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Blood Specimen Collection Blood Cultures (Ambulatory)

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Jun.29.2023

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Specimen Collection: Blood Cultures (Ambulatory) - CE/NCPD

ALERT

Signs and symptoms of nerve injury to the arm include severe, unusual, or shooting pain; tingling; numbness; or a tremor. If the patient complains of any of these during venipuncture, withdraw the needle immediately.^{undefined#ref12">12}

Draw specimens for blood cultures before administering antibiotics.

Take precautions with a patient who takes medications that increase the risk for bleeding.⁹

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

OVERVIEW

Although recommendations are that trained phlebotomy personnel collect peripheral blood culture specimens by venipuncture to minimize collection errors, other health care team members may be responsible for specimen collection. Health care team members should be familiar with the organization’s practice and the state’s nurse practice act regarding venipuncture, blood specimen collection, and delegation.

A blood culture specimen set requires that 20 to 30 ml of blood be obtained at one time from one location.¹ Blood culture specimens should be drawn when the patient is experiencing signs and symptoms of bloodstream infection, including fever or chills, and before the administration of antibiotics to increase the likelihood of obtaining a true-positive result. If the patient has been receiving antibiotics at the time the blood cultures are obtained, the laboratory should be notified because an additive can be applied to the blood culture medium to negate the antibiotic’s effect.¹¹ Typically, two sets of blood cultures are ordered, and each set (Figure 1) contains one aerobic bottle and one anaerobic bottle. Orders regarding the spacing of the specimens may vary among practitioners and organizations.

Blood culture specimens are usually drawn using either a needle and syringe or a vacuum-extraction collection system that draws blood into vacuum-sealed blood culture bottles. In both cases, a hollow-bore needle is inserted into the lumen of a patient’s vein to obtain the blood culture specimen. Straight needles from vacuum-extraction collection systems are not used with blood culture bottles. Instead, winged-butterfly needles with a short length of tubing may be approved by the organization for use. Caution should be taken to avoid contaminating the patient’s skin or equipment to minimize the risk of false-positive test results, which can lead to inappropriate antibiotic use. False-positive results may expose patients to additional laboratory tests and increased length of stay.

The correct amount of blood required by the laboratory must be extracted into each blood culture bottle to ensure accurate test results and decrease the patient’s risk of anemia.⁷ If more than one blood specimen is to be drawn during a single venipuncture, specimens for blood cultures should be drawn first to maintain asepsis and prevent contamination with additives from laboratory tubes.

Because limited venous access may be a life-threatening complication of venipuncture, maintaining the patient’s vein’s integrity is essential. A patient with veins that may collapse or become injured from the vacuum or a patient whose veins may be difficult to locate because of unusual anatomy, trauma from repeated phlebotomy, or edema may also require an alternative method of blood specimen collection. Vascular visualization technology, such as ultrasound, infrared light technology, or transillumination devices, may be necessary to identify vasculature and can be used for difficult access.³

Tourniquets should be used with caution. If a tourniquet is deemed necessary, the nurse should not apply the tourniquet for longer than 1 minute.⁷ Prolonged tourniquet application can cause stasis and hemoconcentration.⁷ Infection control standards require that tourniquets be single use.⁶ Staphylococcus aureus contamination from reused tourniquets is a common finding.¹⁵

Venipuncture can be painful, and the patient may experience anxiety or fear before the procedure. For some patients, just the appearance of a needle is frightening, especially to a pediatric patient. A calm approach and skilled technique may help limit the patient’s aversion to venipuncture. The application of a vapocoolant spray has been shown to be effective in reducing pain during venipuncture.¹⁶ Anxiety may be assuaged by communicating with the patient about how to help relieve the patient’s concerns.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Explain the purpose of collecting the blood specimen and the method to be used.
Explain how a tourniquet, antiseptic swab, and venipuncture may feel.
Explain that pressure is applied to the venipuncture site briefly after the needle is withdrawn, without bending the patient’s arm.
- Explain that the patient may apply pressure if able.
- For a patient who has a bleeding disorder or is undergoing anticoagulant therapy, explain that pressure may have to be applied for a longer period of time to achieve clotting.
Teach the patient the signs and symptoms of recurrent bleeding (e.g., expanding hematoma at the venipuncture site) and provide instructions on when to seek additional care.
Encourage questions and answer them as they arise.

