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Dec.04.2020View related content

Specimen Collection: Blood Cultures (Ambulatory) - CE

ALERT

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

Strictly adhere to guidelines for hand hygiene, standard precautions, and site preparation to minimize the risk for a health care–associated infection.13

Draw specimens for a blood culture before administering antibiotics.

Label blood specimens immediately after collection and in the presence of the patient.11,13

Take extra care with a patient who takes medications that increase the risk for bleeding.13

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.4

OVERVIEW

A blood culture specimen requires 20 to 30 ml1 of blood drawn at one time from one location. 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 on antibiotics at the time cultures are obtained, the laboratory should be notified because an additive can be applied to the culture medium to negate the antibiotic's effect.17 Typically, two sets of blood cultures are ordered, each with one aerobic bottle and one anaerobic bottle. Orders regarding the spacing of the specimens may vary among practitioners and organizations.

Drawing at least two sets of blood cultures and obtaining cultures from two different sites is important.17 If one of the cultures produces bacteria and the other culture does not, assuming that the bacteria in the first culture may be a contaminant and not the infecting agent is safe.17 When both cultures grow the infecting agent, bacteremia exists and is a result of the organism that is growing in the culture.

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.

Blood culture specimens are usually drawn using either a needle and syringe or a vacuum extraction blood-sampling system that draws blood into vacuum-sealed test bottles. In both cases, a hollow-bore needle is inserted into the lumen of a vein to obtain the specimen. Straight needles from 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.

The correct amount of blood required by the laboratory must be extracted into each bottle to ensure accurate results and decrease the patient's risk of anemia.11 If more than one 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 vein's integrity is essential. A patient with veins that may collapse or become injured from the vacuum pressure may require an alternative method of specimen collection. In addition, 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 specimen collection. Transillumination and ultrasonography may be available to aid with detecting veins that are otherwise impalpable or difficult to see.8

Tourniquets should be used with caution. To obtain valid results, the tourniquet should not be applied for longer than 1 minute.11 Prolonged tourniquet application can cause stasis and hemoconcentration.11 Infection-control standards require that tourniquets be single-use.10 Contamination from Staphylococcus aureus with reused tourniquets is common.21

Venipuncture can be painful, and a patient may experience anxiety or fear before the procedure. For some patients, particularly children, just the appearance of a needle is frightening. 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.2 Anxiety may be eased by communicating with the patient about how to help relieve his or her concerns.

SUPPLIES

Click here for a list of supplies.

