Skill 18-9

Using Venipuncture to Collect a Venous Blood Sample

Venipuncture involves piercing a vein with a needle to obtain a venous blood sample, which is collected in a syringe or tube or to initiate an intravenous access. The superficial veins of the arm in the antecubital fossa, which include the basilic, median cubital, and cephalic veins, are typically used for venipuncture for blood sampling (Figure 1) (Fischbach et al., 2022). However, venipuncture for blood sampling can be performed on a vein in the wrist, dorsal forearm, the dorsum of the hand, or another accessible location (Fischbach et al., 2022). When performing a venipuncture for blood sampling, remember the following:

Do not use the inner wrist because of the high risk for damage to underlying structures.
Avoid areas that are edematous, paralyzed, burned, scarred, or have a tattoo or are on the same side as a mastectomy, arteriovenous shunt, or graft.
Avoid an extremity affected by a cerebrovascular accident, areas of infection, or areas with abnormal skin conditions.
Do not draw blood from the same extremity being used for administration of intravenous medications, fluids, or blood transfusions. Some facilities will allow use of such sites as a “last resort,” after the infusion has been held for a period of time. If necessary, choose a site below or distal to the infusion site (Fischbach et al., 2022; Gorski et al., 2021). Check facility policy and procedure.

Explanation and communication with patients about the need for venipuncture can reduce anxiety. It is important to carefully explain the information about the need for blood tests to ensure patient understanding.

Delegation Guidelines

The use of venipuncture to obtain a blood sample may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Tourniquet
Gloves
Additional PPE, as indicated
Antimicrobial wipes, such as chlorhexidine or alcohol
Sterile needle, gauge appropriate to the vein and sampling needs, using the smallest possible
Vacutainer needle adaptor
Blood collection tubes appropriate for prescribed tests
Appropriate label for specimen, based on facility policy and procedure
Waterproof protective pad
Prescribed local anesthetic cream, as indicated
Biohazard bag
Gauze pads (2 × 2)
Adhesive bandage

Assessment

Review the patient's health record for the blood specimens to be obtained. Ensure that the necessary computerized laboratory request has been completed. Assess the patient for any allergies, especially to the topical antimicrobial to be used for skin cleansing. Investigate for the presence of any conditions or use of medications that may prolong bleeding time, necessitating additional application of pressure to the puncture site. Ask the patient about any previous laboratory testing they may have had, including any problems, such as difficulty with venipuncture; fainting; or reports of dizziness, lightheadedness, or nausea. Assess the patient's anxiety level and understanding of the reasons for the blood test. Assess the need/patient preference for use of a prescribed local anesthetic cream (Fischbach et al., 2022). Assess the patency of the veins in both upper limbs and for circulation problems. Avoid areas that are edematous, burned, scarred, or paralyzed; have a tattoo, infectious or skin conditions, or hematoma present; are paralyzed; or are on the same side as a mastectomy or have an actual or planned dialysis access (Fischbach et al., 2022; Van Leeuwen & Bladh, 2017). Palpate the veins to assess the condition of the vessel; the vein should be straight, feel soft, cylindrical, and bounce when lightly pressed. Appropriate vessels will compress without rolling and have rapid rebound filling after compression. Avoid veins that are tender, sclerosed, thrombosed, fibrosed, or hard (Van Leeuwen & Bladh, 2017).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Injury risk
Infection risk

Outcome Identification and Planning

The expected outcome to achieve is that an uncontaminated specimen will be obtained without injury to the patient and sent to the laboratory promptly. In addition, the patient demonstrates an understanding of the need and process for specimen collection.

