Blood Specimen Collection: Venipuncture Vacuum-Extraction Method (Home Health Care) - CE

ALERT

Strictly adhere to guidelines for hand hygiene, standard precautions, and site preparation to minimize the risk for a health care–associated infection.^{undefined#ref12">12}

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

OVERVIEW

Infection control standards must be followed when obtaining a blood specimen. Appropriate safety devices should always be used and standards should be followed to minimize the risk of exposure to blood-borne pathogens.¹³ The use of safer needleless devices such as those with a reliable integrated safety feature is recommended.¹³ Venipuncture requires an aseptic no-touch technique and sterile gloves if contact with the skin is required after the skin preparation with an antiseptic.⁶ Veins used for venipuncture should be repeatedly assessed for infiltration, extravasation, infection, or phlebitis using standardized scales.^8,9,10 Pain, burning, stinging, erythema, warmth, and subcutaneous swelling should be reported to the practitioner.

The correct amount of blood required by the laboratory must be drawn into each blood collection tube (Table 1) to ensure accurate laboratory test results and decrease the patient’s risk of anemia.⁷ Some blood collection tubes contain additives that require an exact amount of blood in the collection tube. Blood collection tubes without additives allow variable amounts of blood. Some laboratory tests require less blood than others; the minimum amount of blood needed for a required test should be confirmed with the organization’s laboratory and the manufacturer’s instructions for use.⁷ Some additives are more likely to contaminate other blood specimens when blood collection tubes are sequentially engaged in the rubber-sheathed needle. Knowing the correct laboratory order of the blood specimens to be obtained into the blood collection tubes is essential.¹⁴ Blood specimens should be delivered to the laboratory immediately after collection per the organization’s practice. Some blood specimens may require special storage or handling, such as being placed on ice, refrigerated, or frozen.¹⁴

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 pressure may require an alternative method of blood 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 blood specimen collection.²

The patient’s anatomy should be assessed for sites contraindicated for venipuncture, such as:³

• Current IV access site, a site with a hematoma, or signs of phlebitis or previous infiltration on the same extremity
• History of a mastectomy on the same side as proposed site
• History of trauma or other lymphatic system compromise to the same extremity
• Extremity site affected by radiation, tissue injury, stroke, or infection
• Dialysis access site on the same extremity
• Nerve injury or other complication on the same extremity

Venipuncture can be painful, and the patient may experience anxiety or fear before the procedure. A calm approach and skilled technique may help limit a patient’s aversion to venipuncture. To reduce pain during venipuncture, an appropriate pain management strategy for the patient should be determined based on the patient’s condition, developmental level, and engagement of the patient and family.⁴ Anxiety may be assuaged by communicating with the patient about how to help relieve the patient’s concerns.

Appropriate laboratory tubes should be obtained before the home visit. If needed, the laboratory should be called so that the proper tubes and the volume required to process the specimens can be confirmed.

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 venipuncture complications (e.g., hematoma, nerve pain, extravasation, excessive bleeding, arterial puncture, infection, phlebitis) and provide instructions on when to seek additional care.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
5. Verify the practitioner’s order and assess the patient for pain.
6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
7. Consult with the practitioner to minimize venipuncture and conserve blood by substituting point-of-care testing for venipuncture, using low-volume collection tubes, performing all daily tests during one venipuncture, and eliminating routine testing.⁷
8. Review the patient’s history for risks associated with venipuncture, such as anemia, anticoagulant therapy, low platelet count, bleeding disorder (e.g., history of hemophilia), venous collapse, traumatic venipuncture, or phlebitis.
9. Review the patient’s personal history with blood specimen collection (e.g., anxiety or fear related to venipuncture), ask about signs of adverse responses to previous venipunctures (e.g., vagal response), and determine the patient’s ability to cooperate with the procedure.
10. Review the patient’s history for an allergy or sensitivity to antiseptic solutions,⁵ adhesives, and dressings.¹¹
11. Review the patient’s anatomy for sites contraindicated for venipuncture, such as:
    1. Current IV access site, a site with a hematoma, or signs of phlebitis or previous infiltration on the same extremity
    2. History of a mastectomy on the same side as proposed site
    3. History of trauma or other lymphatic system compromise to the same extremity
    4. Extremity site affected by radiation, tissue injury, stroke, or infection
    5. Dialysis access site on the same extremity
    6. Nerve injury or other complications on the same extremity

       Rationale: Drawing blood specimens from contraindicated sites can result in false blood test results or may injure the patient.