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 after the needle is withdrawn. Explain that the patient may apply pressure if he or she is able. If the patient has a bleeding disorder or is undergoing anticoagulant therapy, explain that pressure may have to be applied for a longer time to achieve clotting.
  • Teach the patient the signs and symptoms of recurrent bleeding (e.g., expanding hematoma) and instruct him or her on when to seek additional care.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves and PPE as indicated for needed isolation precautions.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Ensure that laboratory results are communicated to the clinical team leader per the organization's practice.
  6. Determine whether antibiotics have been administered before 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. 17
    If cultures are to be performed while the patient is on antibiotics, take the specimen shortly before the next antibiotic dose.17
  7. 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.
  8. Review the patient's history of venipunctures and ask about signs of adverse responses to previous venipunctures, including a vagal response.11
  9. Determine the patient's ability to cooperate with the procedure and his or her experience with blood specimen collection (e.g., anxiety or fear related to the procedure).
  10. Determine the need to apply a local anesthetic to reduce pain per the organization's practice for blood culture specimen venipunctures.
  11. Ask the patient about an allergy or sensitivity to antiseptic or analgesic agents or latex, if latex is used in any equipment (e.g., collection barrels, sheathed needles, tourniquets, bandages, specimen tube tops, gloves).21
    Replace latex equipment with nonlatex equipment if the patient has a latex allergy.
  12. Evaluate the patient for sites contraindicated for venipuncture, such as the presence of IV access; a hematoma; signs of phlebitis or previous infiltration at the potential site; a 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 access site.11
  13. Determine the patient's hydration and perfusion status.
  14. Determine the need for equipment to help localize the vein, such as a transilluminator or ultrasound machine.
  15. Review the anatomy of the venous system and the organization's practice for the preferred veins for venipuncture.
  16. Review the manufacturer's instructions for using a blood culture vacuum-extraction system or a syringe and needle for the collection. If drawing blood from a central line, review the manufacturer's instructions for the central venous access device (CVAD), including the connector caps, proper syringe size for flushing and aspiration, and port clamping.
  17. Determine whether precautions or preconditions must be met before collecting blood cultures. Specimen timing can be affected by medication administration, nutritional intake, procedures, or diagnostic testing.
  18. Review 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.
  19. Identify the appropriate laboratory tubes and bottles and validate the sequence in which the specimens are to be collected (if multiple specimens are required) and the volume required for each test with the laboratory.
    1. Plan to aspirate only the amount needed to avoid blood loss.11
    2. Plan to obtain all ordered blood specimens at one time, if possible, to minimize entries into the bloodstream and the risk of infection.11
  20. Identify special requirements for the laboratory specimen.
  21. Review the laboratory requirements for labeling and handling of the specimens.
  22. Gather supplies and equipment, including specimen bottles and labels and an ultrasound machine or transilluminator, if required. Two culture bottles (one aerobic and one anaerobic) are required for each set of cultures.17
    1. Ensure that all equipment has been cleansed and disinfected using an Environmental Protection Agency (EPA)–registered disinfectant per the organization's practice.7
    2. Ensure that all work surfaces used to hold blood-drawing equipment, including chair arm extensions and tables, have been disinfected to protect the patient and the specimen from contamination.21
    3. Ensure that tube expiration dates have not passed and that all equipment and tubes are intact and free from defects or compromises.3
    4. Ensure that tubes have been stored upright and at the correct temperature (i.e., some fixative agents require refrigeration).17
    5. Do not preassemble devices before patient identification.3
    6. Ensure devices for the blood collection process are from the same manufacturer.6
  23. Provide privacy for the patient.
  24. Ensure that lighting is appropriate for observing vein contours and colors.
  25. Raise or lower the bed or chair to a comfortable working height to prevent injury.
  26. Assist the patient to a comfortable supine21 or low-recumbent position and have him or her remove gum, mints, or food from the mouth and discard in a trash receptacle.3 If drawing blood from a CVAD, position the patient so the device is exposed.
    Rationale: A low, supported position and an empty mouth 3 reduce the risk of injury to the patient if he or she experiences lightheadedness, faints from vagal stimulation, or experiences a seizure.
  27. Be prepared to manage venipuncture-associated vasovagal or seizure21 reactions for a patient who is at risk.11
  28. Perform hand hygiene and don gloves and PPE as indicated for needed isolation precautions.
  29. Prepare or compare laboratory requisitions and computer-generated labels with the patient by reading at least two identifiers (per the organization's practice) and having the patient confirm the spelling of his or her full name and date of birth (when possible).3 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.3
    1. Blood culture sets are usually drawn in immediate succession.
    2. Blood specimens should be obtained from different peripheral sites.17
  30. Indicate the volume of blood needed for each test on the label on each bottle. Typically, the required amount is a minimum of 10 ml of blood for each bottle.18
  31. 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: Proper patient positioning helps stabilize the arm.
  32. Place a clean cloth or paper drape under the patient's arm.21
  33. Identify the best sites for venipuncture per the organization's practice, avoiding contraindicated sites, such as the presence of IV access.
    1. Choose a vein that is easily visible without applying a tourniquet.
      Avoid the use of a tourniquet, if possible. 10
      1. If IV fluid is being administered in one arm, choose a site on the opposite arm for blood specimen collection.5 If unable to locate a site in the arm opposite an IV infusion site, reevaluate for a venipuncture site distal to the IV infusion site.5