Implementation

Action	Rationale
1. Gather the necessary supplies. Check product expiration dates. Identify the prescribed laboratory tests and select the appropriate blood collection tubes.	Organization facilitates efficient performance of the procedure. Use of products that have not expired ensures proper functioning of equipment. Using correct bottles ensures accurate blood sampling.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the transmission of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Explain the procedure to the patient. Allow them time to ask questions and verbalize concerns about the venipuncture procedure. Assess for the need/patient preference for the use of a prescribed local anesthetic cream.	Explanation provides reassurance and promotes engagement. Venipuncture is associated with pain; local anesthetic crease may be applied to the area before venipuncture (Fischbach et al., 2022.
5. Check the specimen label with the patient's identification bracelet. The label should include the patient's name and identification number, the time the specimen was collected, the route of collection, identification of the person obtaining the sample, and any other information required by facility policy. Depending on facility policy, specimen labels may be verified after obtaining blood samples, prior to application to blood sample tubes.	Verifying the patient's identity validates that the correct procedure is being done on the correct patient, and the specimen is accurately labeled.
6. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
7. Close the curtains around the bed and close the door to the room, if possible.	Closing the door or curtain provides for patient privacy.
8. Provide for good light. Artificial light is recommended. Place a trash receptacle within easy reach.	Good lighting is necessary to perform the procedure properly. Having the trash receptacle within easy reach allows for safe disposal of contaminated materials.
9. Assist the patient to a comfortable position, either sitting or lying. If the patient is lying in bed, raise the bed to a comfortable working height (VHACEOSH, 2016).	Proper positioning allows easy access to the site and promotes patient comfort and safety. The proper bed height helps reduce back strain on the part of the nurse while performing the procedure.
10. Determine the patient's preferred site for the procedure based on their previous experience. Expose the arm, supporting it in an extended position on a firm surface, such as a tabletop. Position yourself on the same side as the site selected. Apply a tourniquet to the upper arm on the chosen side approximately 3 to 4 inches above the potential puncture site. Apply sufficient pressure to impede venous circulation but not arterial blood flow.	Eliciting the patient's preference promotes patient participation in their treatment and gives the nurse information that may aid in site selection. Positioning yourself close to the chosen site reduces back strain. Use of a tourniquet increases venous pressure to aid in vein identification. The tourniquet should remain in place no more than 60 seconds to prevent stasis and hemoconcentration (Gorski et al., 2021).
11. Put on gloves. Assess the veins using inspection and palpation to determine the best puncture site. Refer to the Assessment section above.	Gloves reduce transmission of microorganisms. Using the best site reduces the risk of injury to the patient. Observation and palpation allow for making distinction between other structures, such as tendons and arteries in the area, to avoid injury.
12. Release the tourniquet. Check that the vein has decompressed.	Releasing the tourniquet reduces the length of time the tourniquet is applied. The tourniquet should remain in place no more than 1 minute; prolonged tourniquet application causes stasis and hemoconcentration and alterations in test results (Fischbach et al., 2022). Thrombosed veins will remain firm and palpable and should not be used for venipuncture.
13. Attach the needle to the Vacutainer device. Place the first blood collection tube into the Vacutainer but not engaged in the puncture device in the Vacutainer.	The device is prepared for use to ensure efficiency with the task.
14. Use a single-use sterile applicator containing sterile antiseptic solution to cleanse the patient's skin at the selected puncture site with the antiseptic solution identified in facility policy (Figure 2). Follow the manufacturer's directions for use to determine the product application process and dry times (Gorski et al., 2021). Allow the antiseptic to dry naturally; do not wipe, fan, or blow on the skin (Gorski et al., 2021).	Cleaning the patient's skin reduces the risk for transmission of microorganisms. Allowing the skin to dry maximizes antimicrobial action and prevents contact of the substance with the needle on insertion, thereby reducing the sting associated with insertion. Allowing the area to thoroughly dry avoids the possibility of the solution causing hemolysis (Gorski et al., 2021).
