VENIPUNCTURE

I. INDICATIONS
Venipuncture
Venipunctureisthecollectionofabloodspecimenfromaveinforlaboratorytesting.Thetestsperformedonbloodoffermanyimportant
andvaluableparametersthataddtothediagnosisofavarietyofdifferentdiseases.Theintegrityofthevenipuncturesampledependson
goodtechnique,drawingfromanappropriatesiteandavoidanceofhemolysisorcontaminationofthesample.
Veins
Veinscarrydeoxygenatedbloodtotheheart.Themuscleswithintheveinfacilitatethemovementofbloodwithinthevein;valvesinthe
veinpreventbackflow.
Blood
Bloodisusedfortransportationofoxygen,food,wasteproductsandothermaterialswithinthebody.Itisusedfortheconstantregulation
ofbodytemperature,regulationoffluidsandacidbaseequilibrium.
Bloodhasmanycomponentsincludingplasma(fluidportionofblood),serumandavarietyofcellularcomponents(redbloodcells,white
bloodcellsandplatelets).Serumiswhatremainswhenfibrinogenhasbeenremovedfromtheplasma.
Thereareasmanyreasonstodrawbloodastherearediseaseentities.Asmallsampleoftestsandtheirindicationsinclude:
- Theperipheralbloodsmear:canprovidemoreinformationthananyotherhematologicprocedure
- TheCompleteBloodCount(CBC):thisincludesthewhitebloodcount(WBC),hemoglobin(Hgb),hematocrit(HCT),differential,
redbloodcellcount(RBC),whitebloodcellmorphologyandplatelets.Thistestcanbeusedtoevaluateanemia,leukemia,
reactionstoinflammationandinfections,stateofhydrationanddehydration,polycythemia,hemolyticdiseasesandtoactively
managechemotherapydecisions.
- TheChemistryProfile:apanelofteststhatcanincludeasmanyastwentyfiveseparateanalysesandcalculations.Thefollowing
testsaremostoftenincludedinachemistryprofile:Totalprotein,albumin,calcium,phosphorus,glucose,ureanitrogen(BUN),uric
acid,creatinine,totalbilirubin,alkalinephosphatase,electrolytesandothertestsasdesignedbyspecificlaboratories.The
significanceofthenormalresultismuchgreaterthanisgenerallyrecognized.Abaselinesetofserumchemistrytestscanbe
extremelyvaluableforcoordinatingthecareofthepatient.Theusesofthesetestsincludethefollowing:amultipleorgansystem
survey,anadmissionprofile,theestablishmentofbaselinevaluesandamethodtoevaluatepatientswhopresentwithdiagnostic
problems.
- TheAntinuclearAntibody(ANA):atestthatdetectsautoantibodies,whicharedirectedagainstavarietyofantigenswhichreside
mainlyinthecellnucleus.Thistestcanbeusefulinthediagnosisofconnectivetissuedisease,progressivesystemicsclerosisand
mixedconnectivetissuedisease.Thistestisnotspecificforjustonecollagenvasculardisease.
- TheAspartateAminotransferase(AST):atestthatexaminesthealterationofAST,whichoriginatesinavarietyoforgans.LowAST
canbeseeninuremiaandvitaminB6deficiency.IncreasedlevelsofASTcanbeseenincirrhosis,Reyessyndrome,infection
mononucleosis,alcoholism,viralhepatitis,andevencertaintypesoftrauma,chemicalinjury,andgangrene.
II. CONTRAINDICATIONS
Themostimportantdecisionwhenperformingvenipunctureistheselectionofthesitefromwhichtodrawthesample.Sitestoavoid
includethefollowing:
1. Obviousareasofskininfection(suchascellulitis,skinrashesandnewlytattooedareas).
2. Avoidskinsitesthathaveextensivescarringfromburns,surgery,injuriesortrauma.Scartissueisverydifficultto
puncture.
3. Avoidtheupperextremityonthesamesideofapreviousmastectomy.Thissitemayaffectthetestresultsdueto
thepresenceoflymphedema.
4. Avoidaprevioushematoma,whichmayalsooffererroneoustestresults.Ifanothersiteisnotpossible,drawa
samplefromthedistalaspectofthehematoma.
5. Bloodshouldnotbedrawnfromanarmwithafistulaorcannulainplacewithoutspecificdirectionsfromyour
supervisingphysician.
6. Ifanextremityisedematousanothersiteshouldbechosen.
Itsessentialtousetheoppositearm,ifthepatienthasanintravenousline(IV)forfluidsand/orbloodtransfusions.Satisfactory
samplescanbedrawnfrombelowtheIVsiteifthisisnotpossible.Tofollowthisprocedure:theIVshouldbeturnedoffforatleasttwo
minutes,ifpossible.ThenbloodshouldbewithdrawnfromaveinotherthantheveininwhichtheIVisplaced.Thefirst5mlofblood
shouldbedrawnanddiscardedbeforedrawingsamplesfortesting.
Patientswithdiffuseintravascularcoagulation(DIC),hyperfibrinolysis,thrombocytopeniaorhereditaryclottingdisorders
characteristicallybleedforalongtimeaftervenipuncture.
III. PLANNINGFORTHEPROCEDURE
Properplanningandpreparationareessentialpriortoperformingavenipunctureinordertoobtaingoodresultsandhavea
satisfactorypatientoutcome.Developaroutineplanforthevenipunctureprocedurethatofferseffectiveandefficientresultswiththe
leastamountofdiscomfortforyourpatient.
Knowwhatlabstudiesyouneedtoperformandinwhatordertowithdrawthespecimen.Identitytheadditive,additivefunction,
volumeandspecimenconsiderationsforeachcorrespondingcolortoptube.Thiswillsavethepatientunduestressandofferthebest
outcomesforeachtestthatyouwishtoperformwitheachsampleofblood.
 Befamiliarwiththeamountofbloodneededinordertocompleteaparticularlabtest.Thiswillpreventunnecessarysticks.
Assembleandorganizethepriorequipmentneededfortheprocedure.Thefollowingrepresentsacomprehensivelistofequipmentthat
youmayrequire.Theequipmentneededdependsonthepatient,theirmedicalcondition,thesiteyouwillusefortheprocedure,the
numberofsamplesrequiredandtypeofsetting(hospital,outpatient,pediatricward,nursery,emergencyroom)whereyouwillperform
theprocedure.

