VENIPUNCTURE

o  a process of collecting or "drawing" blood from a vein of

the patient for laboratory testing purposes.
o a phlebotomist should acquire the knowledge and skill to
perform venipuncture since he will perform this
procedure frequently as part of his duties and
responsibilities in the healthcare institution.
THE REQUEST PROCESS
o the first step of the pre-examination phase is the test
request that came from a physician.
o a request form includes information on the type of test
ordered and any special instructions or conditions that
should be considered during the pre-examination and
examination phase.
o test requisition could be manual, computerized or bar-
coded.
Required Requisition information are as follows:
 Name of the physician who ordered the test
 Patient's full name including the middle initial
 The medical record number for inpatients
 Birthday and age of the patient
 Room number and bed number if inpatient
 Type of test ordered
 Date when the test is to be performed
 Billing information with ICD-9 codes for outpatient
 Test status
 Special precaution
Accessioning the test request helps improve the
documentation, handling and reporting of test results.
This means that the specimen to be collected is assigned a
special number that will serve as the reference number for
all associated processes and paperwork.
Status designations, status priorities and procedure for each status designation

Table 5.1 Common Test Status Designations

Step 2: Approach, Identify, & Prepare Patient
Proper "bedside manner" and handling special
situations associated with patient contact
- organize the test request according to priority, and prepare
all the necessary equipment and supplies needed to
complete his collection round.
- check for phlebotomy-related signs and warnings regarding
the condition of the patient such as "No BP or venipuncture
right arm", Do not Resuscitate (DNR) or Do Not Attempt to
Resuscitate (DNAR), etc.
 The Bedside Manner is the behavior of a healthcare
worker as perceived by the patient which is applicable to
both in- and out-patient settings. The following should be
followed when doing collection:
 Knock on the door gently before entering the room.
 Make a good impression by greeting the patient warmly.
 Stay organized and have all supplies available and
approach the patient in a professional manner that goes
well with having a neat appearance.
 Most patients are afraid of blood collection, so maintain a
calm expression.
 Introduce yourself and explain the procedure. Obtain the
verbal or expressed consent of the patient before
proceeding with the test.
 Remain compassionate and professional during the
procedure.
 Thank the patient for their cooperation before leaving.
 If there is a physician or clergy in the room, interrupt
only if the ordered test is stat or timed.
 Family members or visitors can stay in the room, but it
would be better if they could step out of the room until
you are finished.
Importance of proper patient identification
- Obtaining a specimen from the wrong person can have
serious consequences and can even be fatal in cases that
involve blood transfusion.
- Misidentifying patients can be a ground for dismissal or
lawsuit on the grounds of malpractice.
- When identifying patients, confirm the name and date of
birth of the patient.
- If the patient is fast asleep, the phlebotomist should wake
him up gently for proper identification.
- If the patient is young, mentally incapacitated or there is
language barrier:
(1) the phlebotomist should ask a relative, attendant, or
the nurse to identify the patient and
(2) the information provided should match those on record
and the information on the ID bracelet.
Patient preparation for testing
 The phlebotomist should explain the test procedure to
the patient and confirm that the patient understood what
was discussed.
 It is best to direct inquiries on the purpose or result of
the test to the patient's nurse or physician to avoid any
miscommunication.
 The phlebotomist must remain calm and professional
even if the patient is being difficult or have needle-
phobia.
Step 3: Verify Diet Restrictions & Latex Sensitivity
 Verifying fasting and other diet requirements
 The phlebotomist should verify if there are special
instructions on the diet of the patient that needs to be
followed such as fasting for about 8 to 10 hours.
 A patient with allergic reaction to latex can have life-
threatening reactions upon exposure, so it is important to
check that all equipment used on him is latex-free, and
there are no latex items in the room.
Step 4: Sanitize Hands
Proper hand hygiene should be observed to avoid
spreading infection.
 