PROCEDURE

Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Explain the procedure and ensure that the patient agrees to treatment.
Ensure that laboratory results are communicated to the clinical team leader per the organization’s practice.
Evaluate the patient for signs and symptoms of bacteremia, including fever and chills, before drawing blood cultures.
Rationale: Three blood culture samples should be drawn at least 1 hour apart beginning at the earliest signs of sepsis.¹¹
Determine whether antibiotics have been administered before blood culture specimen collection and inform the clinical team leader per the organization’s practice and the laboratory of the time of antibiotic administration.
Rationale: Resin can be added to the culture medium to negate the antibiotic effect.¹¹

If cultures are needed while the patient is receiving antibiotic therapy, obtain the blood culture specimen shortly before the next antibiotic dose.¹¹
Review the patient’s history for risks associated with venipuncture, such as anemia, anticoagulant therapy, low platelet count, a bleeding disorder, venous collapse, traumatic venipuncture, and phlebitis.
Determine the patient’s ability to cooperate with the procedure and the patient’s experience with blood specimen collection (e.g., anxiety or fear related to venipuncture).
Review the patient’s history for any allergy or sensitivity to antiseptic solutions,⁶ adhesives, and dressings.⁸
Evaluate the patient’s anatomy for sites contraindicated for venipuncture, such as an IV access site; a site with a hematoma or signs of phlebitis or previous infiltration; potential site on the arm on the side of a mastectomy or other lymphatic system compromise; a site affected by radiation, tissue injury, or infection; a site on the arm on the affected side of a stroke; or a current or planned hemodialysis shunt.⁷
Determine the patient’s hydration and perfusion status.
Determine the need to apply a local anesthetic to reduce pain from venipunctures per the organization’s practice.
Determine the need for equipment to help localize the vein, such as a transilluminator, infrared light technology, or ultrasound machine.
Review the anatomy of the venous system and the organization’s practice for the preferred veins for venipuncture.
Review the manufacturer’s instructions for using a blood culture vacuum-extraction system or a syringe and needle for the collection.
Identify whether precautions or preconditions must be met before the blood cultures can be collected. Specimen timing can be affected by medication administration, nutritional intake, procedures, or diagnostic testing.
Review the practitioner’s orders for the number of blood culture specimen sets to be drawn and the time required between the venipuncture for each set. Compare them to the laboratory requisitions and labels.
Review the practitioner’s orders for blood specimens and any additional laboratory tests required during the venipuncture and compare them with the laboratory requisitions and labels. Use a bar-coding system if available.
Identify the appropriate laboratory culture tubes and bottles and validate the sequence in which the blood specimens are to be collected (if multiple specimens are required) and the volume required for each test with the laboratory.⁷
Gather supplies and equipment, including specimen labels, blood culture bottles and vascular visualization devices, if required, and bring them to the patient’s side.
1. Ensure that all equipment has been cleaned and disinfected using an Environmental Protection Agency (EPA)–registered disinfectant per the organization’s practice.
2. Ensure that all work surfaces used to hold blood specimen collection equipment, including chair arm extensions and tables, have been disinfected to protect the patient and the specimen from contamination.¹⁵
3. Ensure that the blood collection tubes’ expiration dates have not passed and that all equipment, bottles, and tubes are intact and free from defects or compromises.
4. Ensure that the bottles and tubes have been stored upright and at the correct temperature (e.g., tubes with some fixative agents require refrigeration).¹¹
5. Do not preassemble devices before patient identification.
6. Ensure that devices and systems for the blood collection process are from the same manufacturer.
Provide privacy for the patient.
Ensure that lighting is appropriate for observing vein contours and colors.
Raise or lower the bed or chair to a comfortable working height to prevent injury.
Assist the patient to a comfortable supine¹⁵ or low-recumbent position and have the patient remove gum, mints, or food from the mouth and discard in a trash receptacle.
Rationale: A low, supported position and an empty mouth reduce the risk of injury if the patient experiences lightheadedness or a seizure or faints from vagal stimulation.

