Page 1 of 5 Patient Positioning Have patient lie or sit down. Never draw blood on a patient who is standing. Make the patient as comfortable as you possibly can. Always watch and ask patient if he/she is fine. Look for signs of fainting and dizziness. Patient Sitting Down Have the patient sit so his/her arm can rest on the armrest, table, desk, or bed. Extend the arm so that it is a straight line from the shoulder to the wrist. The arm should be supported firmly by the armrest and should not be bent at the elbow. Patient Lying Down Ask the patient to lie on his/her back in a comfortable position. Place a pillow (if additional support is needed) under the arm from which the specimen is being drawn. Have patient extend his/her arm so as to form a straight line from the shoulder to the wrist. Tourniquet Application Ideally, place the tourniquet on the patient s arm should before needle is placed into the vein. If unable to see or feel the vein without the tourniquet place the tourniquet on the patient s arm prior to inserting the needle. The tourniquet increases venous filling and makes the veins more prominent and easier to enter with a needle. If one tourniquet application must be applied for the preliminary vein selection, it should be released and reapplied after a wait of two minutes. If possible, wrap the tourniquet around the sleeve of the garment; this eliminates some of the discomfort of having blood drawn or if the patient has a skin problem. Procedure for Applying Tourniquet 1. Wrap the tourniquet around the arm (on sleeve if available), 3-4 inches above the venipuncture site. 2. Tuck the end under the last round, thus making it easy to release.
Page 2 of 5 Closure of Patient s Hand (if needed) When the patient forms a fist the veins become more prominent and easier to enter, but vigorous hand exercise pumping should be avoided. If the veins protrude well enough without the patient forming a fist then let the hand relax. If superficial veins are not readily apparent, blood can be increased into the vein by: 1. Massaging the arm from wrist to elbow. 2. Tapping sharply at the vein site with the index and second finger a few times. 3. Application of heat to the site may bring the vein forward. 4. Lower the arm over the bed side, allowing the veins to fill to capacity and apply the tourniquet. (This is used most often.) Remember to check both arms. Blood that could not be obtained from a vein 6 months ago, may now be obtainable If unable to obtain blood from the arms consider obtaining blood from the hands and lastly from the feet (Approval from nursing/physician must be obtained). The back of the hands and feet are very sensitive to pain and should be used only as a last resort. Some veins roll, some veins must be held in position. Venipuncture Site Cleansing 1. The vein site should be cleansed to prevent any chemical or microbiological contamination of either the patient or specimen. 2. Cleanse site with 70% isopropyl alcohol or chlorhexidine. 3. Cleanse the site with circular motion from the centre out. 4. Allow the area to dry to prevent haemolysis of the specimen and a burning sensation to the patient, when the venipuncture is performed. 5. If the phlebotomist must touch the site after it has been cleansed in order to locate the vein, then he/she may swab the end of probing finger before touching the site. Both finger and site are considered sterile.
Page 3 of 5 Inspection of Needle Check the needles to ensure that they are not bent, and that they are securely attached to barrel and the opening is free of debris. Checking Position of Arm Arm must be in a secure position to prevent movement when needle is in the vein. The skin may not be taut enough by stretching arm out therefore with one or two fingers; you pull gently on the skin. Removing the Needle Lightly place the gauze pad or cotton ball above the venipuncture site. Remove the needle while keeping the bevel in an upward position. When needle is out of the vein and arm, apply pressure to the site; do not bend arm as this may cause bruising. When/if the bleeding stops, apply an adhesive or gauze bandage over the venipuncture site. Do not walk away until bleeding has stopped or a nurse is taking care of it. Venipuncture using Vacutainer Method 1. Allow site to dry naturally after cleansing. 2. Insert the first tube into the vacutainer holder; the tube will retract slightly. 3. You will now put the needle into the vein. If you need to feel the site again, you can swab the end of your probing finger with antiseptic, let dry and then feel the site. The site is still considered sterile. 4. Once the blood is flowing in the tube, let it fill naturally. Do not move or touch the tube and try to hold barrel and needle very still.
Page 4 of 5 Changing of Vacutainer Tubes 1. Fill up the tubes until the vacuum has exhausted itself and blood flow has ceased. This will guarantee that there is appropriate anticoagulant to blood. 2. When the tube is full, grasp the vacutainer tube with your hand that held the skin taut and remove. Ask the patient to keep his/her arm still and straight. Hold the barrel and needle as still as possible while interchanging tubes. 3. If there is an anticoagulant involved, invert tube so the blood will mix thoroughly. Refer to Collection tube procedure. Place the tube of blood in a safe location. 4. When all the tubes have been filled, the tourniquet is released. Take a dry gauze or cotton ball. Place gently where needle is in arm. Slide needle out of arm, keeping the bevel up. When the needle point is out, press firmly with dry cotton ball or gauze to stop excess bleeding. Make sure that the bleeding has stopped before leaving the bedside. If Blood is Unobtainable No Blood Flow 1. Change the position of the needle. BE CAREFUL! The vein may be damaged. (a) Pull back. You may have gone through the vein. (b) Push in a bit more. You may not have gone in far enough. 2. Try another tube. The tube may not have had sufficient vacuum. 3. Loosen the tourniquet. The tourniquet may have been applied too tightly, stopping the blood flow. If possible, reapply the tourniquet. This sometimes helps the vein to bounce back. 4. Probing is not recommended. This can be very painful to the patient. In most cases another puncture just below the original site is recommended. You may gently and carefully probe to access the vein. Use extreme caution because the vein may be rupture or bruise very easily. PROCEDE SLOWLY. 5. Never attempt a venipuncture more than twice. Have another person attempt to draw the specimen or notify the doctor.
Page 5 of 5 Other tips Patient inquiry- If a patient asks which tests are being collected, inform patient that it is better to ask their physician because he/she can explain the tests and provide more detail. Patient objection to test- report patient s objections to the nurse, who will then notify the doctor. The physician can explain why the tests are needed. Physician relationship- the phlebotomist should not enter the room while the doctor is visiting the patient. If it is a stat request, ask physician if the blood should be drawn now or at a later time. If the phlebotomist accidentally pricks him/herself with a dirty needle report the incident to your departmental supervisor and fill out an Employee incident report form. Report to Occupational Health (or Emergency Department when Occupational Health is closed) for initial assessment of the injury. Monitoring Blood Volume Collected Monitoring of the amount of blood drawn for pediatric and critically ill patients can minimize phlebotomy induced anemias.