertain if bleeding has completely stopped. Label tubes according to the Specimen Labeling procedure. Paper tape is preferred. Green (Sodium Heparin) g. Royal Blue c. Red (No additive) d. Blood Culture b. 22. 17. 18. Gently invert anticoagulated tubes as they are collected in order to eliminate clotting. 15. loosely reapply the tourniquet. Apply a gauze bandage. 20. Light Blue (Sodium Citrate) e. Dismiss the patient in a courteous and professional manner . Pearl j. 23. Pink (TMS) i. Dispose of needle properly and carefully in the appropriate container. Tape it down with medical tape. Suggested order of draw is as follows. Serum Separation (Gold Top w/ gel in bottom) f. 14.If blood flow is still not adequate. Lavender (EDTA) 16.