20 Steps | Successful Venipuncture

20 steps to successful venipuncture

A new nurse should be given a skills checklist and the rationale for each step. This will help them to understand why certain steps are necessary when learning how to perform an action or complete a procedure.

1. Review the order

If the lab test ordered doesn't seem appropriate for your patient, don't be afraid to double-check with the provider.

2. Gather the supply tray/cart

If your hospital has a blood tray and a range of supplies, bring it along for convenience. Many facilities don't have these trays immediately accessible to nurses though. In this case, make sure you assess the patient's veins first before gathering any supplies as appropriate for their condition and the location of the injection site.

3. Approach, identify and prepare the patient

A patient should be prepared for the procedure ahead of time. The best thing to do is ask if they have had any trouble with needles, or blood draws in the past so that you are aware of their needs. It's also important to know whether or not a person faints during these procedures because then it would be beneficial for them to lie down while getting this done just in case anything happens!

Your patient's identity must be verified before you can perform a blood draw. To do this, ask your patient for their full name and date of birth, which should match the information on the lab requisition or wristband they are wearing. You may also verify it by using a medical record number (MRN) or personal identification number (PIN).

4. Hand hygiene

Before you perform any invasive procedure, be sure to wash your hands with soap and water or an alcohol-based hand sanitizer. 

5. Apply a tourniquet, instruct the client to clench fist, and evaluate the anterior elbow space

Antecubital veins are the best place to draw blood from, so you should try and get one there. If not, it's okay if they have a good vein in their hands or backs of them rather than waiting for another time when this is possible! 

6. Select an appropriate vein, loosen the tourniquet, and have the patient unclench his or her fist

The best place to draw blood is in the median cubital vein, which provides safe access for healthcare professionals. The second-best option would be the more lateral cephalic or basilic veins because they both lie deeper than other parts of your arm and are less likely to harm you during a procedure.

7. Cleanse the site

Prepare your skin by using friction and applying 70% isopropyl or ethyl alcohol in concentric circles, moving outward for a total prep area of 2.5 to 3 inches (6.4-7.6 cm). You may also use benzalkonium or chlorhexidine to prepare the site, using the same technique before venipuncture air-drying completely without recontaminating it.

8. Apply clean gloves and prepare your equipment

Before you get a blood test, scrub your skin with alcohol. Then air dries it completely without touching the area again. Prepare your skin by using friction and applying 70% isopropyl or ethyl alcohol in concentric circles, moving outward for a total prep area of 2.5 to 3 inches (6.4-7.6 cm). You may also use benzalkonium or chlorhexidine to prepare the site, but before venipuncture make sure that they are fully dried out. Now you're ready to start. It's a good idea to have extra tubes available in case there's a faulty tube, and it can be helpful to use gauze and tape immediately after the draw as well. By the time everything is prepared though, your site should be dry so that we can cap off your needle successfully!

9. Reapply the tourniquet, have the patient make a fist, and uncap the needle

When applying the tourniquet, make sure you don't contaminate your cleaned site. If contamination occurs, then resanitize it before continuing with treatment. When uncapping the needle after cleaning and disinfecting it properly, inspect its bevel to ensure there are no barbs or defects in it that could cause injury during insertion into a vein.

10. Anchor the vein and insert the needle

When inserting an IV, you should anchor the vein with your thumb 1 to 2 in below the insertion site being careful not to touch it. If you do happen to touch it then resanitize and insert at a 30[degrees]-angle for antecubital veins or 10[degrees]-angled hand veins if it's deeper into tissue. When inserting the needle, aim for an angle of around 20 degrees by measuring from your patient's skin. Then rest this first tube in a specialized holder before you puncture it and begin filling.

11. Establish blood flow, have the patient open his or her fist, and release the tourniquet

If you're using a butterfly needle, blood will flashback in the tubing when you've successfully reached the vein. If it's a straight multisample needle, there is no way to see if your access has been successful or not because of a lack of visual confirmation. You'll have to feel that the vein has been accessed and then engage with the tube by turning quarter turn clockwise before pulling out from the skin. Once blood flow is established, you may release the tourniquet. As long as your total time with it on remains under a minute, feel free to leave it in place while placing new needles or tubes.

12. Fill tubes using the correct order of draw and mix tubes

A tube should fill to the appropriate amount automatically because of the vacuum in each one. Be sure not to remove it before full, as this can throw off your additive-to-blood ratio. When you switch tubes, stabilize the holder with your nondominant hand so that you don't change needle insertion depth - practice makes perfect! The ETS tubes are filled in a specific order to avoid additive contamination from tube to tube. It's important that you don't transfer the solution between different test tubes, as this might cause problems with your samples later on! The first tube you must collect for a lab test is often clear or white and contains around 3-5 mL of blood. This prevents possible contamination from the other samples collected during your visit to the facility, which may include red top tubes that can contain either additive or nonadditive material.

The order of draw is as follows:
 
*clear yellow sterile tubes (blood culture)
 
*The tubes were a light blue color.
 
* red-serum tubes with or without clot activator
 
* gold-serum tubes with or without separator gel
 
* green-heparin tubes with or without separator gel
 
* lavender, purple, pink-ethylenediamine tetraacetic acid, or EDTA, tubes
 
* gray-glycolytic inhibitor tubes.

