Blood Specimen Collection: Venipuncture Syringe Method (Home Health Care) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Strictly adhere to guidelines for hand hygiene, standard precautions, and site preparation to minimize the risk of a health care–associated infection.^{undefined#ref10">10}

OVERVIEW

The health care team member must follow infection prevention practices when obtaining a blood specimen, including using the appropriate safety and blood-borne pathogen standards, to minimize the risk of exposure to blood-borne pathogens.¹¹ The use of safer needleless devices, such as those with a reliable integrated safety feature, is recommended.¹¹ The patient’s veins used for venipuncture requires an aseptic, no-touch technique.⁴ Veins used for venipuncture should be repeatedly assessed for infiltration, extravasation, infection, and phlebitis using standardized scales.^6,7,8 Pain, burning, stinging, erythema, warmth, and subcutaneous swelling should be reported to the practitioner.

The health care team member must withdraw the correct amount of blood required by the laboratory for each blood collection tube (Table 1) to ensure accurate laboratory test results and decrease the patient’s risk of anemia.⁵ Some blood collection tubes contain additives that require an exact amount of blood in the collection tube. Some laboratory tests require less blood than others; the minimum amount needed for a required laboratory test should be confirmed with the organization’s laboratory and the manufacturer’s instructions for use (IFU).⁵ Knowing the correct laboratory order of the blood specimens to be obtained into the collection tubes is essential, as some additives are more likely to contaminate other blood specimens when blood collection tubes are sequentially engaged in the rubber-sheathed needle.¹² Some blood specimens may require special storage or handling, such as being placed on ice, refrigerated, or frozen.¹²

Restrict performing venipuncture for blood specimen collection:⁵

• In the same extremity of patients with IV fluids infusing or use a vein below the site of the infusion.
• In a patient’s extremity with lymphedema or in those patients at risk for lymphedema (e.g., patients who have had axillary lymph node dissection or radiation therapy)
• In patients with an extremity alteration in normal venous blood flow (e.g., paralysis and hemiparesis from a cerebrovascular accident) or decreased sensation that could prevent pain perception, such as needle-to-nerve contact

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.² Anxiety may be assuaged by communicating with the patient about how to help relieve the patient’s concerns.

The nurse should obtain the appropriate laboratory tubes before the home visit. If needed, the nurse should call the laboratory so that the correct tubes and the volume required to process the blood 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 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 a vasovagal response (e.g., pale skin, lightheadedness, tunnel vision, nausea) and provide instructions on when to seek additional care.
• Teach the patient on 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 personal protective equipment (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. Review the patient’s history for risks associated with venipuncture, such as anemia, anticoagulant therapy, low platelet count, a bleeding disorder (e.g., history of hemophilia), venous collapse, traumatic venipuncture, or phlebitis.
8. Review the patient’s personal history with blood specimen collection (e.g., anxiety or fear related to venipuncture), ask about signs of adverse reactions to previous venipuncture (e.g., vagal response), and determine the patient’s ability to cooperate with the procedure.
9. Review the patient’s history for an allergy or sensitivity to antiseptic solutions,³ adhesives, and dressings.⁹
10. Review the patient’s anatomy for sites contraindicated for venipuncture, such as:
    1. Current IV or dialysis access site, a site with a hematoma, or signs of phlebitis or previous infiltration on the same extremity
    2. In a patient’s extremity with lymphedema or in those patients at risk for lymphedema (e.g., patients who have had axillary lymph node dissection or radiation therapy)
    3. In patients with an extremity alteration in normal venous blood flow (e.g., paralysis and hemiparesis from a cerebrovascular accident) or decreased sensation that could prevent pain perception, such as needle-to-nerve contact

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

11. Ensure that the patient has not exercised for 24 hours⁵ 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.⁵

12. Determine the need for appropriate pain management strategies to reduce the patient’s pain from the venipuncture.²
13. Review the anatomy of the patient’s venous system for the preferred veins for venipuncture.
14. 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).⁵
15. Review the practitioner’s orders for blood specimens and consult with the practitioner about obtaining blood for all required tests during one venipuncture.
16. Identify the appropriate laboratory 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 manufacturer’s IFU (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 or sensitivity.
    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.¹²
    4. Ensure that the blood collection tubes have been stored upright and at the correct temperature (e.g., tubes with some additives require refrigeration).¹²
    5. Do not preassemble devices before patient identification.¹²
    6. Ensure that devices for the blood specimen collection process are from the same manufacturer.
    7. Review the manufacturer’s IFU for 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. Don eye protection or face shield if the risk of splashing exists.
23. Identify the patient’s best sites for venipuncture per the organization’s practice.

    Avoid contraindicated sites.¹

    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 opposite arm, look for a venipuncture site distal to the IV infusion site.¹²

       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.¹²

       Consult with the practitioner about stopping the IV infusion for a minimum of 2 minutes¹² before obtaining the blood specimen, as applicable.

    2. Ask the patient to make a fist for 10 seconds to distend the veins for venipuncture.¹²
    3. If the patient’s selected vein cannot be palpated or viewed easily, apply a warm compress over the arm.

       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).¹²

    Rationale: To reduce the risk of a hematoma, avoid venipuncture in a location where a vein branches.⁵

25. Apply a single-use tourniquet proximal to the insertion site.⁵
    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.⁴

       Do not keep the tourniquet on the patient longer than 1 minute⁴ 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.⁵

    2. Release the tourniquet before preparing the site for venipuncture.
26. Apply a topical anesthetic as prescribed, as needed.² Remove the anesthetic completely from the skin after the prescribed dwell time.²
27. Remove gloves, perform hand hygiene, and don clean gloves.
28. Prepare the blood collection equipment using blood collection tubes, holders, needles, and syringes 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 the single-ended straight needle or winged-butterfly needle with tubing is securely attached to the syringe.
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 manufacturer’s IFU.^3,12
    2. Use a single-use applicator containing antiseptic solution.³
    3. Allow the area to air-dry.
30. Perform venipuncture.
    1. Reapply the tourniquet and relocate the vein.