12. Ensure that the patient has not exercised for 24 hours⁷ before blood sampling.

    Rationale: Exercise and changes from supine to upright positions can alter plasma volume because of the force of gravity on venous hydrostatic changes and distribution of bodily fluids, which can change the values of hemoglobin, hematocrit, and other blood cell counts.⁷

13. Determine the need for appropriate pain management strategies to reduce the patient’s pain from the venipuncture per the organization’s practice.⁴
14. Review the anatomy of the patient’s venous system and the organization’s practice for the preferred veins for venipuncture.
15. Identify whether cautions or preconditions must be met before the blood specimen can be collected. Blood specimen collection can be related to medication administration (e.g., medication peak and trough levels), nutritional intake (e.g., fasting), procedures, or diagnostic testing (e.g., timed endocrine hormone levels).⁷
16. Identify the appropriate laboratory blood collection tubes and validate the order in which the specimens are to be transferred into the collection tubes (if multiple specimens are required) and the volume required for each test per the laboratory’s practice and the manufacturer’s instructions for use (Table 1).
17. Review the laboratory’s requirements for labeling and handling the blood specimens.
18. Gather supplies and equipment, including specimen labels, blood collection tubes, and vascular visualization devices, if required, and bring them to the patient’s side. Replace latex equipment with nonlatex equipment if the patient has a latex allergy.
    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 blood specimen from contamination.
    3. Ensure that the blood collection tubes’ expiration dates have not passed and that all equipment and tubes are intact and free from defects or compromises.¹⁴
    4. Ensure that the blood collection tubes have been stored upright and at the correct temperature (e.g., some additives require refrigeration).¹⁴
    5. Do not preassemble devices before patient identification.¹⁴
    6. Ensure that devices for the blood specimen collection process are from the same manufacturer.
    7. Review the manufacturer’s instructions for using blood collection tubes and transfer devices.
19. Provide privacy for the patient.
20. Ensure proper lighting to aid observation of vein contours and colors.
21. Assist the patient to a comfortable position.
22. Perform hand hygiene and don gloves.
23. Identify the patient’s best sites for venipuncture.

    Avoid contraindicated sites.³

    1. If IV fluid is being administered in one arm, choose a site on the opposite arm for blood specimen collection.

       Rationale: Obtaining a blood specimen from an arm with an existing peripheral access device may interfere with laboratory analysis of the specimen.¹⁴

    2. If unable to locate a site in the arm opposite an IV infusion site, look for a venipuncture site distal to the IV infusion site.¹⁴

       Consult with the practitioner about stopping the IV infusion for a minimum of 2 minutes¹⁴ before obtaining the blood specimen, as applicable.

       Rationale: Stopping an IV infusion allows the medication to clear before obtaining the blood specimen, as the medication may interfere with laboratory analysis of the specimen.¹⁴

    3. Ask the patient to make a fist for 10 seconds to distend the veins for venipuncture.¹⁴
    4. 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.

       Rationale: Warming enhances blood flow, making veins more prominent.

24. Choose a vein that is straight and does not divert into another branch; that is easily palpable; that has no swelling, hematoma, phlebitis, infection, or infiltration; and that has not had recent venous access or venipuncture. The basilic, cephalic, and median cubital veins are the most commonly used sites for venipuncture (Figure 1).¹⁴

    Rationale: Avoiding venipuncture in a location where a vein branches reduces the risk of a hematoma.⁷

25. Apply a single-use tourniquet proximal to the insertion site.⁷
    1. 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.⁶
    2. Do not keep the tourniquet on the patient longer than 1 minute⁶ before the procedure is performed.

       Rationale: Prolonged tourniquet application causes stasis, hemolysis, and hemoconcentration because of changes in the vascular epithelium from increased venous pressure and hypoxia.⁶

    3. Release the tourniquet before preparing the site for venipuncture.
26. Apply a topical anesthetic as prescribed or per the organization’s practice to reduce pain, as needed.⁴ Remove the anesthetic completely from the skin after the prescribed dwell time.⁴
27. Remove gloves, perform hand hygiene, and don clean gloves.
28. Prepare the blood collection equipment using blood collection tubes, holders, and needles from the same system and manufacturer to prevent equipment incompatibility.
    1. Choose the smallest needle that will fit into the vein but will also accommodate the prescribed blood tests without contributing to hemolysis.
    2. Ensure that a double-ended straight or winged-butterfly venipuncture with tubing 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 double-ended straight or winged-butterfly needle and attach the needle to the collection barrel (Figure 2). If a single-ended straight or winged-butterfly needle is used, attach the needle securely to a collection barrel housing a sheathed needle.
29. Prepare the venipuncture site.
    1. Cleanse the site with an organization-approved antiseptic solution (e.g., alcohol-based chlorhexidine, 70% isopropyl alcohol or povidone-iodine solution) per the organization’s practice and the manufacturer’s instructions for use.^5,14
    2. Use a disposable sterile applicator containing sterile solution.⁵
    3. Allow the area to air-dry.