        Consult with the clinical team leader per the organization's practice to stop the IV infusion for 2 minutes before obtaining the blood specimen as applicable.5
      2. Choose a vein that is straight and does not divert into another branch21 and has no swelling, hematoma, recent venous access or venipuncture, phlebitis, infection, or infiltration. Typically, the median cubital vein is the easiest to puncture because it lies between muscles (Figure 1)Figure 1.21
    2. Consider using ultrasonography or transillumination, per the organization's practice, for a patient with veins that are difficult to locate by observation or palpation.
    3. Apply a single-use tourniquet four to five finger widths above the selected venipuncture site.21 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.5
      Rationale: A tourniquet blocks venous return to the heart from the arm, causing the veins to dilate for easier assessment.
      1. Encircle the arm and pull one end of the tourniquet tightly over the other, looping one end under the other (Figure 2)Figure 2 (Figure 3)Figure 3.
        A tourniquet should not be used on 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.11 Prolonged tourniquet application causes stasis, hemolysis, and hemoconcentration because of changes in the vascular endothelium from increased venous pressure and hypoxia.11
    4. Palpate the selected vein for firmness and rebound (Figure 4)Figure 4.
      Rationale: A healthy vein is elastic and rebounds on palpation. A thrombosed vein is rigid, rolls easily, and is difficult to puncture.
      Do not use a vein that feels rigid or cordlike or one that rolls when palpated.
    5. Instruct the patient to make a fist without vigorously opening and closing the fist.
      Rationale: Making a fist facilitates the distention of veins by forcing blood up from the distal veins. Vigorously opening and closing the fist may cause pseudohyperkalemia. 9
    6. If the selected vein cannot be palpated or viewed easily, remove the tourniquet, apply a warm compress over the arm for several minutes (per the organization's practice), and reapply the tourniquet.
      Rationale: Warming increases arterial blood flow, making veins more prominent.
      If unable to locate an acceptable vein after reapplying the tourniquet, use transillumination or ultrasonography, per the organization's practice, to help locate an appropriately perfused vein before attempting venipuncture.
    7. Quickly inspect the vein distal to the tourniquet to confirm the selected venipuncture site.
      Do not select a vein on the ventral surface of the wrist.9
    8. Release the tourniquet.
  34. Apply a topical anesthetic as prescribed or per the organization's practice to reduce pain. Remove the anesthetic completely from the skin after the prescribed dwell time.
  35. Prepare the collection equipment using bottles, holders, needles, syringes (if necessary), and transfer devices from the same system and manufacturer.6
    Rationale: Combining systems may cause injury to the patient or yield incorrect test results because of hemolysis, needle disengagement, or inadequate tube filling. Incompatibility of components may cause failure of the process. 6
    Do not use pediatric culture bottles for adult blood samples because smaller volumes diminish the yield of pathogens.
    1. Choose an appropriate-size needle that is small enough to fit in the vein but will not cause hemolysis.
      1. Adults: 21 G to 23 G21
      2. Children, older adults, or patients with small veins: 22 G to 23 G21
      3. Neonates: 23 G21
        Rationale: Hemolysis may disrupt specimens drawn after blood culture specimens are drawn during the same venipuncture. Needles that are 23 G or smaller increase the risk of hemolysis. 21 If the needle is too large for the vein, it tears the vein and causes bleeding. 21
    2. If using a winged-butterfly needle system, ensure that the venipuncture needle with tubing21 and a safety device is securely attached to the vacuum-extraction system collection barrel. Alternatively, and if required, remove the sterile cap from the rubber sheathed end of the winged-butterfly needle tubing and make the Luer-lock connection of the sheathed needle and the collection barrel. If a single-ended, winged-butterfly needle with tubing is used, make the Luer-lock connection between the needle and the collection barrel housing of a sheathed needle.
      Keep the needle hub and the connection sites sterile.
      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.21 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.21
    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 upright bottle. Rest the collection barrel over the aerobic bottle. Wait to puncture the rubber stopper with the sheathed needle.
      Rationale: Puncturing the stopper before the needle is in the vein causes the tube 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.
  36. Relocate the selected venipuncture site.
  37. Prepare the venipuncture site.
    1. Cleanse the skin with alcohol, then allow to dry completely.18
    2. Prepare the insertion site with greater than 0.5% chlorhexidine in alcohol solution,10,16 using a back-and-forth motion for a minimum of 30 seconds,12 and allow to dry completely.
      Use chlorhexidine cautiously because it may cause skin irritation and chemical burns in infants less than 2 months old or infants with compromised skin integrity (premature infants).10
    3. Disinfect culture bottle tops with 70% isopropyl alcohol (i.e., alcohol pad).18
  38. Obtain the blood cultures.
    1. Locate the selected venipuncture site. If a tourniquet is deemed necessary, reapply the tourniquet and locate the vein.
    2. Remove the cap from the venipuncture needle, maintaining the needle's sterility. Inform the patient that he or she will 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 by the wings; hold a straight needle attached to a syringe at the hub. Insert the needle at a 30-degree angle with the bevel up, just distal to the selected site.3
      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 vein (Figure 5)Figure 5.
      Rationale: Inserting the needle slowly prevents puncture through the opposite side of the vein.
  39. Transfer the specimen to 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, ensuring a minimum of 10 ml for each bottle.20 Fill the aerobic bottle first.20
        When using the butterfly method, collect the aerobic sample first and then collect the anaerobic sample. There is air in the butterfly tube that can expose the sample, so the opposite collection order is used for this method. Be sure to label the samples to reflect the order of collection. 20