       Do not fasten the tourniquet for longer than 1 minute.¹²

       Rationale: Prolonged tourniquet application can cause stasis, localized acidemia, and hemoconcentration.¹²

    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 syringe in a sharps container and prepare a new venipuncture needle.

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

       Rationale: Gently pulling and stretching the patient’s skin help stabilize the vein and prevent 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 15-degree angle¹² slowly into the patient’s skin with the needle bevel facing upward (Figure 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. 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.⁴

31. Obtain the blood specimen.
    1. Observe for a blood return (Figure 3).
    2. Hold the syringe securely, then slowly and gently pull back on the plunger.

       Rationale: Gently pulling on the plunger creates just enough vacuum needed to draw blood into the syringe. If the plunger is pulled back too quickly, pressure may collapse the vein.

    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. If the blood is flowing sufficiently into the syringe and a tourniquet was used, release the tourniquet just before collecting the total amount of blood required for the laboratory tests. If blood flow is slow, wait to release the tourniquet until the syringe is almost full.

       Rationale: Releasing the tourniquet before obtaining the required amount of blood for the laboratory tests reduces bleeding at the site when the needle is withdrawn.

32. After the required amount of blood is collected, apply a sterile 2 × 2-inch 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.¹¹
33. Apply pressure to the venipuncture site with the gauze pad until the bleeding stops. Use tape or a bandage to secure the gauze pad in place.

    Rationale: Direct pressure minimizes bleeding and prevents hematoma formation, which may cause compression and nerve injury.

    For a patient who has a bleeding disorder or is undergoing anticoagulant therapy, hold pressure, as needed, until the bleeding stops.

34. Discard the protected needle into an appropriate sharps container.

    Do not recap needles or attempt to remove the needle from the collection barrel.¹¹

35. Transfer the blood from the syringe into the correctly colored blood collection tubes using the correct sequence.
    1. Transfer blood specimens using the correct sequence per the laboratory’s practice and the manufacturer’s IFU to prevent carryover of additives between collection tubes.⁵

       Rationale: Blood collection tubes contain different additives as indicated by the colored closure top and labeling and are based on international standards. Do not remove the colored closure top from the tube.⁵

    2. Connect the syringe to a sterile safety-transfer device to fill the blood collection tubes, ensuring that the syringe nozzle is not contaminated.

       Rationale: Using a safety-transfer device with the blood collection tubes allows the vacuum to draw the blood into the tube, reducing the risk of needlestick injury.

    3. Advance the first blood collection tube into the sheathed needle inside the transfer device so that the needle pierces the blood collection tube’s rubber top.
    4. After the blood collection tube is filled to the correct level for the ordered tests (indicated by the marking on the tube or by laboratory practice), grasp the transfer device firmly and remove the blood collection tube.

       Rationale: 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 collection specimen tubes, in the order specified by the laboratory or per the manufacturer’s IFU, into the transfer device and engage the sheathed needle, as needed, to fill the remaining blood collection tubes.
    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 IFU for the number of inversions.¹²

       Rationale: Inverting the tube gently ensures that the additives are properly mixed and prevents erroneous test results.

       Do not shake the blood collection tube.^5,12

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

36. Discard the syringe and transfer device into an appropriate sharps container.

    Do not recap needles or attempt to remove the needle from the collection barrel.¹¹

    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.¹¹

37. Check the blood collection tubes for any signs of external contamination with blood. Decontaminate the blood collection tubes, if necessary.

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

38. Assist the patient to a comfortable reclining position.
39. Label the specimen(s) in the presence of the patient.¹⁰
40. Place the labeled specimen(s) in a biohazard bag and transport it to the laboratory.
41. Reassess the venipuncture site to determine whether bleeding has stopped or a hematoma has formed.
42. Discard or store supplies, remove PPE, and perform hand hygiene.
43. 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 specimen collection.
• Patient tolerates procedure with minimal anxiety, fear, or discomfort.
• All required laboratory specimens are collected accurately for testing.
• Blood specimen is appropriately labeled and transported immediately after home visit.
• 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 venipuncture
• 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

OLDER ADULT CONSIDERATIONS

• Older adults have fragile veins that are easily traumatized during venipuncture. Applying a warm compress may help when samples are obtained. Using a small-gauge needle may also help.

REFERENCES

1. 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)
2. 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)
3. 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)
4. 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)
5. 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)
6. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 46: Phlebitis. Journal of Infusion Nursing, 44(Suppl. 1), S138-S141. (Level I)
7. 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)
8. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 50: Infection. Journal of Infusion Nursing, 44(Suppl. 1), S153-S157. (Level I)
9. 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)
10. Joint Commission, The. (2023). National Patient Safety Goals for the home care program. Retrieved November 16, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_ome_jan2024.pdf (Level VII)
11. Occupational Safety and Health Administration (OSHA). (n.d.). Hospitals eTool: Patient care unit: Needlestick/sharps injuries. Retrieved November 16, 2023, from https://www.osha.gov/etools/hospitals/patient-care-unit/needlestick-sharps-injuries (Level VII)
12. 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 November 16, 2023, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf

World Health Organization (WHO). (2010). WHO guidelines on drawing blood: Best practices in phlebotomy. Retrieved November 16, 2023, from https://apps.who.int/iris/bitstream/handle/10665/44294/9789241599221_eng.pdf?sequence=1&isAllowed=y

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

Clinical Review: Kerrie L. Chambers, MSN, RN, CNOR, CNS-CP(E)

Published: January 2024