Be prepared to manage venipuncture-associated vasovagal reactions for a patient who is at risk.
Perform hand hygiene and don gloves.
At the patient’s side, prepare or compare laboratory requisitions and computer-generated labels (if available). Compare the labels with the patient’s self-identification (per the organization’s practice) by having the patient confirm the spelling of the patient’s name and date of birth (when possible). Use computer-scanning verification, if available.
Do not draw blood if there is a discrepancy between the laboratory requisitions or labels and the patient’s identity.
Support the patient’s selected arm and extend it to form a straight line from the shoulder to the wrist. Place a small pillow or towel under the upper arm or place the arm on the arm extension of the chair.
Rationale: Correct patient positioning helps stabilize the patient’s arm.
Place a clean towel or paper drape under the patient’s arm.¹⁵
Identify the best sites for venipuncture per the organization’s practice, avoiding contraindicated sites.⁵
1. Choose a vein that is easily visible without applying a tourniquet.
  1. If IV fluid is being administered in one arm, choose a site on the opposite arm for blood specimen collection. If unable to locate a site on the arm opposite an IV infusion site, reevaluate for a venipuncture site distal to the IV infusion site.
    Consult with the clinical team leader, per the organization’s practice, about stopping the IV infusion for 30 seconds to 2 minutes before obtaining the blood specimen (as applicable).⁷
  2. Choose a vein that is straight and does not divert into another branch;¹⁵ that has no swelling, hematoma, phlebitis, infection, or infiltration; and that has not had recent venous access or venipuncture. Typically, the median cubital vein is the easiest to puncture because it lies between the muscles (Figure 2).¹⁵
2. Consider using ultrasonography, infrared light technology, or transillumination,³ per the organization’s practice, for a patient with veins that are difficult to locate by observation or palpation.
3. If needed, apply a single-use tourniquet proximal to and four to five finger widths from the insertion site.¹⁵ If the venipuncture site will be on the same arm as an IV infusion site, place the tourniquet between the IV infusion site and the intended venipuncture site.
  Rationale: A tourniquet blocks venous return to the heart from the arm, causing the veins to dilate for easier access.
  1. Encircle the patient’s arm and pull one end of the tourniquet tightly over the other, looping one end under the other (Figure 3) (Figure 4).
    Avoid using a tourniquet for a patient who has a history of bleeding, is easily bruised, has fragile skin, or has diminished circulation; however, if a tourniquet must be used, apply it loosely.
  2. Apply the tourniquet so that it can be removed by pulling one end with a single motion.
    Do not keep the tourniquet on the patient longer than 1 minute before the procedure is performed.⁷ Prolonged tourniquet application causes stasis, hemolysis, and hemoconcentration because of changes in the vascular endothelium from increased venous pressure and hypoxia.⁷
4. Palpate the selected vein for firmness and rebound (Figure 5).
  Rationale: A patent, healthy vein is elastic and rebounds on palpation. A thrombosed vein is rigid, rolls easily, and is difficult to puncture.¹⁵
  
  Do not use a vein that feels rigid or cordlike or one that rolls when palpated.
5. If the selected vein cannot be palpated or viewed easily, apply a warm compress over the arm for several minutes per the organization’s practice. If a tourniquet was deemed necessary, remove it and apply a warm compress for several minutes and then reapply the tourniquet.
  Rationale: Warming increases arterial blood flow, making veins more prominent.
  