        1. Without dislodging the needle from the vein, push the attached collection barrel onto the prepared aerobic culture bottle by inserting the sheathed needle through the rubber stopper so the vacuum pulls the blood into the bottle. Collect a minimum of 10 ml of blood into the aerobic bottle.1
          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, which may cause a false-positive result.
        2. Detach the collection barrel and insert the sheathed needle through the rubber stopper of the prepared anaerobic bottle. Collect a minimum of 10 ml of blood into the anaerobic bottle.1
          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.5
      2. Detach the collection barrel after the anaerobic bottle is filled with 10 ml.1
      3. If additional blood specimens are required for other laboratory tests, insert additional specimen tubes into the collection barrel and engage the sheathed needle, as needed. After tubes that contain additives are filled with blood, gently turn them up and down immediately.
        Keep the bottles upright to prevent a backflow of broth into the patient's vein.
        Blood does not flow out of the collection barrel needle when it is detached from the bottles because the rubber sheath stops the flow of blood.
      4. If the blood flows sufficiently into the bottles or tubes, release the tourniquet just before filling the last specimen tube or syringe. If blood flow is slow, wait to release the tourniquet until the last bottle or tube is almost full.
        Rationale: Releasing the tourniquet before filling the last specimen tube reduces bleeding at the site when the needle is withdrawn.
      5. Apply a sterile 2 × 2-in gauze pad over the venipuncture site, but do not apply pressure. Quickly but carefully withdraw the needle from the vein, activating the safety mechanism to help prevent an accidental needlestick injury.6
        Rationale: Applying pressure over the needle can cause discomfort and injury. Carefully removing the needle minimizes discomfort and vein trauma.
      6. Immediately apply pressure over the venipuncture site with gauze until bleeding stops.
        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 is undergoing anticoagulant therapy, hold pressure for several minutes, as needed, until the bleeding stops.
        Do not use a cotton ball or a rayon ball when applying pressure because of the potential for dislodging the platelet plug at the venipuncture site.3
      7. Observe the venipuncture site for bleeding for 5 to 10 seconds before applying a bandage.3 Use tape or a bandage to secure the gauze and allow it to remain in place for at least 15 minutes.3
        Rationale: Applying gauze with tape or a bandage keeps the venipuncture site clean and controls any final oozing.
        Instruct the patient not to bend his or her arm.
    2. Needle and syringe method
      1. Gently aspirate 20 ml of blood from the site in an appropriate-size syringe (Figure 6)Figure 6.
        Carefully evaluate the patient for the potential for venous collapse when using a syringe barrel that is 10 ml or larger.21 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, release the tourniquet just before filling the 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-in gauze pad over the venipuncture site, but do not apply pressure. Quickly but carefully withdraw the needle from the vein, activating the safety mechanism to help prevent an accidental needlestick injury.6
        Rationale: Applying pressure over the needle can cause discomfort and injury. Carefully removing the needle minimizes discomfort and vein trauma.
      4. Immediately apply pressure over the venipuncture site with gauze until bleeding stops (Figure 7)Figure 7.
        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 is undergoing anticoagulant therapy, hold pressure for several minutes, as needed, until the bleeding stops.
        Do not use a cotton ball or a rayon ball when applying pressure because of the potential for dislodging the platelet plug at the venipuncture site.3
      5. Observe the venipuncture site for bleeding for 5 to 10 seconds before applying a bandage.3 Apply gauze with tape or a bandage for at least 15 minutes.3
        Rationale: Applying gauze with tape or a bandage keeps the venipuncture site clean and controls oozing.
        Instruct the patient not to bend his or her arm.
      6. Distribute the blood volume evenly between the culture bottles without replacing the needle. If both anerobic and aerobic samples are needed, fill the anaerobic culture bottle first.18
        1. Keep the bottle and syringe upright and inoculate the anaerobic bottle first, ensuring that no air is transferred from the syringe into the anaerobic bottle.
          Rationale: Transferring from the syringe alters the bottle's anaerobic environment. If the bottle and syringe are held upright, air near the syringe plunger should not enter the anaerobic culture bottle.
          After skin antisepsis, the volume of cultured blood is the next most important variable affecting the sensitivity of detection of bacteria and fungi in the blood.
        2. Inoculate the aerobic culture bottle with a minimum of 10 ml for the most accurate results.1
  40. Immediately discard the remaining sharp devices, including the collection barrel and transfer device, into an easily accessible sharps container.3
    Rationale: Discarding the collection barrel, needle, and tubing prevents cross-contamination from needlesticks and contact with blood.
    Do not recap needles or attempt to remove the needle from the collection barrel.15
  41. Repeat the 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 on the same day or consecutive days and with two separate site preparations. 18
  42. Gently mix the culture broth and blood in the bottles.
    Rationale: Mixing gently blends the medium and the blood.
  43. Examine the culture bottles for signs of external contamination with blood. Decontaminate the bottles, if necessary, per the laboratory's practice.
    Rationale: Decontamination prevents cross-contamination and reduces the risk for exposure to blood-borne pathogens.
  44. Assist the patient to a comfortable reclining position for several minutes.
  45. Prepare the specimens for the laboratory.
    1. In the presence of the patient, label the specimens per the organization's practice.13
    2. Prepare the specimens for transport.
    3. Place the labeled specimens in a biohazard bag.
  46. Transport the specimens to the laboratory per the organization's practice.
  47. 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.
  48. Observe the venipuncture site to determine whether bleeding has stopped or a hematoma has formed.
  49. Discard supplies, remove PPE, and perform hand hygiene.
  50. Document the procedure in the patient's record.

