VENIPUNCTURE • Refusal of Consent

- An individual has a constitutional right to refuse a

PUBLIC RELATIONS & CLIENT INTERACTIONS medical procedure such as venipuncture

A. Professionalism PATIENT IDENTIFICATION PROCEDURES

▫ Appearance 1. Conscious inpatients/Hospitalized patients
• The impression a phlebotomist makes when first ▫ Verbally ask their full names.
approaching a patient sets the stage for future ▫ Verify the name using the identification bracelet w/c
interaction includes first & last names, hospital/unit number,
• Lab coats should protect clothing underneath room/bed number, and physician’s name
• Shoes should be conservative and clean 2. Sleeping patients
• Hair, if long, must be pulled back and fingernails ▫ They are identified in the same manner as conscious
should be short for safety’s sake. in-patients
▫ Attitude ▫ They MUST be awakened before Blood Collection
• Integrity or honesty: doing what is right regardless of 3. Unconscious, mentally incompetent patients
the circumstances. ▫ They are identified by asking the attending nurse or
• Compassion: a deep awareness of the distress of relative; ID bracelets
others and a desire to alleviate it. 4. Infants & children
• Motivation: having the drive to meet a need or ▫ A nurse or relative may identify the patient, or by
achieve a goal means of an identification bracelet.
• Ethical behavior: conforming to a standard of right 5. Outpatient/Ambulatory patient
and wrong conduct ▫ Verbally ask their full names, address, or birthdate,
• Dependability and work ethic: able to be relied upon, & countercheck with driver’s license, or ID card with
and being self-directed because of a belief in the photo.
importance of work
• Diplomacy: skill in handling situations without Venipuncture
creating hostility - Process by w/c blood is obtained from a patient’s vein.
▫ Communication Skills - SITES: Antecubital Fossa, Veins on the Wrist & Dorsal
• If the phlebotomist responds properly to the needs Aspect of Hands, Veins on the Ankle.
of a patient due to good communication between - MEDIAN CUBITAL VEIN is the BEST site for Venipuncture
the two of them, the patient typically develops a because it is the largest and the best anchored vein.
favorable impression of the phlebotomist and the - According to CLSI Standards, an attempt must have been
facility made to locate the Median Cubital Vein on both arms
• Listening forms the foundation for good before considering an alternate vein.
interpersonal communication and is especially - Cephalic Vein is the SECOND choice if the median cubital
important in establishing rapport with patients vein is unsuitable
▫ Bedside Manner - Basilic Vein is the THIRD Choice.
• A phlebotomist may encounter family or visitors - Basilic Vein should NOT be chosen unless no other vein is
when collecting specimens. more prominent due to its close proximity to the brachial
• Discretion is important in dealing with them as they artery.
can help calm the patient’s fears or they can raise - Veins on the dorsal part of hand & wrist area can be
the patient’s anxiety level. chosen provided the antecubital veins are not
• If the phlebotomist feels it would be best, they can Acceptable.
be asked to leave the room - Ankle vein should be used ONLY if arm veins have been
determined to be unsuitable
B. Patient’s Consent
• Informed Consent
- Implies voluntary permission for a medical
procedure, test, or medication will be given
• Implied Consent
- Does not require a verbal expression of consent.
Actions can imply consent
• Expressed Consent
- May be given verbally or in writing
• HIV Consent
- Laws specify exactly what type of information must
be given to inform the client properly
• Consent for Minors
- Parent or guardian consent is required ETS & SYRINGE PROCEDURE
1. Greet the patient politely and with gladness. 13. Anchor the vein & insert the needle into the vein at a
2. Determine the identity of the patient. shallow angle (e.g., 10–15 degrees). A “flash” or small
3. Decontaminate hands, put gloves & prepare the materials. amount of blood appears in the tubing when the needle is in
4. Position the patient’s arm in a downward and comfortable the vein. “Seat” the needle by slightly threading it within the
manner. vein to keep it from twisting out of it.