Youmayrequirethefollowingequipment(placeitallwithineasyreach):

1. Needles18,20or22gauge,singleandmultidraw(haveaneedlewithrubbersheathsonthepartoftheneedlethatinserts
intotheVacutainerbarrel).
2. Evacuatedbarrels:Vacutainerbarrelsarenowavailablewithsafetyreleaseorretractfeatures.
3. Evacuatedtubes:SST,EDTA,SodiumCitrate,SodiumHeparin,Plain,etc.(alwayshavesparetubessothatifyoulosethe
vacuumorhaveatubewithinsufficientvacuumyouarepreparedanddonothavetorepeattheprocedure).
4. Labelsforevacuatedtubes.
5. Syringes:1ml,3ml,5ml,10mlorlarger.
6. IVbutterflyinfusionsets:21,23and/or25gauge
7. Tourniquets:inch,1inchforadults,and1/8inchforchildren.Theseshouldbeclean,widestripsoflatex.Checkfor
latexallergiespriortobeginningprocedure.Latexfreetourniquetsareavailable.Analternativeoptionistousean
adult/childbloodpressurecuff.
8. 2pairs(incaseonesetbecomescontaminated)ofsterilegloves.Again,askpatientaboutlatexallergiespriortoprocedure.
Latexfreeglovesareavailable.
9. 2x2or4x4gauzepads.
10. 70%isopropylalcoholpads
11. ChloraPrep(chlorhexadine)isusedforcleaningtheskinforbloodculturedraws.

12. BandAids(askpatientifallergictoadhesivetapepriortoprocedure)aswellasnylontapeandpapertape.
13. ASharpsdisposablecontainer.
14. Biohazardwastecontainer.

IV. SITESELECTION

Observethepatientsanatomyinthechosensitepriortoapplyingtourniquet.Theantecubitalfossaisthemostcommonsitefor
sampling.Theantecubitalfossaisthetriangularhollowareaonanterioraspectoftheelbow.Theboundariesinclude:superiorlyan
imaginarylineconnectingthemedialandlateralepicondyles,mediallythepronatorteres,laterallythebrachioradialis.Thecephalic
andbasilicaveinsareoftenthemostprominentintheregionoftheantecubitalfossa.

