BLOOD COLLECTION:ROUTINE VENIPUNCTURE AND SPECIMEN HANDLINGObjectives for the tutorial:
VENIPUNCTURE PROCEDUREThe venipuncture procedure is complex, requiring both knowledge and skill to perform. Each phlebotomist generally establishes a routine that is comfortable for her or him. Phlebotomists are considered to have occupational exposure to blood borne pathogens. The performance of routine vascular access procedures by skilled phlebotomists requires, at a minimum, the use of gloves to prevent contact with blood. Airborne precautions may be considered to provide a level of safety against infectious diseases such as tuberculosis, influenza, and COVID-19. Precautions include a medical grade face mask. With risk for blood spatter a face shield provides protection. A face mask reduces risk for blood culture specimen contamination. Laboratory coats or work smocks are not typically needed as personal protective equipment during routine venipuncture, but an employer must assess the workplace to determine whether certain tasks, workplace situations, or employee skill levels may result in an employee's need for laboratory coats or other personal protective equipment to prevent contact with blood. It is an employer's responsibility to provide, clean, repair, replace, and/or dispose of personal protective equipment/clothing. As part of presenting a professional appearance, an institutional dress code may include wearing of a laboratory coat or smock. Patient identification is critical for safety. At least two patient identifiers, such as name and date of birth, are needed. Label collection tubes after identification of the patient. Interruptions and distractions during medical encounters and procedures should be avoided. Several essential steps are required for every successful collection procedure:
ORDER FORM / REQUISITIONA 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:
An example of a simple requisition form with the essential elements is shown below: LABELING THE SAMPLEA properly labeled sample is essential so that the results of the test match the patient. The key elements in labeling are:
Automated systems may include labels with bar codes. Examples of labeled collection tubes are shown below: EQUIPMENT:THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE:
ORDER OF DRAWBlood collection tubes must be drawn in a specific order to avoid cross-contamination of additives between tubes. The recommended order of draw for plastic collection tubes is:
NOTE:Tubes with additives must be thoroughly mixed. Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive. Transferring a sample from one collection tube to another or mixing blood from different collection tubes must be avoided. PROCEDURAL ISSUESPATIENT RELATIONS AND IDENTIFICATION: The phlebotomist's role requires a professional, courteous, and understanding manner in all contacts with the patient. Greet the patient and identify yourself and indicate the procedure that will take place. Effective communication - both verbal and nonverbal - is essential. Proper patient identification MANDATORY. If an inpatient is able to respond, ask for a full name and always check the armband or bracelet for confirmation. For an inpatient DO NOT DRAW BLOOD IF THE ARMBAND OR BRACELET IS MISSING. For an inpatient the nursing staff can be contacted to aid in identification prior to proceeding. An outpatient must provide identification other than the verbal statement of a name. Using the requisition for reference, ask a patient to provide additional information such as a birthdate. A government issued photo identification card such as a driver's license can aid in resolving identification issues. If possible, speak with the patient during the process. The patient who is at ease will be less focused on the procedure. Always thank the patient and excuse yourself courteously when finished. 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). The basic patient rights endorsed by the JCAHO follow in condensed form are given below. The patient has the right to:
VENIPUNCTURE SITE SELECTION: Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a last resort because of the higher probability of complications. Certain areas are to be avoided when choosing a site:
PROCEDURE FOR VEIN SELECTION:
PERFORMANCE OF A VENIPUNCTURE:
PHLEBOTOMY PROCEDURE ILLUSTRATED:
PERFORMANCE OF A FINGERSTICK:
FINGERSTICK PROCEDURE ILLUSTRATED:
ADDITIONAL CONSIDERATIONS:To prevent a hematoma:
To prevent hemolysis (which can interfere with many tests):
Indwelling Lines or Catheters:
Hemoconcentration: An increased concentration of larger molecules and formed elements in the blood may be due to several factors:
Prolonged Tourniquet Application:
Patient Preparation Factors:
REASONS FOR CANCELING A LABORATORY TESTA test that has been ordered may be cancelled due to problems unrelated to drawing the specimen, and these are the most common causes for cancellations:
A test may be cancelled due to a technical problem in the specimen collection process:
SAFETY AND INFECTION CONTROLBecause of contacts with sick patients and their specimens, it is important to follow safety and infection control procedures. PROTECT YOURSELF
PROTECT THE PATIENT
TROUBLESHOOTING GUIDELINES:IF AN INCOMPLETE COLLECTION OR NO BLOOD IS OBTAINED:
IF BLOOD STOPS FLOWING INTO THE TUBE:
PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:
BLOOD COLLECTION ON BABIES:
HEELSTICK PROCEDURE ILLUSTRATED:
PEDIATRIC PHLEBOTOMY:
COLLECTION TUBES FOR PHLEBOTOMY
ReferencesGiavarina D, Lippi G. Blood venous sample collection: Recommendations overview and a checklist to improve quality. Clin Biochem. 2017;50(10-11):568-573. Kiechle FL. So You're Going to Collect a Blood Specimen: An Introduction to Phlebotomy, 13th Edition (2010), College of American Pathologists, Northfield, IL. Dalal BI, Brigden ML. Factitious biochemical measurements resulting from hematologic conditions. Am J Clin Pathol. 2009 Feb;131(2):195-204. Lippi G, Salvagno GL, Montagnana M, Franchini M, Guidi GC. Phlebotomy issues and quality improvement in results of laboratory testing. Clin Lab. 2006;52(5-6):217-30. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, Vassault AJ, Mattiuzzi C, Plebani M. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med. 2009;47(2):143-53. Occupational Safety and Health Administration, United States Department of Labor. https://www.osha.gov/laws-regs/standardinterpretations/2007-10-26 and https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact03.pdf (Accessed June 13, 2022). Phelan MP, Reineks EZ, Berriochoa JP, Schold JD, Hustey FM, Chamberlin J, Kovach A. Impact of Use of Smaller Volume, Smaller Vacuum Blood Collection Tubes on Hemolysis in Emergency Department Blood Samples. Am J Clin Pathol. 2017;148(4):330-335. Sanders AM, Agger WA, Gray AM, Fischer CM, Kamprud EA. Use of hair nets and face masks to decrease blood culture contamination rates. Diagn Microbiol Infect Dis. 2019;95(1):15-19. doi: 10.1016/j.diagmicrobio.2019.04.001. Uman LS, Birnie KA, Noel M, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2013 Oct 10;(10):CD005179. doi: 10.1002/14651858.CD005179.pub3. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med. 2004;24(4):979-96, vii. World Health Organization. WHO guidelines on drawing blood: best practices in phlebotomy. https://www.ncbi.nlm.nih.gov/books/NBK138650/pdf/Bookshelf_NBK138650.pdf (Accessed June 13, 2022) And for our furry friends: Joslin JO. Blood Collection Techniques in Exotic Small Mammals. Journal of Exotic Pet Medicine. 2009;18(2):117-139. What is the most common location for a skin puncture?The distal end of the third or fourth finger is the most commonly used site. The very tip of the finger should not be punctured because there is a greater chance of puncturing bone as the bone is close to the skin surface.
When performing a dermal puncture what needs to be done?Perform the skin puncture.
Place the puncture device on the patient's skin and activate the release mechanism. Dispose of the puncture device in a Sharps container. For infants, the heel puncture should be no deeper than 2.0 mm. Wipe the first drop of blood away with dry gauze.
What is a dermal puncture in phlebotomy?Overview: A dermal (skin) puncture may be required when a venipuncture cannot be performed or may be the option of choice for some point-of-care test procedures. A dermal puncture may be a fingerstick or, in the case of small infants, may be a heelstick.
What is the preferred site for a venipuncture on a child younger than 2?The scalp veins can be used in infants. Veins of the foot can be used in infants who are not yet walking. The nurse must have a good understanding of the anatomy, physiology, and physics related to venipuncture. Venipuncture can be a painful and stressful experience for a child.
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