5. Apply the tourniquet 3 -4 inches above the site, & instruct 14. Establish blood flow & release tourniquet
the patient to make a fist. Check for potential sites by gently 15. Fill, Remove, and Mix Tubes in Order of Draw.
palpating the vein. Never leave the tourniquet longer than 16. Clean folded gauze is placed over the site so pressure can
one minute. be applied immediately on needle removal.
6. If a suitable vein is not felt on the first arm, remove the 17. The needle is removed in one smooth motion without
tourniquet and try the other arm or other site. lifting up or pressing down on it.
7. If a vein has already been chosen, release the tourniquet 18. Pressure is immediately applied with the free hand while
and disinfect the patient’s skin with an alcohol pad starting at the needle safety device is simultaneously activated with the
the point where you expect to insert the needle, and moving other to reduce the risk of a needle stick.
outward in even-widening concentric circles. 19. Discard the collection unit.
8. Allow the site to dry by allowing the alcohol to evaporate 20. Label the tubes. Apply bandage or tape to the patient’s
or remove excess alcohol with sterile gauze pad. Do not blow arm. Thank patient, remove gloves, & sanitize hands
or touch the site after cleaning.
9. Re-apply the tourniquet and instruct the patient to make a ○ SITES TO AVOID ○
fist. - Intravenous line in both arms
10. Pull the skin gently with the thumb, and position the - Burned or scarred areas
needle parallel or running in the same direction as the vein. - Areas with hematoma
11. Insert the needle quickly, with the bevel side up at a 15- - Thrombosed Veins
30-degree angle with the skin. A slight “pop” should be felt as - Edematous arms
the needle enters the vein. - Partial/Radical Mastectomy on one or both arms
12. For evacuated tube, push the tube and as the blood - Arms with arteriovenous (AV) shunt or fistula
begins to flow, instruct the patient to open his fist, and - Cast(s) on arm(s)
release the tourniquet. The tourniquet can be left on until
after the tubes have been filled if it appears that blood flow is ○ TROUBLESHOOTING ○
slow. But always remove the tourniquet first before
withdrawing the needle. Bevel against the vein wall: If the
 For multidraw, carefully remove each tube from the needle bevel is up against a vein
holder with a gentle twist-and-pull motion. wall, tube vacuum can pull the wall
 For syringe, gently pull the plunger and as blood against the bevel and block blood
begins to flow, instruct the patient to open his fist, & flow. Remove the tube from the
release the tourniquet. holder and retract the needle
13. When blood collection is done or all tubes have been slightly. Rotating the bevel slightly
filled and removed from the holder, withdraw the needle may also help. Do not retract or
with a quick motion and hold a dry sterile gauze pad over the rotate the needle with the tube in
site. Apply pressure to the site for a minimum of 2 minutes. place or the vein may be injured.
14. Label the tubes with patient’s full name, date and time of
collection, and initials of the phlebotomist. Check the Needle too deep: The needle can
condition of the patient before leaving. go all the way through a vein on
15. Dispose all materials in the designated waste bins. insertion or as a tube is engaged
if the holder is not held securely.
BUTTERFLY PROCEDURE Withdraw the needle slightly to
1 – 8. Follow the same procedure as ETS & Syringe procedure establish blood flow. Stop the draw
9. Preparing it while the site dries save time. Attach a if a hematoma forms.
butterfly to an ETS holder or syringe adapter. Grasp the
tubing near the needle end and stretch it lightly to help keep Needle not deep enough: Partial
it from coiling back up. Position the first tube in the holder needle insertion causes slow blood
now, or wait until after needle entry flow. Gently advance the needle to
10. Reapply tourniquet, Uncap, & inspect needle establish correct flow. Stop the draw
11. Hold the butterfly wings between your thumb and index if a hematoma forms.
finger or fold them upright and grasp them together.
12. Cradle the tubing and holder in the palm of your Needle beside the vein: If a vein
dominant hand or lay it next to the patient’s hand. Uncap and is not anchored well, it may roll
inspect the needle for defects, and discard it if flawed. and the needle may slip beside
it instead of into it. Remove the • Thrombophlebitis
tube to preserve its vacuum, - inflammation of the vein often accompanied by a
withdraw the needle until the clot which occurs as a result of trauma to the vessel
bevel is just under the skin, anchor the vein, and redirect the wall
needle into it. If redirection is unsuccessful, do not probe.