  If unable to locate an acceptable vein after reapplying the tourniquet, consider using transillumination, infrared light technology, or ultrasonography, per the organization’s practice, to help locate an appropriately perfused vein before attempting venipuncture.
6. Quickly inspect the vein distal to the tourniquet to confirm the selected venipuncture site.
7. Release the tourniquet.
Apply a topical anesthetic as prescribed or per the organization’s practice to reduce the patient’s pain, as needed. Remove the anesthetic completely from the patient’s skin after the prescribed dwell time.
Remove gloves, perform hand hygiene, and don clean gloves.
Prepare the blood collection equipment using blood collection bottles, holders, needles, syringes, and transfer devices from the same system and manufacturer to prevent equipment incompatibility.
Rationale: Combining different manufacturers or systems for blood specimen collection equipment may cause injury to the patient or yield incorrect test results. Incompatibility of components may cause failure of the process.

Do not use pediatric culture bottles for adult blood specimens because smaller volumes diminish the yield of pathogens.
1. Choose an appropriate-size needle that is small enough to fit in the patient’s vein but will accommodate the prescribed therapy and the patient’s need.⁴
  1. Adults: 20 G to 24 G⁴
  2. Neonates, children, older adults, and patients with limited venous access options: 22 G to 26 G⁴
    Rationale: Needles that are 22 G or smaller minimize insertion-related trauma to the vein.⁴
2. Ensure that a double-ended straight needle or winged-butterfly needle with tubing and a safety device is securely attached to the vacuum-extraction system collection barrel.¹⁵ Alternatively, and if required, remove the sterile cap from the rubber sheathed end of the double-ended straight or winged-butterfly needle and attach the needle to the collection barrel. If a single-ended straight or winged-butterfly needle is used, attach the needle securely to a collection barrel housing a sheathed needle.
  Rationale: Safety devices can decrease the risk of needlestick injury by 75%.¹⁵
  
  Vacuum-extraction system sheathed needles are considered sharps that are associated with needlestick injuries, and they must be disposed of in a sharps container that is within arm’s reach and is large enough to allow disposal of the entire device without detaching the needle.¹⁵ The sheathed needle’s flexible cover prevents blood from flowing when the needle is not engaged in a vacuum tube; however, the sheath does not prevent a needlestick injury if a finger inadvertently enters the collection barrel.
  
  Use a new collection barrel for each patient. Do not detach the needle from the collection barrel for disposal after use.¹⁵
  
  Keep the needle hub and the connection sites sterile.
3. If using a vacuum-extraction system, position the culture bottles securely, upright, and close enough to the venipuncture site so that the tubing connected to the needle reaches from the selected vein to the culture bottle. Place the collection barrel over each culture bottle. Wait to puncture the rubber stopper with the sheathed needle.
  Rationale: Puncturing the stopper before the needle is in the vein causes the culture bottle to lose its vacuum.
  
  Do not contaminate the top of the bottle after it is prepared with alcohol.
4. If using a winged-butterfly or straight needle attached to a syringe, position the culture bottles securely upright and place a sterile transfer device housing a rubber-sheathed needle within reach.
  Rationale: The rubber-sheathed needle housed in the collection barrel is used to puncture the rubber top of the vacuum bottle. When the rubber top is punctured, the vacuum in the bottle extracts blood from the syringe.
  
