NCM 112 SKILLS: USING VENIPUNCTURE TO COLLECT VENOUS BLOOD SAMPLE FOR ROUTINE TESTING

Group 6 | Angeles, Monserate, Yeban

VENIPUNCTURE
OVERVIEW AND DEFINITION
Phlebotomy or Venipuncture is the most common method of obtaining blood specimens. This involves inserting a
hollow-bore needle into the lumen of a large vein to obtain a specimen using either a needle and syringe or a Vacutainer
device that allows the drawing of multiple samples.

Draw cultures before antibiotic therapy begins since the antibiotic may interrupt the organism’s growth in the
laboratory. If the patient is receiving antibiotics, notify the laboratory of the specific antibiotics the patient is receiving
(Pagana and Pagana, 2011).

INDICATIONS
. Blood Sampling
. Short-term infusion (via butterfly needle)

CONTRAINDICATIONS
. Evidence of cellulitis or abscess
. Venous fibrosis on palpation
. Presence of a hematoma
. Presence of a vascular shunt or graft
. Presence of a vascular access device
TECHNICAL CONSIDERATIONS

ANATOMY
The superficial veins of the upper extremities, particularly those in the antecubital fossa, are the ones
most commonly selected for phlebotomy because they are usually readily visible and easily palpable.
The antecubital fossa contains four veins: Cephalic Vein, Accessory Cephalic Vein, Median Cubital Vein,
Basilic Vein.

Antecubital veins, right arm. Antecubital veins, left arm.

Antecubital veins, right arm. Note

variable anatomy; median cubital
vein is not visible.

Transcribed by: M.A. Yeban

 DELEGATION CONSIDERATIONS
The skill of collecting blood specimens by venipuncture can be delegated to specially trained nursing assistive
personnel (NAP). In some agencies, phlebotomists obtain the venipuncture samples. Agency and governmental regulations
and policies differ regarding personnel who may draw blood specimens. The nurse informs the NAP to report any patient
discomfort or signs of excessive bleeding from the puncture site to the nurse.

EQUIPMENTS
All Procedures
. Chlorhexidine or antiseptic swab (check agency policy for use of 70% alcohol)
. Clean gloves
. Small pillow or folded towel
. Sterile 2 × 2–inch gauze pads
. Tourniquet
. Adhesive bandage or adhesive tape
. Completed identification labels with proper patient identifiers
. Completed laboratory requisition (appropriate patient identification, date, time, name of test, and
source of culture)
. Small plastic biohazard bag for delivery of specimen to laboratory (or container specified by agency)
. Sharps container

VENIPUNCTURE WITH SYRINGE

. Sterile safety needles (20 to 21 gauge for adults; 23 to 25 gauge for children)
. Sterile 10- to 20-mL Luer-Lok safety syringes
. Needle-free blood transfer device
. Appropriate blood specimen tubes

VENIPUNCTURE WITH VACUTAINER

. Vacutainer and safety access device with Luer-Lok adapter
. Sterile double-ended needles (20 to 21 gauge for adults; 23 to 25 gauge for children)
. Appropriate blood specimen tubes
BLOOD CULTURE
. Sterile double needles (20 to 21 gauge for adults; 23 to 25 gauge for children)
. Two 20-mL sterile syringes
. Anaerobic and aerobic culture bottles (check agency policy)
CENTRAL VENOUS CATHETER COLLECTION
. Two empty 10-mL sterile syringes
. Sterile 10-mL normal saline flushes
. Vacutainer and safety access device with Luer-Lok adapter
. Appropriate blood specimen tubes