EXPECTED OUTCOMES

  • Venipuncture is successful on initial attempt.
  • Aseptic technique is maintained.
  • Venipuncture site shows no evidence of continued bleeding or hematoma after specimen collection.
  • Patient tolerates procedure with minimal anxiety, fear, or discomfort.
  • All required laboratory 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.
  • Specimen has a false-positive result.
  • Laboratory 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
  • Specimens obtained and their disposition
  • Location and description of venipuncture site
  • Volume of blood drawn for a child, a patient undergoing frequent blood sampling, or a patient with anemia
  • Abnormal laboratory test results and related interventions
  • Laboratory results communicated to the clinical team leader per the organization's practice
  • Inability to obtain sample
  • Patient education
  • Patient's tolerance of venipuncture
  • Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

  • The procedure should be explained to the child in a manner that is consistent with his or her developmental level. Atraumatic care should be provided.14
  • Appropriate-size vacuum bottles or tubes and vacuum strength should be used. Large tubes with full vacuum may exert too much pressure on a child's vein.17
  • Distraction techniques or the assistance of a child-life specialist should be used to assist in pain management.
  • Before performing a venipuncture on a child, several age-appropriate, organization-approved veins, such as the scalp, antecubital fossa, saphenous, and hand veins should be considered.
  • The organization's practice should be followed for use of chlorhexidine gluconate on neonates.
  • Minimum and ideal volumes for blood culture specimens for neonates and children vary based on their weight.19
  • When a blood culture specimen is collected from a child, the aerobic bottle should be filled first and then the anaerobic bottle. If there is insufficient blood for both bottles, only the aerobic bottle should be filled.