15. Reapply the tourniquet approximately 3 to 4 inches above the identified puncture site (Figure 3). Apply sufficient pressure to impede venous circulation but not arterial blood flow. After disinfection, do not palpate the venipuncture site. If repeated palpation is necessary, the antiseptic solution must be reapplied before venipuncture (Gorski et al., 2021).	Use of a tourniquet increases venous pressure to aid in vein identification. The tourniquet should remain in place no more than 1 minute; prolonged tourniquet application causes stasis and hemoconcentration and alterations in test results (Fischbach et al., 2022).
16. Hold the patient's arm in a downward position with your nondominant hand. Align the needle and Vacutainer device with the chosen vein, holding the Vacutainer and needle in your dominant hand. Use the thumb or first finger of your nondominant hand to apply pressure and traction to the skin about 1 to 2 inches below the identified puncture site (Fischbach et al., 2022; Van Leeuwen & Bladh, 2017).	Applying pressure helps immobilize and anchor the vein. Taut skin at the entry site aids smooth needle entry; pressure on the distal end of the vein during the puncture decreases the possibility of rolling veins (Fischbach et al., 2022).
17. Inform the patient that they are going to feel a pinch. With the bevel of the needle up, insert the needle into the vein at a 15- to 30-degree angle to the skin (Van Leeuwen & Bladh, 2017) (Figure 4).	Warning the patient prevents a reaction related to surprise. Positioning the needle at the proper angle reduces the risk of puncturing through the vein.
18. Grasp the Vacutainer securely to stabilize it in the vein with your nondominant hand, and push the first collection tube into the puncture device in the Vacutainer, until the rubber stopper on the collection tube is punctured. You will feel the tube push into place on the puncture device. Blood will flow into the tube automatically (Figure 5).	The collection tube is a vacuum; negative pressure within the tube pulls blood into the tube.
19. Remove the tourniquet as soon as blood flows adequately into the tube (Gorski et al., 2021).	Tourniquet removal reduces venous pressure and restores venous return to help prevent venous stasis, bleeding, bruising, and inaccurate results (Fischbach et al., 2022; Van Leeuwen & Bladh, 2017).
20. Continue to hold the Vacutainer in place in the vein and continue to fill the required tubes, removing one and inserting another. Gently rotate each tube as you remove it.	Filling the required tubes ensures that the sample is accurate. Gentle rotation helps to mix any additive in the tube with the blood sample.
21. After you have drawn all required blood samples, remove the last collection tube from the Vacutainer. Place a gauze pad over the puncture site and slowly and gently remove the needle from the vein. Engage the needle guard. Do not apply pressure to the site until the needle has been fully removed.	Slow, gentle needle removal prevents injury to the vein. Releasing the vacuum before withdrawing the needle prevents injury to the vein and hematoma formation. Use of a needle guard prevents accidental needlestick injuries.
22. Apply gentle pressure to the puncture site for 2 to 3 minutes or until bleeding stops.	Applying pressure to the site after needle removal prevents injury, bleeding, and extravasation into the surrounding tissue, which can cause a hematoma.
23. After bleeding stops, apply an adhesive bandage. Discard the Vacutainer and needle in the sharps container. Remove your gloves and perform hand hygiene.	The bandage protects the site and aids in applying pressure. Proper disposal of equipment reduces transmission of microorganisms. Removing gloves and performing hand hygiene reduce transmission of microorganisms.
24. Remove equipment and return the patient to a position of comfort. Raise the side rail and lower the bed.	Repositioning promotes patient comfort. Raising the rails promotes safety.
25. Record the date and time the samples were obtained on the labels as well as the required information to identify the person obtaining the samples. Compare the specimen label with the patient identification bracelet, as required by facility policy. Depending on facility policy, specimen labels may be verified prior to obtaining blood samples (refer to Step 5). Apply labels to the specimens, according to facility policy. Place them in a biohazard bag.	Proper labeling ensures accurate communication of results. Use of a biohazard bag prevents contact with blood and body fluids.
26. Put on gloves. Check the venipuncture site to see if a hematoma has developed.	Gloves prevent contact with blood and body fluids. Development of a hematoma requires further intervention.
27. Remove your gloves and other PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene reduces the transmission of microorganisms.
28. Transport the specimen to the laboratory immediately. If immediate transport is not possible, check with laboratory personnel or the policy manual to see whether refrigeration is contraindicated.	Timely transport ensures accurate results.