Theprominenceandaccessibilityofthecephalicandbasilicaveinsandantecubitalfossamakesthisthemostoftenusedsitefor
venipuncture.Considerablevariationscanoccurintheconnectionofthebasilicaandcephalicveins.Themediancubitalveincrossesthe
bicipitalaponeurosis,whichseparatesitfromtheunderlyingbrachialarteryandmediannerve.Themediancubitalveinoftenreceivesthe
medianantebrachialveinandcanbifurcatetoformamediancephalicveinandamedianbasilicvein.Theseveinsmaybeembedded
withinsubcutaneoustissuemakingthemdifficulttovisualize,theuseofatourniquetwilloccludevenousreturn,distendtheveinsand
makethemnotonlypalpablebutalsovisible.Checkbilaterally,distally,andproximallytothemostcommonsiteforvenipunctureinthe
adult,whichistheantecubitalfossa.

Learntouseyoursenseoftouch.Usethepalmaraspectsofyourglovedfingers.Dontrelytotallyonvision.Darkskinand
deepveinsaredifficulttovisualize.Siteselectionmaybedifficultinapatientrecoveringfromchemotherapyorapatientthathashada
numberofvenipuncturesorapatientthatusesIVdrugs.Itmaybehelpfultoaskthepatientwhereagoodveincanbefound.Application
ofwarmcompresslightlyappliedpriortotheprocedurecanassistwithfindinganacceptablevein.Ifpossiblemakesurethepatientis
wellhydratedpriortocominginforvenipuncture.

Takethetimetofindagoodvein.Theselectionshouldincludeaveinthatiseasilypalpated,large,wellanchoredanddoestnot
rollwhenpalpated.Observethepatientforanyofthecontraindicationspreviouslymentionedsuchasabradedskin,newtattoos,body
piercing,recentmastectomy,edema,hematomas,etcetera.Ifanyofthesearepresent,chooseanothersite.

Thebestveinsforvenipunctureintheorderofchoice:
Mediancubitalveinwhichiseasilypalpated,wellanchored,lesspainful,leastlikelytobruiseandisusuallythelargestveinin
theantecubitalspace.
Cephalicvein,alargeveinthatiseasilypalpated,poorlyanchored,andcanbepainfultothepatient.
 Basilicvein,easytopalpate,notwellanchored,andveryclosetothebrachialarteryandthemediannerve.

Prep
Placeallequipmentwithincomfortablereachingdistance.Checkpatientidentification,makingsureyouhavetherightpatient.Make
surethepatienthasfollowedanyprelabinstructionspriortodrawingblood(i.e.fastingbeforebloodglucoseorlipidprofile).Discuss
patientspreviousexperiencewithvenipuncture(i.e.fainting,vomiting,etc.)

Discusstheneedfortheprocedurewiththepatient,potentialpossibilityofaninitialstinging,pain,andbruisingwhilestressingthe
importantofthepatientscooperationforasuccessfulprocedure.Itispreferablethatthepatientremainsasstillaspossibleduringthe
procedure.Itisnotusefultosay,Thiswillonlybealittleuncomfortable.Thepatientknowsthatitwillhurt.Explainthatyouwilldo
everythingtominimizethediscomfortandyouwillneedthepatientshelptodoso.Themostimportantissuetorememberaboutthis
patientinteractionisthatpainandbruisingareindirectlyproportionaltoyourpopularity!Answeranyandallquestions.

Alwayscheckthetestordered,evenifyouorderedityourself.Organizethenecessaryequipmentintheproperorderforcollectingthe
appropriatesamples,withtherightvolumeofbloodinthecorrectorderofcollection.Observethepotentialsitetodeterminetheright
typeofequipmentandveinquality.

Washyourhandswithwarmwaterandbacteriostaticsoap.Useproperglovingtechnique.Alwaysobserveuniversalprecautionsforthe
preventionoftransmissionofHIV,hepatitisB&Candotherbloodborneinfections(CDCGuidelinesforthepreventionoftransmissions
ofhumanimmunodeficiencyvirus&hepatitisBvirustohealthcare&publicsafetyworkers.MMWR1989:38(S6):136).

Thepatientshouldbepositionedproperlyforprocedureandforcomfort.Ifpossible,laypatientdown.Thistendstorelaxthepatient.
However,ifthepatientissittingup,extendarmstraightdownfromshouldertowrist.