       Do not touch the site after preparation unless sterile gloves are worn.¹

30. Perform the venipuncture.
    1. Reapply the tourniquet and relocate the vein.

       Do not fasten the tourniquet for longer than 1 minute.¹⁴

       Rationale: Prolonged tourniquet application can cause stasis, localized acidemia, and hemoconcentration.¹⁴

    2. Remove the cap from the venipuncture needle, maintaining the needle’s sterility. Warn the patient to expect to feel a stick.

       If contamination occurs, discard the needle and the collection barrel in a sharps container and prepare a new venipuncture needle.

    3. Place the thumb or forefinger of the nondominant hand distal to the venipuncture site and gently pull and stretch the patient’s skin until it is taut and the vein is stabilized.

       Rationale: Gently pulling and stretching the patient’s skin helps stabilize the vein and prevent 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 15-degree angle¹⁴ slowly into the patient’s skin with the needle bevel facing upward (Figure 3).
    5. Observe the patient’s response.

       Signs of nerve injury include severe, unusual, or shooting pain, tingling or numbness, or a tremor in the arm. If the patient complains of any of these symptoms during venipuncture, withdraw the needle immediately and notify the practitioner.⁶

31. Obtain a blood specimen.
    1. Observe for a blood return (Figure 4).

       Rationale: If blood does not appear, the needle is not in the vein.

    2. Hold the collection barrel securely and advance the first blood collection tube into the sheathed needle inside the barrel so that the needle pierces the rubber top of the blood collection tube.

       Rationale: Pushing the sheathed needle through the rubber top breaks the vacuum, pulling blood into the tube.

       Do not advance the needle farther into the patient’s vein.

       Rationale: If the needle advances too far, it may transverse the vein through the opposite wall into the subcutaneous tissue.

    3. Obtain the required amount of blood for all of the ordered laboratory tests, keeping the needle stabilized in the patient’s vein.

       Rationale: Laboratory results are more accurate when the required amount of blood is obtained.

    4. After the blood collection tube is filled to the correct level for the ordered test(s) (indicated by the marking on the tube or per the laboratory’s practice), grasp the collection barrel firmly and remove the blood collection tube, using caution not to disrupt the venipuncture needle’s location in the patient’s vein.

       Rationale: Grasping the collection barrel prevents the venipuncture needle from advancing or dislodging. The blood collection tubes should be filled to the correct level because additives in certain tubes are measured in proportion to the filled tube.

    5. Insert and remove additional blood specimen tubes per the laboratory’s and manufacturer’s instructions for use, as needed.

       Collect blood specimen coagulation studies before collecting other blood specimens that require a tube that contains a clot activator or other additive. If using a butterfly needle with tubing, use a nonadditive tube to collect the air from the tubing before engaging a blood collection tube for a coagulation study.^7,14

    6. Gently invert each blood collection tube back and forth immediately after it is filled with blood if the tube contains additives. Follow the manufacturer’s instructions for the number of inversions.¹⁴

       Rationale: Inverting the tube gently ensures the additives are properly mixed to prevent erroneous test results.

       Do not shake the blood collection tube.^7,14

       Rationale: Shaking the blood collection tube may cause lysis of the blood cells, resulting in inaccurate test results.

    7. If the blood is flowing sufficiently into the blood collection tubes and a tourniquet was used, release the tourniquet just before filling the last blood collection tube. If blood flow is slow, wait to release the tourniquet until the last tube is almost full. Fill the last tube and remove it from the collection barrel.

       Rationale: Releasing the tourniquet before filling the last specimen tube reduces bleeding at the site when the needle is withdrawn.

32. After the required amount of blood is collected, apply a 2 × 2-inch sterile gauze pad to the venipuncture site (without applying pressure). After the last collection tube is removed, quickly but carefully withdraw the needle from the patient’s vein, activating the safety mechanism to prevent an accidental needlestick injury.¹³

    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.