Step 5: Position Patient, Apply Torniquet, and Ask Patient
to Make a fist
 Be sure that the hand or arm for venipuncture procedure
is well supported.
 The phlebotomist can then proceed to the tourniquet
application and fist clenching. The tourniquet should be
placed 3 to 4 inches from the intended site.
Step 6: Select Vein, Release Tourniquet, and Ask Patient to
Open Fist
 The antecubital area of the arm is the preferred
venipuncture site.
 Roll his finger from one side to the other to gauge its
size.
 Using your fingers, trace the path to determine a possible
entry point.
 If the vein is not suitable, look for an alternative site, or
capillary puncture could be an option.
Tourniquet Application
1. Place the tourniquet 3 to 4 inches from the intended
puncture site.
2. Hold one side of the tourniquet in each hand. It should be
a few inches from the end.
3. Apply a little tension so that it will be snug when tied.
4. Bring the two sides together. Hold both ends between the
thumb and forefinger of the right hand.
5. Bring the two sides together. Hold both ends between
the thumb and forefinger of the right hand.
6. Reach over the right hand and grasp the right side of the
tourniquet between the thumb and forefinger of the left
hand and release it from the grip of the right hand.
7. Near the left index finger, cross the left end over the right.
Hold both sides together between the thumb and
forefinger of the left hand, close to the patient's arm.
8. While securely holding both sides, use either the left
middle finger or the right index finger to tuck a portion of
the left side under the right side and pull into a loop.
9. A properly tied tourniquet has its ends pointing toward
the shoulder.
If the tourniquet was applied, release it and the patient
should be asked to open his fist.
Step 7: Clean and Air-Dry the Site
The venipuncture site should be cleaned using an
antiseptic, such as 70% Isopropyl alcohol, to prevent
infection or contamination. The area should cover about 2 to
3 inches diameter using a circular motion, and moving
outward in concentric circular motion. Allow the area to dry
for about a minute, but don't use unsterile gauze, fan, or
don't blow the site. Avoiding touching the site after cleaning.
Step 8: Prepare Equipment and Put on Gloves
  The age of the patient, volume of blood for collection,
and the size and location of the vein are factors considered
in choosing the system, needle size and volume of the tube
that will be used. Make sure that you are wearing a clean
pair of gloves.
Steps in equipment preparation of different
venipuncture procedure
Evacuated Tube System
1. Select the appropriate tube for ETS and tap to dislodge
any additives in the stopper.
2. Select and inspect the needle for defects.
3. Twist needle to expose the back of the needle.
4. Screw this end to the threaded hub of the tube holder.
5. Place the first tube in the holder.
6. Position the tube in the holder.
 Winged Infusion set (Butterfly)
1. Use a 23-gauge butterfly gauge with a safety feature.
2. Inspect the package before aseptically opening and
removing the butterfly.
3. Attach the butterfly to an ETS holder or syringe.
4. Select the appropriate small-volume tube for the test.
 Syringe System
1.Select the appropriate syringe and needle
2.Test the plunger before opening the sterile package.
3.Open the package aseptically.
4.Securely attach the needle to the syringe.
Step 9: Reapply Tourniquet, Uncap and Inspect Needle
  Reapply the tourniquet without touching the cleaned
area. Get the collection equipment using your dominant
hand. Remove the needle cover and inspect the needle. The
needle should not get into contact with anything prior to
venipuncture. If this happens, remove and replace with a
new one.
Step 10: Ask Patient to Remake a Fist, Anchor to Vein, and
Insert Needle
 The patient is asked to make a first. Anchor the
antecubital vein by holding the patient's arm with your
free hand.
 The fingers support the back of the arm just below the
elbow. Place the thumb at least 1 to 2 inches below, but
slightly on the side of the site of venipuncture, and
pulling the skin towards the wrist.
 When inserting the needle, the phlebotomist should hold
the collection device or butterfly needle with his dominant
hand. Position the needle above the insertion site with
the bevel facing up, then insert using a smooth forward
motion in a 30 degree angle.
Step 11: Establish Blood Flow, Release Tourniquet, and Ask
Patient to Open Fist
  The phlebotomist should press on the collection tube into
the tube holder. Make sure that the needle has completely
penetrated the stopper. Push the tube with the thumb while
the middle and index fingers straddle and grasp the flanges
of the tube holder while slightly pulling it back. Let the blood
flow into the tube. Release the tourniquet and ask the
patient to release his fist.
Step 12: Fill, Remove, and Mix Tubes in Order of Draw or Fill
Syringe
  The phlebotomist should make sure that required volume
has been collected. Tubes that contain additive must be
inverted gently several times to mix the content. Release the
tourniquet before removing the needle.
Step 13: Place Gauze, Remove Needle, Activate Safety
Feature, and Apply Pressure
  Fold a gauze square into fourths and place it lightly over
the site where the needle is inserted. Do not apply pressure.
Remove the needle and activate the safety feature (if
applicable) while simultaneously apply pressure with your
free hand. The arms should be extended or raised.
Step 14: Discard Collection Unit, Syringe Needle, or Transfer
Device
 Step 15: Label Tubes
Necessary Information in the specimen tube labeling
a) Patient's complete name (First & Last name)
b) Date of Birth
c) ID Number (if applicable)
d) Date & time of collection
e) Initials of the phlebotomist
f) Additional information such as "fasting"
Step 16: Observe Special Handling Instructions
Step 17: Check Patient's Arm and Apply Bandage
Step 18: Dispose of Contaminated Materials
Step 19: Thank Patient, Remove Gloves, and Sanitize Hands
Step 20: Transport Specimen to the Lab
REQUIREMENTS FOR DRAWING BLOOD FROM SPECIAL
POPULATION
 