Discontinue the draw and choose a new site. 3. LATE GENERAL COMPLICATION
• Serum Hepatitis & AIDS
Collapsed vein: If tube
vacuum is too great for ○ CAUSES OF HEMATOMA ○
the vein, a syringe plunger - The vein is fragile or too small for the needle size
is pulled too quickly, or - The needle penetrates all the way through the vein.
the tourniquet is too tight or too close to the site, blood - The needle is partly inserted into the vein
cannot be replaced as quickly as it is withdrawn and the vein - The needle is removed while the tourniquet is still on.
collapses. A vein may also collapse when the tourniquet is - Pressure is not adequately applied after venipuncture
removed during the draw, especially if the patient is elderly
and has fragile veins. (Blood stoppage on tourniquet removal ○ NOTES TO REMEMBER ○
is not always the result of vein collapse. Needle position may Multiple venipuncture attempts
have changed and readjustment is needed.) Use a smaller • If you are unable to obtain a specimen on the first
tube or pull the syringe plunger more slowly. If blood flow attempt, try again below the first site, on the other
does not return, discontinue the draw and try again at arm, or on a hand or wrist vein
another site. • If the second attempt is unsuccessful, ask someone
else to take over
○ COMPLICATIONS ○ • Unsuccessful venipuncture attempts frustrate both
patient and phlebotomist. If a second person is
1. IMMEDIATE LOCAL COMPLICATION unsuccessful on two attempts, give the patient a rest
• Hemoconcentration and try later unless the test is stat or timed
- an increase in the number of formed elements in • If a specimen is not obtained, notify the nurse or
blood resulting either from a decrease or increase in physician according to facility policy.
plasma volume.
• Failure of blood to enter the syringe/vacutainer ○ PEDIATRIC VENIPUNCTURE ○
- Excessive pull of the plunger Interacting with the Child
- Piercing the other pole of the vein • Approach the child slowly and determine his or her
- Transfixation of vein degree of anxiety or fear before handling equipment
- Incorrect bevel position (bevel down) or touching arms to look for a vein
- Absence of Vacuum • Physically lower yourself to the child’s level to be
• Syncope (Fainting) less intimidating. Explain the procedure in terms the
- the transient loss of consciousness due to lack of child can understand and answer questions honestly.
oxygen in the brain resulting in an inability to stay • Never tell a child it will not hurt; instead say it may
upright. hurt just a little, but it will be over quickly.
- Warning signs that a person may faint include • It is important to let the child know that it is all right
perspiration beads on the forehead, to cry
hyperventilation, and loss of color. Immobilizing the Child
• Bruise • Immobilization of pediatric patients is critical to
- discoloration of the site due to the leakage of blood successful venipuncture and helps ensure their
into the surrounding tissue safety. An infant can be wrapped in a blanket
• Hematoma • A toddler can be restrained while sitting on a
- A swelling or mass of blood that escaped from a parent’s lap
vein during or following venipuncture. Never draw • The parent uses one arm to support and steady the
blood through a hematoma because it is painful and venipuncture arm and places the other arm around
leads to inaccurate test results. If no other site is the child and the child’s other arm.
suitable, draw the specimen distal to the hematoma • If the child is in a bed, a parent or helper leans over
so that free flowing blood is collected. the child from the opposite side of the bed, reaching
one arm around the child to support the
venipuncture arm and the other over the child to
secure the child’s other arm.
2. LATE LOCAL COMPLICATION
• Thrombosis ○ GERIATRIC VENIPUNCTURE ○
- an abnormal vascular condition in which thrombus • It is extremely important to treat geriatric patients
develops within a blood vessel of the body. with dignity and respect and not demean them
• It is best to address the patient with a more formal
title, such as Mrs., Ms., or Mr., rather than by his or
her first name
• As with patients in general, older patients may enjoy
a short conversation
• If a patient appears to be having difficulty hearing,
speak slightly slower and louder