IMPLEMENTATION

1. Complete preprocedure protocol

2. Determine if special conditions need to be met before specimen
Rationale: Some tests require meeting specific conditions to obtain accurate measurement of blood elements
3. Assess patient for possible risks associated with venipuncture: anticoagulant therapy, low platelet count, bleeding
disorders. Review medication history.
Rationale: Patient history may include abnormal clotting abilities caused by low platelet count, hemophilia, or medications
that increase risk for bleeding and hematoma formation.
4. Assess patient for contraindicated sites for venipuncture: presence of IV fluids, hematoma at potential site, arm
on side of mastectomy, or hemodialysis shunt.
Rationale: Drawing specimens from such sites can result in false test results or may injure patient. Samples taken from
vein near IV infusion may be diluted or may contain concentrations of IV fluids. Postmastectomy patient may have reduced
lymphatic drainage in arm on operative side, increasing risk for infection from needlesticks. Never use arteriovenous shunt
to obtain specimens because of risks of clotting and bleeding. Hematoma indicates existing injury to vessel wall.
5. Apply tourniquet so it can be removed by pulling an end with a single motion.
Rationale: Tourniquet blocks venous return to heart from extremity, causing veins to dilate for easier visibility.
a. Position tourniquet 5 to 10 cm (2 to 4 inches) above venipuncture site selected (antecubital fossa site is most
often used).
b. Cross tourniquet over patient’s arm. May place tourniquet over gown sleeve to protect skin.
Rationale: Older adult’s skin is very fragile.
c. Hold tourniquet between your fingers close to arm. Tuck loop between patient’s arm and tourniquet so you can
grasp free end easily.
Rationale: Pull free end to release tourniquet after venipuncture.

! SAFETY ALERT !
Palpate distal pulse (e.g., brachial) below tourniquet. If pulse is not palpable, remove tourniquet, wait 60 seconds, and
reapply tourniquet more loosely. If tourniquet is too tight, pressure will impede arterial flow.

6. Do not keep tourniquet on patient longer than 1 minute.

Rationale: Prolonged tourniquet application causes stasis, localized acidemia, and hemoconcentration (Pagana and
Pagana, 2011).

7. Ask patient to open and close fist several times, finally leaving fist clenched.
Rationale: Facilitates distention of veins by forcing blood up from distal veins. Vigorous opening and closing may cause
erroneous laboratory results of hemoconcentration (Pagana and Pagana, 2011).

8. Quickly inspect extremity for best venipuncture site, looking for straight, prominent vein without swelling or
hematoma.

Rationale: Straight and intact veins are easiest to puncture.

9. Apply clean gloves. Palpate selected vein with finger (Fig. 83-1). Note if vein is firm and rebounds when palpated
or if it feels rigid or cordlike and rolls when palpated. Avoid vigorously slapping vein, which can cause vasospasm.

Rationale: Patent, healthy vein is elastic and rebounds on palpation. Thrombosed vein is rigid, rolls easily, and is difficult
to puncture.

10. Obtain blood specimen

SYRINGE METHOD
1. Have syringe with appropriate needle securely attached.

Rationale: Needle must not dislodge from syringe during venipuncture.

2. Cleanse venipuncture site with antiseptic swabs, with first swab moving back and forth on horizontal plane,
another swab on vertical plane, and last in circular motion from site outward for about 5 cm (2 inches) for 30
seconds. Allow to dry.

Rationale: Antimicrobial agent cleans skin surface of resident bacteria so organisms do not enter puncture site. Allowing
antiseptic to dry completes its antimicrobial task and reduces “sting” of venipuncture. Alcohol left on skin can cause
hemolysis of sample and retraction of tissue away from puncture site.

(a) If drawing sample for blood alcohol level or blood cultures, use only antiseptic swab, not alcohol swab.
 Rationale: Ensures accurate test results.

3. Remove needle cover, and inform patient that “stick” lasts only a few seconds.

Rationale: Patient has better control over anxiety when prepared about what to expect.

! SAFETY ALERT !
Observe needle for defects, such as burrs, which can cause increased discomfort and damage to the patient’s vein
(McCall and Tankersley, 2012).

4. Place thumb or forefinger of nondominant hand 2.5 cm (1 inch) below site, and gently pull skin taut. Stretch skin
steadily until vein is stabilized.

Rationale: Stabilizes vein and prevents rolling during needle insertion.

5. Hold syringe and needle at 15- to 30-degree angle from patient’s arm with bevel up.

Rationale: Reduces chance of penetrating both sides of vein during insertion. Bevel up decreases chance of contamination
by not dragging bevel opening over the skin and allows point of needle to first puncture skin, reducing trauma.

6. Slowly insert needle into vein (Fig. 83-2), stopping when “pop” is felt as needle enters vein.

Rationale: Prevents puncture through vein to opposite side.

7. Hold syringe securely and pull back gently on plunger.

Rationale: Syringe held securely prevents needle from advancing. Pulling on plunger creates vacuum needed to draw blood
into syringe. If plunger is pulled back too quickly, pressure may collapse vein.