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

  1. Barie, P.S. (2017). Chapter 11: Blood cultures: Surgical infections and antibiotic use. In C. Townsend and others (Eds.), Sabiston textbook of surgery: The biological basis of modern surgical practice (20th ed., pp. 241-280). St. Louis: Elsevier.
  2. Dalvandi, A. and others. (2017). Comparing the effectiveness of vapocoolant spray and lidocaine/procaine cream in reducing pain of intravenous cannulation: A randomized clinical trial. American Journal of Emergency Medicine, 35(8), 1064-1068. doi:10.1016/j.ajem.2017.02.039 (Level II)
  3. Ernst, D.J. and others. (2017). Chapter 2: Blood specimen collection process. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 5-30). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
  4. Ernst, D.J. and others. (2017). Chapter 4: Complications. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 35-41). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
  5. Ernst, D.J. and others. (2017). Chapter 5: Special situations. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 41-48). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
  6. Ernst, D.J. and others. (2017). Chapter 6: Quality management system elements. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 49-60). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
  7. Infusion Nurses Society (INS). (2016). Infection prevention and safety compliance. In Policies and procedures for infusion therapy (5th ed., pp. 28-41). Norwood, MA: INS. (Level VII)
  8. Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 22: Vascular visualization. Journal of Infusion Nursing, 39(Suppl. 1), S44-S45. (Level VII)
  9. Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 27: Site selection. Journal of Infusion Nursing, 39(Suppl. 1), S54-S56. (Level VII)
  10. Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 33: Vascular access site preparation and device placement. Journal of Infusion Nursing, 39(Suppl. 1), S64-S67. (Level VII)
  11. Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 43: Phlebotomy. Journal of Infusion Nursing, 39(Suppl. 1), S85-S91. (Level VII)
  12. Infusion Nurses Society (INS). (2016). Therapeutic phlebotomy. In Policies and procedures for infusion therapy (5th ed., pp. 252-255). Norwood, MA: INS. (Level VII)
  13. Joint Commission, The. (2020). National patient safety goals for the ambulatory health care program. Retrieved November 18, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_ahc_jul2020.pdf (Level VII)
  14. Mondozzi, M.A., Urdiales Baker, R.A., Hockenberry, M.J. (2019). Chapter 23: The child with fluid and electrolyte imbalance. In M. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong's nursing care of infants and children (11th ed., pp. 736-777). St. Louis: Elsevier.
  15. Occupational Safety and Health Administration (OSHA). (n.d.). Healthcare wide hazards: Needlesticks/sharps injuries. Retrieved November 18, 2020, from https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html
  16. O’Grady, N.P. and others. (2011, updated 2017). Guidelines for the prevention of intravascular catheter-related infections, 2011. Centers for Disease Control and Prevention. Retrieved November 18, 2020, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf (Level VII)
  17. Pagana, K.D., Pagana, T.J. (2018). Chapter 2: Blood studies. In Mosby's manual of diagnostic and laboratory tests (6th ed., pp. 14-22). St. Louis: Elsevier.
  18. Septimus, E. (2019). Collecting cultures: A clinician guide. Centers for Disease Control and Prevention. Retrieved November 18, 2020, from https://www.cdc.gov/antibiotic-use/core-elements/collecting-cultures.html (Level VII)
  19. Wanger, A. and others (Eds.). (2017). Chapter 2: Specimen collection and handling in microbiology laboratory. In Microbiology and molecular diagnosis in pathology: A comprehensive review for board preparation, certification, and clinical practice (pp. 11-21). Cambridge, MA: Elsevier.
  20. 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.
  21. World Health Organization (WHO). (2010). WHO guidelines on drawing blood: Best practices in phlebotomy. Retrieved November 18, 2020, from (classic reference)* (Level VII)

*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