Evaluation

The expected outcomes have been met when an uncontaminated specimen has been obtained without injury to the patient and has been sent to the laboratory promptly, and the patient has demonstrated an understanding of the need and process for specimen collection.

Documentation

Guidelines

Document any pertinent assessments; the laboratory specimens obtained; the date and time specimens were obtained; disposition of specimens; the amount of blood collected, if required; and any significant assessments or patient reactions.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

After applying the tourniquet, you have trouble finding a distended vein: Have the patient make a fist, or try tapping the skin over the vein lightly several times. To prevent venous stasis and reduce risk for inaccurate results, do not have the patient repeatedly clench their fist or pump their hand (Gorski et al., 2021), which may increase plasma potassium levels (Fischbach et al., 2022). If unsuccessful, remove the tourniquet and try lowering the patient's arm to allow blood to pool in the veins. If necessary, apply warm compresses for about 10 minutes before reapplying the tourniquet.
Patient has large, distended, highly visible veins: Perform venipuncture without a tourniquet to minimize the risk for hematoma (Fischbach et al., 2022).
Patient has a clotting disorder or is receiving anticoagulant therapy: Maintain firm pressure on the venipuncture site for at least 5 minutes after withdrawing the needle to prevent hematoma formation.
Oozing or bleeding continues from the puncture site for more than a few minutes: Elevate the area and apply a pressure dressing. If bleeding is excessive or persists for longer than 10 minutes, notify the health care team.
Hematoma develops at the venipuncture site: Apply pressure until you are sure the bleeding has stopped (about 5 minutes). Notify the health care team. Document the size and appearance of the hematoma, notification of the health care team, and any prescribed interventions.
Patient reports feeling lightheaded and says they are going to faint: Stop the venipuncture. If the patient is in bed, have them lie flat and elevate their feet. If the patient is in a chair, have them put their head between their knees. Encourage the patient to take slow, deep breaths. Call for assistance and stay with the patient. Obtain vital signs, if possible.

Special Considerations

General Considerations

Obtain only the volume of blood needed for accurate testing.Phlebotomy (puncture of a vein to withdraw blood) contributes to anemia in newborns, pediatrics, and critically ill adult patients and hospital-acquired anemia in patients of all ages (Gorski et al., 2021). Consider interventions to conserve blood, including the use of small-volume blood collection tubes, point-of-care testing methods, avoidance of routine and/or unnecessary testing, and consolidation of all daily tests with one blood draw (Gorski et al., 2021).
Perform venipuncture for phlebotomy on the opposite extremity of an infusion (Gorski et al., 2021). If phlebotomy must be performed on an extremity with infusing solutions, use a vein below or distal to the site of infusion (Gorski et al., 2021).
In patients with a dialysis fistula or graft, or patients who have a planned dialysis fistula or graft, restrict venipuncture for blood sampling to the dorsum of the hand whenever possible (Gorski et al., 2021).
Be aware of the facility's policy regarding the order of collection of multiple tubes of blood to ensure accurate results.
If the flow of blood into the collection tube or syringe is sluggish, leave the tourniquet in place longer, but always remove it before withdrawing the needle. Do not leave the tourniquet on for more than 1 minute (Fischbach et al., 2022).
If necessary, use a blood pressure cuff inflated to a point between systolic and diastolic pressure values as an alternative to a tourniquet (Fischbach et al., 2022).
Avoid collecting blood from edematous areas, arteriovenous shunts, an upper extremity on the same side as a previous lymph node dissection or mastectomy, infected sites, the same extremity as an intravenous infusion, and sites of previous hematomas or vascular injury.
Avoid previous sites of venipuncture to reduce the potential for infection (Van Leeuwen & Bladh, 2017).
Do not use veins in the lower extremities for venipuncture, because of an increased risk of thrombophlebitis. Some facilities allow collection from lower extremities as a prescribed intervention to collect blood from a leg or foot vein. Check your facility's policies.
Apply warm compresses to the selected site 15 to 20 minutes before venipuncture to aid in distending veins that are difficult to locate.
Consider the use of topical anesthetic creams to minimize discomfort and pain for the patient, based on facility policy. Allow 60 seconds after application for patients with light skin tones and 120 seconds for patients with dark skin tones before performing the venipuncture (Fischbach et al., 2022). Be familiar with the requirements and specifications for a particular product available for use. Application needs to occur sufficiently in advance to allow enough time to become effective.
Use distraction, if appropriate. Distraction has been shown to be of benefit in reducing anxiety related to venipuncture, especially with children (Erdogan & Ozdemir, 2021; Kuo et al., 2018). Asking the patient to concentrate on relaxing and performing deep breathing may help them relax.