33. Immediately discard the collection barrel, needle, and tubing in an appropriate sharps container.

    Do not recap needles or attempt to remove the needle from the collection barrel.¹³

34. Check the blood collection tubes for any sign of external contamination with blood. Decontaminate the blood collection tubes, if necessary, per the laboratory’s and organization’s practice.

    Rationale: Decontamination prevents cross-contamination and reduces the risk of exposure to pathogens present in the blood specimen.

35. Assist the patient to a comfortable position for several minutes.
36. In the presence of the patient, label the specimen per the organization’s practice.¹²
37. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
38. Reassess the venipuncture site to determine whether bleeding has stopped or a hematoma has formed.
39. Report adverse events in an organization-approved occurrence reporting system.
40. Assess pain, treat if necessary, and reassess.
41. Discard supplies, remove PPE, and perform hand hygiene.
42. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Vein is accessed successfully without nerve or adjacent tissue injury.
• Aseptic technique is maintained.
• Venipuncture site shows no evidence of continued bleeding or hematoma after specimen collection.
• Blood specimen is appropriately labeled and transported immediately after home visit.
• Patient tolerates procedure with minimal anxiety, fear, or discomfort.
• All required laboratory blood specimens are collected accurately for testing.
• No needlestick injury occurs to the patient or health care team member.

UNEXPECTED OUTCOMES

• Hematoma forms at venipuncture site.
• Needle is inserted through the vein.
• Patient has vasovagal response, including dizziness, fainting, or loss of consciousness.
• Infection or phlebitis develops at the venipuncture site.
• Nerve or adjacent tissue injury occurs after venipuncture.
• Hemostasis is not achieved.
• Laboratory specimen is inadequate for testing or hemolyzed and cannot be processed.
• Aseptic technique is not maintained.
• Blood specimen is not obtained.
• Needlestick injury occurs to the patient or health care team member.

DOCUMENTATION

• Date and time of venipuncture, number and location of attempts, and name and credentials of person performing procedure
• Blood specimens obtained and disposition of specimens
• Location and description of venipuncture site
• Volume of blood drawn for a patient undergoing frequent blood specimens or a patient with anemia
• Laboratory to which the specimen was delivered and any information required by the laboratory
• Inability to obtain sample, if unsuccessful
• Patient’s tolerance of venipuncture
• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions
• Assessment of pain, treatment if necessary, and reassessment

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 be beneficial.

REFERENCES

1. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 18: Aseptic non touch technique (ANTT). Journal of Infusion Nursing, 44(Suppl. 1), S56-S58. (Level I)
2. 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)
3. 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)
4. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 32: Pain management for venipuncture and vascular access procedures. Journal of Infusion Nursing, 44(Suppl. 1), S94-S95. (Level I)
5. 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)
6. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 34: Vascular access device placement. Journal of Infusion Nursing, 44(Suppl. 1), S97-S101. (Level I)
7. 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)
8. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 46: Phlebitis. Journal of Infusion Nursing, 44(Suppl. 1), S138-S141. (Level I)
9. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 47: Infiltration and extravasation. Journal of Infusion Nursing, 44(Suppl. 1), S142-S147. (Level I)
10. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 50: Infection. Journal of Infusion Nursing, 44(Suppl. 1), S153-S157. (Level I)
11. 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)
12. Joint Commission, The. (2023). National Patient Safety Goals for the home care program. Retrieved March 30, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_ome_jan2023.pdf (Level VII)
13. Occupational Safety and Health Administration (OSHA). (n.d.). Hospitals etool. Patient care unit: Needlesticks/sharps injuries. Retrieved March 30, 2023, from https://www.osha.gov/etools/hospitals/patient-care-unit/needlestick-sharps-injuries (Level VII)
14. Pagana, K.D., Pagana, T.J., Pagana, T.N. (2022). Chapter 2. Blood studies. In Mosby’s manual of diagnostic and laboratory tests (7th ed., pp. 11-497). St. Louis: Elsevier.

ADDITIONAL READINGS

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 March 30, 2023, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf (classic reference)*

World Health Organization (WHO). (2010). WHO guidelines on drawing blood: Best practices in phlebotomy. Retrieved March 30, 2023, from https://apps.who.int/iris/bitstream/handle/10665/44294/9789241599221_eng.pdf?sequence=1&isAllowed=y (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