8. Observe for blood return.

Rationale: If blood flow fails to appear, needle may not be in vein.

9. Obtain desired amount of blood, keeping needle stabilized.

Rationale: Test results are more accurate when required amount of blood is obtained. You cannot perform some tests
without minimal blood requirement. Movement of needle increases discomfort.

10. After obtaining specimen, release tourniquet.

Rationale: Reduces bleeding at site when needle is withdrawn.

11. Apply 2 × 2–inch gauze pad without applying pressure. Quickly but carefully withdraw needle from vein, and apply
pressure following removal of needle. Check for hematoma.

Rationale: Pressure over needle can cause discomfort. Careful removal of needle minimizes discomfort and vein trauma.
Hematoma may cause compression injury (McCall and Tankersley, 2012).

12. Activate safety cover and immediately discard needle in appropriate container.

Rationale: Prevents needlestick injury.

13. Attach blood-filled syringe to needlefree blood transfer device. Attach tube and allow vacuum to fill tube to
specified level. Remove and fill other tubes as appropriate. Gently rotate each tube back and forth 8 to 10 times.

Rationale: Additives prevent clotting. Shaking can cause hemolysis of red blood cells (RBCs).

VACUTAINER METHOD (VACUUM TUBE SYSTEM METHOD)

1. Attach double-ended needle to Vacutainer tube.

Rationale: Long end of needle is used to puncture vein. Short end fits into blood tubes.

2. Have proper blood specimen tube resting inside Vacutainer, but do not puncture rubber stopper.

Rationale: Puncturing causes loss of tube’s vacuum.

3. Clean venipuncture site by following Step 10(2). Allow to dry.

Rationale: Cleans skin surface of resident bacteria so that organisms do not enter puncture site. Drying maximizes effect
of antiseptic.

4. Remove needle cover and inform patient that “stick” will occur, lasting only a few seconds.

Rationale: Patient has better control over anxiety when prepared about what to expect.

5. Place thumb or forefinger of nondominant hand 2.5 cm (1 inch) below site, and gently pull skin taut. Stretch skin
down until vein stabilizes.

Rationale: Helps to stabilize vein and prevent rolling during needle insertion.

6. Hold Vacutainer needle at 15- to 30-degree angle from arm with bevel up.

Rationale: Smallest and sharpest point of needle will puncture skin first. Reduces chance of penetrating sides of vein during
insertion. Keeping bevel up causes less trauma to vein.

7. Slowly insert needle into vein.

Rationale: Prevents puncture on opposite side.

8. Grasp Vacutainer securely, and advance specimen tube into needle of holder (do not advance needle in vein).

Rationale: Pushing needle through stopper breaks the vacuum and causes flow of blood into tube. If needle in vein
advances, vein may become punctured on other side.

9. Note flow of blood into tube (should be fairly rapid) (Fig. 83-3).

Rationale: Failure of blood to appear indicates that vacuum in tube is lost or needle is not in vein.

10. After filling specimen tube, grasp Vacutainer firmly, and remove tube. Insert additional specimen tubes as needed.
Gently rotate each tube back and forth 8 to 10 times.

Rationale: Vacuum in tube stops flow at amount to be collected. Grasping prevents needle from advancing or dislodging.
Tube should fill completely because additives in certain tubes are measured in proportion to filled tube. Ensures proper
mixing with additive to prevent clotting.

11. After last tube is filled and removed from Vacutainer, release tourniquet.

Rationale: Reduces bleeding at site when needle is withdrawn.

12. Apply 2 × 2–inch gauze pad over puncture site without applying pressure, and quickly but carefully withdraw
needle with Vacutainer from vein.

Rationale: Pressure over needle can cause discomfort. Careful removal of needle minimizes discomfort and vein trauma

13. Immediately apply pressure over venipuncture site with gauze or antiseptic pad for 2 to 3 minutes or until bleeding
stops. Observe for hematoma. Tape gauze dressing securely.

Rationale: Direct pressure minimizes bleeding and prevents hematoma formation. A hematoma may cause compression
on nerve injury. Pressure dressing controls bleeding.

BLOOD CULTURE
1. Clean venipuncture site as in Step 10(2) with antiseptic swab to follow agency policy. Allow to dry.