Infant and Child Considerations

Use smaller-gauge needles with infants and children because their veins are smaller and more fragile.
Consider automatically applying warm compresses to distend the small veins of infants and young children before attempting any venipuncture.
Use butterfly needles, as appropriate, for obtaining blood from infants and small children.
Heelsticks, using the outer aspect of the heel, may be used for infants. Warming the heel for 5 to 10 minutes before the sample is taken dilates the blood vessels in the area and aids in sampling (KarabiyikOğurlu et al., 2020; Vedder, 2021). This technique is not without controversy, as it is painful and can lead to scarring and infection, including infection of bone and cartilage, due to excessive depth of the puncture (Gorski et al., 2021; Vedder, 2021). Venipuncture by a skilled phlebotomist is suggested instead of heel lance methods due to the increased pain from the heel lance (Gorski et al., 2021). Automatic lancing devices are preferred over manual devices to control the depth of puncture and to reduce the risk of bone or cartilage infection (Gorski et al., 2021).
Consider a combination of techniques including swaddling, breastfeeding, pacifiers, rocking, and/or administration of oral sucrose (24%) beginning 1 to 2 minutes before the venipuncture procedure for young infants to decrease the incidence of procedure-related pain (De Bernardo et al., 2018; Gorski et al., 2021).
Consider using topical anesthetic creams or gels, refrigerant spray, or iontophoresis (application of electric current to carry ionized lidocaine through the skin) with infants and children, to decrease the incidence of procedure-related pain (Kyle & Carman, 2021). Apply the product for a sufficient time to reach maximal effectiveness.
Consider the use of distraction to reduce anxiety and procedure-related pain (Erdogan & Ozdemir, 2021; Gorski et al., 2021; Kuo et al., 2018).

Older Adult Considerations

Keep in mind that the veins of an older adult are fragile and may collapse easily. In addition, the skin is less elastic and may be more difficult to pull taut.
The superficial veins of the hands of older adults are fragile, and venipuncture can cause a hematoma to form. Insert the needle for venipuncture at no more than a 30-degree angle unless using ultrasound guidance; use a 5- to 15-degree angle for veins of older adults (Gorski et al., 2021). In addition, these veins move due to the age-related loss of supportive muscle and connective tissue, making it difficult to enter the lumen of the vein.
Consider performing venipuncture without a tourniquet for older adults to prevent rupture of capillaries (Fischbach et al., 2022).

EVIDENCE FOR PRACTICE

Relief of Pain During Blood Specimen Collection in Pediatric Patients

Needle insertion for venipuncture is painful, frightening, and distressful for children. What interventions can assist nurses to reduce the emotional and physical effects of painful procedures, such as venipuncture, in children?

Related Research

Erdogan, B., & Ozdemir, A. A. (2021). The effect of three different methods on venipuncture pain and anxiety in children: Distraction cards, virtual reality, and Buzzy^® (randomized controlled trial). Journal of Pediatric Nursing, 58, e54-e62. https://doi.org/10.1016/j.pedn.2021.01.001

The purpose of this randomized-controlled study was to determine the effect of distraction cards, virtual reality, and Buzzy^® methods on venipuncture pain and anxiety in children ages 7 to 12 years at a pediatric venipuncture unit of a university hospital in Turkey. Participants (n = 142) were randomized into four groups: the experimental groups (n = 108) received one of three interventions, and the control group received no intervention during venipuncture (n = 34). Participants in the distraction card group (n = 35) were asked several questions requiring them to focus on cards with hidden pictures and patterns just before during venipuncture. The participants in the virtual reality group (n = 37) engaged with a 3D dinosaur animation on a smartphone using virtual reality glasses and a headset. The Buzzy^® intervention group received application of cold and vibration 60 seconds before the procedure on the venipuncture site, which was then moved to an area 3 cm above the site and continued during venipuncture. Participants' pain and anxiety levels were measured immediately after the venipuncture procedure, and a volunteer parent and the researcher observed the participants' behavior to measure pain and anxiety levels. Results indicated that all intervention groups had significantly lower pain and anxiety scores than the control group, with the Buzzy^® group scoring the lowest mean on all measurements according to all raters (participant, parent, researcher). The researchers concluded that the Distraction Cards, virtual reality, and Buzzy^® methods were all effective in reducing pain and anxiety related to venipuncture in children.

Relevance for Nursing Practice

Nurses are often responsible for obtaining blood samples from their patients, including children. Using the most efficient techniques can result in decreased pain and anxiety for both the children and their parents. This study suggests several methods of reducing pain associated with venipuncture and should be considered for use when caring for these young patients.

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Skill 18-9

EVIDENCE FOR PRACTICE