Each tube needs to be mixed by inverting it. Don't invert the tubes too quickly or you may cause hemolysis of blood cells, which can lead to erroneous lab results. Most tubes are inverted five times for red and gold ones and four times for light blue ones.

13. Place gauze, remove the needle and apply pressure to the site

To control the bleeding, place gauze lightly over the site just before inserting your needle so that when you remove it, pressure can be applied immediately. You may ask them to hold this for a couple of minutes if they are unable to do this on their own--but only 2 or 5 depending on what kind of anticoagulants they're taking! 

14. Discard the collection unit

After you've taken the needle out of your patient's arm, make sure to engage its safety device by dropping it in a container. Don't ever take the needle off before disposal because this increases the risk of getting stuck with needles yourself.

15. Label the tubes

Many hospitals have pre-made labels for tubes. If this is the case, verify the label information and add your initials/time/date to it before applying it onto a tube. Be sure to include all of these details: last name and first initial; date of birth; initials (yours); time; and date on that said label! 

16. Implement special handling
 
If a lab requires special handling, such as placing the tube in an ice slurry or wrapping it in foil to protect it from light, now is the time to do so. If you aren't sure of any special treatment for samples call and ask if they require anything specific before going through with your sample draw. It's better to clarify than have someone repeat their blood draw because something was mishandled during transport between labs!

17. Check the patient's arm and apply a bandage

Use a pressure bandage to secure gauze over the incision site. If blood seeps through, continue applying new layers of dressing until the bleeding stops or slows down enough for you to maintain constant manual pressure on it without breaking skin contact with your hand. 

18. Dispose of materials and clean up

Follow your facility's policy for the disposal of items with blood on them. Also throw away any used materials, including tourniquets and other equipment that may have come into contact with the patient's blood or bodily fluids during treatment such as bandages, gauze pads, etc.

19. Remove your gloves, perform hand hygiene, and thank the patient

Clean your hands with soap and water or sanitizing gel after you remove the gloves. Then communicate any symptoms to report, let him know that their doctor will discuss abnormal lab values, thank them for being patient then clean up!

20. Transport specimens to the lab

If the lab is close, maybe you can walk there. Sometimes it's easier to bring your own sample if they're special or stat samples that require extra handling by staff members in order to minimize cell hemolysis during transport.

Facilitating accurate results

The preanalytical phase of blood specimen collection and lab value determination is everything that happens from the time a test is ordered to when it's analyzed. There are multiple considerations during this phase including tone of voice, as well as what exactly needs to be done with your sample before testing can commence. Nurses have to take steps in order to decrease the number of errors that can occur during blood tests so patients don't need another test. For example, nurses should make sure their tone is easy for providers and other people to understand when they are discussing lab results with them.

Timing

In other words, when a drug's peak and trough levels are tested, make sure that you're drawing the peak level after the correct dosage. For example, draw at the high point of pharmacologic peak not right before the next dose is taken. Before you draw the patient's blood, make sure to verify with a drug reference guide what time of day serum levels are at their lowest. This is called trough level and usually occurs about 3-4 hours after dosing.

Burns, scars, tattoos, and damaged veins

Any area of skin that is newly burned or injured can be painful for the patient and there's an increased risk of infection. Areas that have healed after an injury, including tattoos may have significant scar tissue and impaired circulation causing erroneous results. When the veins are damaged, it can be difficult for your healthcare provider to get blood samples. They may try multiple times before succeeding in getting a sample or they might even need another vein altogether if that doesn't work out.

Mastectomy or chest and upper extremity surgeries

If lymph nodes are removed or there is a problem with the flow of lymph fluid in your body, you may be at risk for infection and swelling. It's best to consult with your healthcare provider before doing any venipuncture on one side of your breast - specifically the mastectomy site. 

I.V. sites or venous access devices

A doctor should avoid venipuncture on the extremity with an established I.V., such as a peripherally inserted central catheter (PICC) line. You also run the risk of damaging or dislodging said device when placing tourniquets for lab work, so it's not recommended to do this if you're using saline locks and/or administering intravenous fluids in that area either. To be able to draw an accurate blood sample, the patient must turn off any fluids and wait for two minutes. To do this, they should switch which arm is used. If possible use a different site on that arm than one with access from previous procedures such as I.V.'s or saline locks.

Edematous sites and obesity

Swollen sites are more difficult to use for I.V., however, if the patient is obese or there's extra tissue fluid in their arm it may be even harder to find a good vein on them which can cause discomfort during insertion of an IV needle. 

Tourniquet application

You should place a tourniquet 3 to 4 inches above the site, tying it tight enough that it slows venous blood flow and loose enough so as not to impede arterial blood. You need to tie off using a quick-release knot with ends pointed away from the venipuncture site towards you while looping toward your desired area of insertion instead. Because the ends may touch contaminated surfaces while you're taking blood, they should never be used on patients with acute injuries or wounds. You can also use towels under your tourniquet to keep older adults' skin safe from tears and discomfort when drawing their vials of blood. This is important for high-risk patient populations like seniors, who are more likely than other age groups to suffer complications that need intervention during phlebotomy procedures.

Learning curve

When hospitals decentralize services, nurses are being called on more frequently to draw blood. Transitional and home care nurses often perform phlebotomy procedures with little education in the field so there is a high risk of procedural errors during the preanalytical phase leading to inaccurate lab results that result in additional draws or improper treatment. Nurses should take the initiative to educate themselves about phlebotomy techniques and equipment before they are asked to draw blood.