  Do not contaminate the transfer device or the top of the bottle after it is prepared with alcohol.
Relocate the selected venipuncture site.
Prepare the venipuncture site.
1. Clean the skin with alcohol, then allow to dry completely.²
2. Prepare the insertion site with greater than 0.5% chlorhexidine in alcohol solution, using a back-and-forth motion for a minimum of 30 seconds,¹⁴ and allow to dry completely.²
  Do not touch the site after preparation unless sterile gloves are worn.
Disinfect culture bottle tops with 70% isopropyl alcohol (i.e., alcohol pad) and allow to dry completely.²
Obtain the blood culture specimens.
1. Relocate the selected venipuncture site. If a tourniquet is deemed necessary, reapply the tourniquet and locate the selected vein.
2. Remove the cap from the venipuncture needle, maintaining the needle’s sterility. Inform the patient to expect to feel a stick.
  If contamination occurs, discard the needle and the collection barrel or syringe in a sharps container and prepare a new venipuncture set.
3. Place the thumb or forefinger of the nondominant hand distal to the venipuncture site and gently stretch the patient’s skin distal to the site until it is taut and the vein is stabilized.
  Rationale: Gently stretching the patient’s skin helps stabilize the vein and prevents it from rolling during needle insertion.
4. Hold a butterfly needle (if used) by its wings; hold a straight needle (if used) at the hub. Insert the needle at a slight angle with the bevel up, just distal to the selected site.²
  Rationale: The smallest and sharpest point of the needle should puncture the skin first to reduce the chance of penetrating the sides of the vein during insertion. Keeping the bevel up causes less trauma to the vein. Entering the skin distal to the vein prevents unanticipated vein puncture, which may result in inadequate blood specimen retrieval and hematoma.
5. Slowly insert the needle into the patient’s vein (Figure 6). If using a butterfly needle, look for blood return in the tubing of the butterfly setup.
  Rationale: Inserting the needle slowly prevents puncture through the opposite side of the vein.
  
  To avoid false positive results when obtaining blood cultures via a venipuncture, discard a volume of blood, per the organization’s practice, before filling the blood culture bottles.⁷
Transfer the blood specimen into the culture bottles.
1. Butterfly-winged needle device method
  1. Place a safety device on the syringe and distribute the blood volume evenly between the two culture bottles. Ensure that there is 10 ml for each blood culture bottle.⁷
    1. Fill the culture bottles in order per the organization’s practice.
      Do not underfill or overfill the culture bottles because this can adversely affect the laboratory test results.
    2. Without dislodging the needle from the patient’s vein, push the attached collection barrel onto the prepared culture bottle by inserting the sheathed needle through the rubber stopper so that the vacuum pulls the blood into the bottle. Collect 10 ml of blood into each culture bottle.⁷
      Observe the rapid flow of blood into the bottle. Failure of blood to appear indicates that the vacuum is lost or that the needle is not in the vein.
      
      Avoid overfilling the culture bottle, which may cause a false-positive result.
    3. Detach the collection barrel and insert the sheathed needle through the rubber stopper of the prepared culture bottle. Ensure that the culture bottle receives 10 ml of blood.⁷
      If an insufficient amount of blood is drawn, inoculate the aerobic culture bottle with the required amount and then inoculate the anaerobic culture bottle with the remaining volume of blood.
  2. Detach the collection barrel after the culture bottle is filled with 10 ml of blood.⁷
  3. If additional blood specimens are required for other laboratory tests, insert additional blood collection tubes into the collection barrel and engage the sheathed needle, as needed. If the blood collection tubes contain additives, gently invert them back and forth immediately after they are filled with blood. Follow the manufacturer’s instructions for the number of inversions.
    Rationale: Inverting the blood collection tube gently ensures that the additives are properly mixed and prevents erroneous test results.
    
    Do not shake the blood collection tube.
    
    Rationale: Shaking may cause lysis of cells, resulting in inaccurate test results.
  4. If the blood is flowing sufficiently into the blood culture bottles or tubes and a tourniquet was used, release the tourniquet just before filling the last blood collection tube. If blood flow is slow, and a tourniquet was used, wait to release the tourniquet until the last bottle or tube is almost full. Fill the last tube and remove it from the collection barrel.
    Rationale: Releasing the tourniquet before filling the last blood specimen tube reduces bleeding at the site when the needle is withdrawn.
  5. Apply a sterile 2 × 2-inch gauze pad over the venipuncture site without applying pressure. Quickly but carefully withdraw the needle from the patient’s vein, activating the safety mechanism to help prevent an accidental needlestick injury.⁴
    Rationale: Applying pressure over the needle can cause discomfort and injury to the patient. Carefully removing the needle minimizes discomfort and vein trauma.
  6. Immediately apply pressure over the venipuncture site with the gauze pad until bleeding stops. Observe the site for hematoma or bleeding. Instruct the patient to help apply pressure if the patient is able.
    Rationale: Direct pressure minimizes bleeding and prevents hematoma formation. A hematoma may cause compression and nerve injury.
    