Rationale: Antimicrobial agent cleans skin surface so that organisms do not enter puncture site or contaminate culture.
Drying ensures complete antimicrobial action and decreases stinging.

2. Clean bottle tops of culture bottles for 15 seconds with agencyapproved cleaning solution. Allow to dry.

Rationale: Ensures that bottle top is sterile.

3. Collect 10 to 15 mL of venous blood using syringe method in 20- mL syringe from two different venipuncture sites.

Rationale: Two blood cultures must be collected from two different sites to confirm culture growth (Pagana and Pagana,
2011).

4. With each specimen, activate safety guard and discard needle. Replace with new sterile needle before injecting
blood sample into culture bottle.
Rationale: Maintains sterile technique and prevents contamination of specimen.

5. If both aerobic and anaerobic cultures are needed, fill anaerobic bottle first.

Rationale: Anaerobic organisms may take longer to grow (Pagana and Pagana, 2011).

6. Gently mix blood in each culture bottle.

Rationale: Mixes medium and blood.

11. Check tubes for any sign of external contamination with blood. Decontaminate with 70% alcohol if necessary.
Rationale: Prevents cross-contamination. Reduces risk for exposure to pathogens present in blood.

12. Remove gloves and perform hand hygiene after specimen is obtained and any spillage is cleaned.
Rationale: Reduces risk for exposure to bloodborne pathogens.

13. Perform postprocedure protocol.

RECORDING AND REPORTING

1. Record method used to obtain blood specimen, date and time collected, type of test ordered, disposition of
specimen, and description of venipuncture site.
2. Report any STAT or abnormal test results to health care provider.

UNEXPECTED OUTCOMES RELATED INTERVENTIONS

Hematoma forms at venipuncture site.
Bleeding at site continues.
Signs and symptoms of infection at venipuncture site
occur.
Laboratory tests reveal abnormal blood results.
. Apply pressure using 2 × 2– inch gauze dressing.
. Continue to monitor patient for pain and discomfort.
. Apply pressure to site; patient may also apply
pressure.
. Monitor patient.
. Notify health care provider.
. Notify health care provider.
. Apply moist heat to site.
. Notify health care provider.
 S.No. COLOR CODES ADDITIVE COMMONLY USED FOR
1.) Purple / Lavender EDTA (Ethylene diamine CBC, BLOOD TYPING (Rh Factor & ABO
tetra-acetic acid) Screening), Cross match, Hb, Red cell Indices,
ESR by Wintrobe's method etc.
2.) Light blue Tri-Sodium Citrate Prothrombin time (PT), Activated Partial
(Blood:Anticoagulant ratio is Thromboplastin Time (APTT), Fibrinogen
9:1) thrombin time and other blood Coagulation
tests.
3.) Light green Lithium Heparin Basic Metabolic Panel (BMP),
Comprehensive metabolic Panel (CMP) and
other plasma determination tests.
4.) Royal Blue None/ Di-sodium EDTA Trace Elements like Cu, Zn, etc, Toxicology
and Nutrient determination etc.
5.) Gold (commonly Polymer Gel and Powdered BMP, CMP, LFT, KFT, Lipid Profile and other
known as Serum Glass Clot activator biochemistry assays, Serological tests etc.
Separator tube)
6.) Red Powdered glass Clot BMP, CMP, Lipid Profile, Serology tests,
Activator Therapeutic drug monitoring, blood bank
procedures etc.
7.) Dark green Sodium Heparin Arterial blood gas analysis, alpha-TNF,
Lymphocyte Immunotherapy etc.
8.) Gray Sodium Fluoride Blood Sugar testing, Toxicology tests etc.
9.) Black Tri-Sodium Citrate ESR by Westergren method
(Blood:Anticoagulant ratio is
4:1)
10.) Yellow ACD (Acid-Citrate Dextrose) Blood Bank studies, HLA Phenotyping,
Paternity testing, Tissue typing etc.
11.) Pink Dried EDTA Rh factor, ABO typing, CBC, Blood banking
procedures etc.

REFERENCE:
Perry, A. G., Potter, P., & Desmarais, P. (2014). Mosby’s pocket guide to nursing skills & procedures.

https://shop.briggscorp.com/pdf/8523_TOC.pdf

Facep, G. Z. S. M. (n.d.). Phlebotomy: Background, indications, contraindications.

https://emedicine.medscape.com/article/1998221-overview