Pediatric Puncture
 
Special attention is necessary when performing pediatric venipuncture
involving children below two years old. To minimize pain and trauma of the
patients, this should be limited to superficial veins only.
 
The challenges faced when dealing with pediatric patients include veins
that are usually small and underdeveloped making it difficult to draw blood.
A considerable risk of damage could be permanent if proper procedure is not
followed. There is also risk of anemia, since the volume of blood in the body
is smaller.
 
In addition, dealing with the parents or guardians could also be a
challenge. The phlebotomist should exhibit a warm and caring approach and
it would be helpful if they ask the parents or guardians about the child's past
blood collection experience. They should be allowed to stay in the room with
the child if they want to.
 
The phlebotomist should approach slowly and be able to determine the
level of anxiety of the patient, so they can gain his trust. The procedure
should be explained clearly using terms that the child could easily
understand giving emphasis on the importance of staying still during the
venipuncture procedure. It is also useful to offer some form of reward for
the patient's cooperation.
 Eutectic mixture of local anesthetics (EMLA) are used for pain
interventions. This comes in cream and oral form and takes about an hour to
take effect and anesthetize the area.
 
During the procedure, there are several ways to restrain the movement
of the patient: infants are wrapped in the blankets, toddlers are usually held
in the parent's lap, and for children, a second person usually leans over the
child who is in lying position.
Geriatric Venipuncture
 
A geriatric patient or an elderly patient needs special attention because
they may have special conditions such as arthritis, diabetes, Parkinson's &
stroke, atherosclerosis and dementia, which makes blood drawing a
challenge. Other challenges also include hearing, visual and mental
impairment. The elderly have thinner skin and smaller muscles which causes
the veins to roll easily. As we age, our veins also lose its elasticity, making
the them prone to collapse during the procedure.
 
The health care institution also needs to consider safety issues like the
space requirement for walkers and wheelchairs, and maintenance of non-slip
clutter-free floors for the elderly. Patients in wheelchair should ensure that
the wheels are locked during the procedure, and that they have assistance
when using the wheelchair.
 The following procedure should be followed when doing venipuncture
for an elderly patient:

a. Identify the patient properly and confirm the patient information, ask the
attendant or relative if needed
b. Carefully select which needle to use (short draw or butterfly needle)
c. Apply tourniquet carefully to make sure that skin will not be damaged
d. Make sure that the site is not previously the site from previous
venipuncture
e. Avoid rubbing the site vigorously during cleaning
f. Prevent the vein from rolling by anchoring the vein firmly during the
venipuncture
g. Hold the pressure over the site and take note that bleeding could take
longer to stop than regular patients.
Long-term care patients
 
Dialysis Patients
 
A patient who undergoes dialysis may request that the dorsum of their
hands be used for venipuncture to preserve veins of the arms for
hemodialysis access. The phlebotomist should comply and select another site
other than the arm used with arteriovenous (AV) fistula.
 
Long-Term Care Patients
 
Long-term care services are provided to patients who cannot perform
regular daily activities due to their health condition. These can be assisted-
living with the help of relatives or friends, which could be in their private
homes or in community-based rehabilitation facilities such as an adult day
care center. (https://www.nia.nih.gov/health/what-long-term-care)
Home-Care Patients
 
Home health services are for patients who need medical attention and
assistance from the health professionals from time to time. Home care
phlebotomists are independent, flexible, with exceptional interpersonal and
organizational skills, and can carry all necessary equipment with them during
house calls.
 
Hospice Patients
 
Hospice care is for patients that need end-of-life care, wherein most
have a prognosis of six months or less. The phlebotomist should work with
extra care with these patients, treating them kindly and with respect, giving
these dying patients comfort and dignity.