    For a patient who has a bleeding disorder or who is undergoing anticoagulant therapy, hold pressure for several minutes, as needed, until the bleeding stops.
  7. Observe the venipuncture site for bleeding before applying tape or a bandage. Use tape or a bandage to secure the gauze pad in place.
    Rationale: Applying gauze with tape or a bandage keeps the venipuncture site clean and controls any final oozing.
    
    Instruct the patient not to bend the arm of the venipuncture site.
2. Needle and syringe method
  To avoid false positive results when obtaining blood cultures via a venipuncture, discard a volume of blood, per the organization’s practice, before filling the blood culture bottles.⁷
  1. Gently aspirate 16 to 20 ml¹³ of blood from the venipuncture site in an appropriate-size syringe, ensuring 10 ml for each blood culture bottle (Figure 7).⁷
    Carefully evaluate the patient for the potential for venous collapse when using a syringe barrel that is 10 ml or larger.¹⁵ Consider that young children, older adults, and those who have received treatments that are damaging to the veins may not be able to withstand high pressure or may require a smaller syringe barrel.
  2. If the blood is flowing sufficiently into the blood culture bottle or syringe, and a tourniquet was used, release the tourniquet just before filling the bottle or syringe.
    Rationale: Releasing the tourniquet before the last of the blood is drawn reduces bleeding at the site when the needle is withdrawn.
  3. Apply a sterile 2 × 2-inch gauze pad over the venipuncture site without applying pressure. Quickly but carefully withdraw the needle from the vein, activating the safety mechanism to help prevent an accidental needlestick injury.
    Rationale: Applying pressure over the needle can cause discomfort and injury to the patient. Carefully removing the needle minimizes discomfort and vein trauma.
  4. Immediately apply pressure over the venipuncture site with the gauze pad until bleeding stops (Figure 8). Observe the site for hematoma or bleeding. Instruct the patient to help apply pressure if the patient is able.
    Rationale: Direct pressure minimizes bleeding and prevents hematoma formation. A hematoma may cause compression and nerve injury.
    
    For a patient who has a bleeding disorder or who is undergoing anticoagulant therapy, hold pressure for several minutes, as needed, until the bleeding stops.
  5. Observe the venipuncture site for bleeding before applying tape or a bandage. Use tape or a bandage to secure the gauze pad in place.
    Rationale: Applying gauze with tape or a bandage keeps the venipuncture site clean and controls oozing.
    
    Instruct the patient not to bend the arm of the venipuncture site.
  6. Distribute the blood volume evenly between the culture bottles without replacing the needle.² If both anerobic and aerobic samples are needed, fill the culture bottles in order per the organization’s practice.
    1. Keep the bottle and syringe upright and inoculate the culture bottle, ensuring that no air is transferred from the syringe into the bottle.
      After skin antisepsis, the volume of blood is the next most important variable affecting the sensitivity of detection of bacteria and fungi in the blood.
    2. Inoculate the culture bottle with 10 ml for the most accurate results.⁷
Immediately discard the remaining sharp devices, including the collection barrel and transfer device, into an easily accessible sharps container.
Rationale: Transfer devices and sheathed needles are considered sharps that are associated with needlestick injuries, and they must be disposed of in a sharps container. The sheathed needle’s flexible cover prevents blood from flowing when the needle is not engaged in a vacuum tube; however, the sheath does not prevent a needlestick injury if a finger inadvertently enters the collection barrel.¹⁰

