Strictly adhere to guidelines for hand hygiene, standard precautions, and site preparation to minimize the risk of a health care–associated infection.undefined#ref15">15
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.2
Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Infection control standards must be followed when obtaining a blood specimen. Appropriate safety devices should always be used and blood-borne pathogen standards should be followed to minimize the risk of exposure to blood-borne pathogens.16 The use of safer needleless devices, such as those with a reliable integrated safety feature, is recommended.16 Venipuncture requires an aseptic, no-touch technique.8 Veins used for venipuncture should be repeatedly assessed for infiltration, extravasation, infection, and phlebitis using standardized scales.11,12,13 Pain, burning, stinging, erythema, warmth, and subcutaneous swelling should be reported to the practitioner.
Venipuncture with a syringe requires the nurse to exert aspiration pressure against the syringe plunger. This method involves inserting a hollow-bore needle attached to a syringe into the lumen of a large vein to obtain a blood specimen. A hollow-bore straight needle or winged-butterfly needle with a short length of tubing is connected to an appropriate-size syringe. After blood is drawn into the syringe, the needle is withdrawn from the patient’s vein while a safety device is engaged and then detached from the syringe. The syringe is then connected to a blood-transfer device housing a rubber-sheathed needle with a Luer lock. The rubber-sheathed needle housed in the collection barrel is used to puncture the rubber top of a vacuum test tube. Once punctured, the vacuum in the blood collection tube extracts a set volume of blood from the syringe.
The correct amount of blood required by the laboratory must be drawn into each blood collection tube to ensure accurate laboratory test results and decrease the patient’s risk of anemia.10 Some blood collection tubes contain fixative agents that require an exact amount of blood in the collection tube. Blood collection tubes without fixative agents allow variable amounts of blood. 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.10 Some fixatives are more likely to contaminate other blood specimens when blood collection tubes are sequentially engaged in the rubber-sheathed needle. Knowing the prescribed laboratory order of the blood specimens into the collection tubes is essential.17 The sequence of collecting blood specimens is different when using a syringe and transfer device than when using a vacuum-extraction blood collection system. Blood specimens should be transported to the laboratory immediately after collection per the organization’s practice.17 Some blood specimens may require special storage or handling, such as being placed on ice, refrigerated, or frozen.17
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 or the use of a smaller syringe. 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.
Tourniquets should be used with caution. If a tourniquet is deemed necessary, the nurse should not apply the tourniquet for longer than 1 minute.10 Prolonged tourniquet application can cause stasis and hemoconcentration.10 Infection control standards require that tourniquets be single use.7 Contamination from Staphylococcus aureus from reused tourniquets is a common finding.18
When preparing a specimen label, the nurse should confirm the patient’s identifying information per the organization’s practice. A laboratory cannot process a mislabeled blood specimen or one that does not arrive in a timely manner. Errors in any aspect of blood sampling may require repeat samples, placing the patient at risk for blood loss and venous injury. Accuracy in obtaining, labeling, and handling blood specimens reduces the need for redrawing specimens.
Venipuncture can be painful, and the patient may experience anxiety or fear before the procedure. In some cases, just the appearance of a needle is frightening. A calm approach and skilled technique may help limit a patient’s aversion to venipuncture. 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.
Rationale: Drawing blood specimens from contraindicated sites can result in false test results or may injure the patient.
Rationale: A low, supported position and an empty mouth
1 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 or seizure reactions for a patient who is at risk.
Rationale: Correct patient positioning helps stabilize the patient’s arm.
Consult with the practitioner about stopping the IV infusion before obtaining the blood specimen, as applicable.
Rationale: Stopping any infusions allows the catheter to clear any IV solutions or medications that may interfere with laboratory analysis of the specimen. Research has not established an ideal wait time for blood sampling.
Obtain a blood specimen below a peripheral access device, if applicable.
18 Obtaining a blood specimen from an arm with a peripheral access device already in place may cause blood specimen contamination or hemolysis.
To reduce the risk of a hematoma, avoid venipuncture in locations where a vein branches. Puncturing the basilica vein is associated with damage to the underlying artery or nerve and is typically more painful.
Rationale: A tourniquet blocks venous return to the heart from the arm, causing the veins to dilate for easier access.
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.
Do not keep the tourniquet on the patient longer than 1 minute
10 before the procedure is performed. Prolonged tourniquet application causes stasis, hemolysis, and hemoconcentration because of changes in the vascular epithelium from increased venous pressure and hypoxia.
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.
Rationale: Warming increases blood flow, making veins more prominent.
Rationale: Combining systems may cause injury to the patient or yield incorrect laboratory test results. Incompatibility of components may cause failure of the process.
Rationale: Needles that are 22 G or smaller minimizes insertion-related trauma to the vein.
Keep the needle hub and the connection sites sterile.
If the specimen is being collected for a blood alcohol level, use a nonalcohol based cleanser.
Do not touch the site after preparation unless sterile gloves are worn.
If contamination occurs, discard the needle and the collection barrel or syringe in a sharps container and prepare a new venipuncture set.
Rationale: Gently pulling and stretching the patient’s skin help stabilize the vein and prevent it from rolling during needle insertion.
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.
Rationale: Inserting the needle slowly prevents puncture through the opposite side of the vein.
Rationale: Holding the syringe securely prevents the needle from advancing, which could cause the needle to puncture the other side of the patient’s vein. 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.
Carefully assess the patient for the potential for venous collapse when using a syringe barrel that is 10 ml or larger.
18 Consider that some older adults and those who have received treatments damaging to the veins may not be able to withstand high pressure or may require a smaller syringe size.
Rationale: If blood does not appear, the needle may not be in the vein.
Rationale: Laboratory results are more accurate when the required amount of blood is obtained.
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.
Rationale: Applying pressure over the needle can cause discomfort and injury to the patient. Carefully removing the needle minimizes discomfort and vein trauma.
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.
Rationale: Applying gauze with tape or a bandage keeps the venipuncture site clean and controls final oozing.
Instruct the patient not to bend the arm of the venipuncture site.
Rationale: Using the needle to pierce blood test tube stoppers for blood transfer increases the risk of needlestick injury. Placing tubes upright in a rack, using a one-handed technique or a needle shield, and refraining from placing pressure on the syringe plunger are recommended.
Rationale: Safety features help reduce needlestick injuries. 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.
Rationale: The order of the blood specimen collection that is specified by the laboratory that processes the blood specimens should be used for filling the collection tubes from a syringe. Some laboratories vary the order from national recommendations.
Follow the laboratory’s order of the draw for filling blood collection tubes from a syringe with a collection device; it may be different from the order used to fill blood collection tubes using a vacuum-extraction system.
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.
To prevent causing hemolysis, do not press the syringe plunger to force blood into a blood collection tube.
Rationale: Inverting the tube gently ensures that the additives are properly mixed and prevents erroneous test results. Shaking may cause lysis of the cells, resulting in inaccurate test results.
Do not shake the blood collection tube.
Rationale: Shaking the blood collection tube may cause lysis of the blood cells, resulting in inaccurate test results.
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.
Rationale: Decontamination prevents cross-contamination and reduces the risk of exposure to pathogens in the blood specimen.
Rationale: A patient may require more venipunctures in the future; therefore, addressing concerns and letting the patient express emotions may reduce an aversion to future venipunctures. Documenting the patient’s response allows for improved care planning for future venipunctures.
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 June 28, 2021, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf
*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.
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