Do not recap needles or attempt to remove the needle from the collection barrel.¹⁰
Repeat the blood specimen collection sequence for a second set of blood cultures. Blood culture sets are usually drawn in immediate succession.
Rationale: Unless ordered by the practitioner or per the laboratory’s practice, blood cultures should be obtained from at least two separate blood draws from two separate peripheral sites.⁷
Gently mix the culture broth and blood in the culture bottles.
Rationale: Mixing gently blends the medium and the blood.
Examine the culture bottles for signs of external contamination with blood. Decontaminate the blood culture bottles, if necessary, per the laboratory’s practice.
Rationale: Decontamination prevents cross-contamination and reduces the risk for exposure to blood-borne pathogens.
Assist the patient to a comfortable reclining position for several minutes.
In the presence of the patient, label the specimens per the organization’s practice.⁹
Place the labeled specimens in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
Observe the patient for tolerance of the venipuncture, including signs of anxiety or fear.
Rationale: Documenting the patient’s response allows for improved care and planning for future venipunctures.
Reevaluate the venipuncture site to determine whether bleeding has stopped or a hematoma has formed.
Report adverse events in an organization-approved occurrence reporting system.¹⁵
Assess, treat, and reassess pain.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.

EXPECTED OUTCOMES

Venipuncture is successful without nerve or adjacent tissue injury.
Aseptic technique is maintained.
Venipuncture site shows no evidence of continued bleeding or hematoma after blood specimen collection.
Patient tolerates procedure with minimal anxiety, fear, or discomfort.
All required laboratory blood specimens are collected, and accurate results are obtained.

UNEXPECTED OUTCOMES

Hematoma forms at venipuncture site.
Infection or phlebitis develops at venipuncture site.
Nerve or adjacent tissue injury occurs.
Patient has vasovagal response, including dizziness, fainting, or loss of consciousness.
Hemostasis is not achieved.
Blood culture has a false-positive result.
Blood culture specimen is inadequate for testing and cannot be processed.
Aseptic technique is not maintained.
Needlestick injury occurs.

DOCUMENTATION

Date and time of venipuncture, number and location of attempts, and name and credentials of person performing procedure
Blood cultures obtained and disposition of specimens
Location and description of venipuncture site
Volume of blood drawn for a pediatric patient, a patient undergoing frequent blood sampling, or a patient with anemia
Blood culture results communicated to the clinical team leader per the organization’s practice
Inability to obtain blood cultures, if unsuccessful
Education
Patient’s tolerance of venipuncture
Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

Take the time to develop rapport and trust with a pediatric patient before beginning any invasive procedure. Include the family; if the family demonstrates trust, the patient will be less anxious.
Use appropriate-size vacuum bottles or tubes and vacuum strength. Large tubes with full vacuum may exert too much pressure on a pediatric patient’s vein.¹¹
Use distraction techniques or the assistance of a child life specialist to assist with pain management.
Encourage the pediatric patient’s family to remain present during the procedure.
When performing venipuncture on a pediatric patient, consider a variety of age-appropriate, organization-approved veins, such as the scalp, antecubital fossa, and saphenous and hand veins.
Follow the organization’s practice for use of chlorhexidine gluconate on neonates.
Minimum and ideal volumes for blood culture specimens for a neonate and child vary based on weight.¹⁵
When collecting a blood culture specimen in a pediatric patient, fill the culture bottles in order per the organization’s practice. If there is insufficient blood for both bottles, fill only the aerobic bottle.²
Use appropriate developmental approaches:
- Infants: Swaddle with the selected limb exposed.
- Toddlers and preschool-age patients: Avoid opening supplies or showing the patient the needle before the procedure.
- School-age patients:
  - Show them the selected supplies.
  - Allow them to touch or handle safe supplies.
  - Demonstrate the procedure on a doll.
  - Use bandages to help reassure the patient that blood and organs will not leak out.

OLDER ADULT CONSIDERATIONS

Older adults have fragile veins that are easily traumatized during venipuncture. Applying a warm compress may help with obtaining a blood sample. Using a small-gauge needle may also help.
The appropriate-size vacuum bottles or tubes and vacuum strength should be used. Large tubes with full vacuum may exert too much pressure on an older adult’s vein.
An older adult may not be able to withstand vacuum-system pressure or may require a smaller tube. Pressure from larger tubes may cause vein wall damage, leading to infiltration.

REFERENCES

Dean, A.J., Lee, D.C. (2019). Chapter 67: Bedside laboratory and microbiological procedures. In J.R. Roberts and others (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (7th ed., pp. 1442-1469). Philadelphia: Elsevier.
Doern, V.G. and others. (2019). A comprehensive update on the problem of blood culture contamination and a discussion of methods for addressing the problem. Clinical Microbiology Reviews, 33(1), e00009-e00019. Doi:10.1128/CMR.00009-19 Retrieved May 12, 2023, from https://magnolia-medical.com/wp-content/uploads/2020/10/Doern_Blood-Culture-Contamination-Review-Call-to-Action_CMR_January-2020-1.pdf (Level I)
Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 22: Vascular visualization. Journal of Infusion Nursing, 44(Suppl. 1), S63-S65. (Level I)
Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 26: Vascular access device planning. Journal of Infusion Nursing, 44(Suppl. 1), S74-S81. (Level I)
Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 27: Site selection. Journal of Infusion Nursing, 44(Suppl. 1), S81-S86. (Level I)
Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 33: Vascular access site preparation and skin antisepsis. Journal of Infusion Nursing, 44(Suppl. 1), S96. (Level I)
Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 44: Blood sampling. Journal of Infusion Nursing, 44(Suppl. 1), S125-S133. (Level I)
Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 55: Catheter-associated skin injury. Journal of Infusion Nursing, 44(Suppl. 1), S168-S170. (Level I)
Joint Commission, The. (2023). National Patient Safety Goals for the ambulatory health care program. Retrieved May 12, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_ahc_jan2023.pdf (Level VII)
Occupational Safety and Health Administration (OSHA). (n.d.). Patient care unit: Needlesticks/sharps injuries. Retrieved May 12, 2023, from https://www.osha.gov/etools/hospitals/patient-care-unit/needlestick-sharps-injuries (Level VII)
Pagana, K.D., Pagana, T.J., Pagana, T.N. (2021). Chapter B: Blood culture and sensitivity. In Mosby’s diagnostic and laboratory test reference (16th ed., pp. 122-176). St. Louis: Elsevier.
Warekois, R.S., Robinson, R., Primrose, P.B. (2020). Chapter 11: Preanalytic variables and venipuncture complications. In Phlebotomy: Worktext and procedures manual (5th ed., pp. 176-193). St. Louis: Elsevier.
Warekois, R.S., Robinson, R., Primrose, P.B. (2020). Chapter 14: Special collections and procedures. In Phlebotomy: Worktext and procedures manual (5th ed., pp. 218-233). St. Louis: Elsevier.
Wilson, M. and others. (2022). Chapter 3: Preexamination activities. In M47: Principles and procedures for blood cultures (2nd ed., pp. 15-19). Malvern, PA: Clinical and Laboratory Standards Institute.
World Health Organization (WHO). (2010). WHO guidelines on drawing blood: Best practices in phlebotomy. Retrieved May 12, 2023, from https://apps.who.int/iris/bitstream/handle/10665/44294/9789241599221_eng.pdf?sequence=1&isAllowed=y (classic reference)* (Level VII)
Zhu, Y. and others. (2018). Vapocoolant spray versus placebo spray/no treatment for reducing pain from intravenous cannulation: A meta-analysis of randomized controlled trials. American Journal of Emergency Medicine, 36(11), 2085-2092. doi:10.1016/j.ajem.2018.03.068

ADDITIONAL READINGS

Chela, H.K. and others. (2019). Approach to positive blood cultures in the hospitalized patient: A review. Missouri Medicine, 116(4), 313-317.

*In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

Level I - Systematic review of all relevant randomized controlled trials
Level II - At least one well-designed randomized controlled trial
Level III - Well-designed controlled trials without randomization
Level IV - Well-designed case-controlled or cohort studies
Level V - Descriptive or qualitative studies
Level VI - Single descriptive or qualitative study
Level VII - Authority opinion or expert committee reports