Afewhelpfulhintsforfindingveinsinclude:
Keeptheextremitybelowtheleveloftheheartforafewminutes.
Applyawarmtoweltotheextremitytopromotevasodilationfromtheheat.Thetowelshouldbeatatemperaturebelow42 oC
andleftfornolongerthan2min.
Useabloodpressurecuffinflatedtoapointbetweenthesystolicanddiastolicpressureasatourniquet,thisallowsforgreater
controlandcanofferlessdiscomforttothepatient.
Carefullyrubortaptheveinoverthepotentialpuncturesite.Sometimesthiswillmaketheveinincreaseitsvasodilation(this
shouldbedonepriortoprepping).

TheProcedure
Therearemanywaystoobtainabloodsampleusingthevenipuncturetechnique.Thefollowingproceduredescribestechniquesthatuse
Vacutainer,syringesandinfusionsets.UsecautionwhenusingVacutainerbecausetheycanexpertexcessivepressureandcausethevein
tocollapse.Vacuumtubesdrawbloodintothetubesusingselfcontainedvacuumpressure.Usecautionwhenusingasyringebecause
thetemptationwillbetopushthebloodsampleintothevacuumtubeusingthesyringeplungerandthiswillaffectthesample.

V. VACUTAINERSYSTEM
TheVacutainerconsistsofvacuumtubes,aneedleholder(Vacutainerbarrel),andadisposablemultisampleorsinglesampleneedle.
Newermultisampleneedleshaveguardsheaths.

Assembleyourequipment,prepareyourtubesintherightorderandplacetheappropriateneedleonyourVacutainerbarrel.Remove
protectivecoveringfromthreadedhubandscrewneedleintoholder.Placetubeinsidebarrelwithoutpuncturingtubetopwithneedle.

Thecorrectorderofblooddrawpreventscarryoverofadditivesbetweentubes.Theorderisusuallythefollowingwhenusinga
Vacutainer:
1. BloodculturesthisisusuallydonewithasyringeusingonlyChloraPrepforskinprep
2. Redtopchemistries,immunology,serology,bloodbank
3. Goldtopchemistries,immunology,serology
4. Lightbluetoprequiresfulldrawofsample,usesincludecoagulationtestssuchasprotimeandprothrombin
5. Greenand/orlavendertoprequiresfulldrawinvertatleast8timesslowlytopreventclottingandplateletclumping,uses
includehematology,bloodbank
6. Graytoprequiresafulldrawtopreventhemolysis,usesincludelithiumlevel,sodiumheparin,glucose.
 Besurepatienthasnocontraindicationsfortheuseofatourniquet.Firmlysecuretourniquetabout34inchesabovevenipuncture
site.Aveinmaycollapseiftourniquetistooclosetopuncturesite.Useawidetubebandtiedwithbowtiespointingupandawayfrom
thesite.Applyinamannerthatcanbeeasilyremoved.Neverleaveonformorethantwominutes.Latexiscommonlyuseda
tourniquet.Remembertoaskaboutallergiespriortoapplication.Considerusingbloodpressurecuffifpatienthasalatexallergy.

Palpateforaveinafterapplyingthetourniquet.Youshouldhavealreadyexaminedthevenipuncturesiteandthepatientsanatomy.
Tofindthevein:palpategentlyandfirmlyusingthedistalaspectsofyourindexfinger.Practiceonyourselfuntilyoucanfindavein
withyoureyesclosed.

Aveinwillreactimmediatelytoyourgentlepressure.Youwillfeelitbouncebackateverytouch.Youcanalsotaptheveinto
maketheveinmoreprominent.Allowgravitytohelpveinsenlarge.Iftheveinisverytightandhasnoflexibilityitmaybeatendon.
Ifithasapulse,itsanartery.Besureitisavein.

Placetubesinproperdrawsequencetopreventcontaminationbetweentubes.Putongloves!Cleansethesitewith70%isopropyl
alcoholswabsChloraPrep.Theskinshouldbecleansedwithslowandsmallcircularmotions.Startinthecenterofthesiteandmove
outwardtotheperiphery.Repeatprocessatleasttwotimes.Alwaysmoveoutandawayfromthesite.Thesiteshouldbesecuredprior
toskincleansing.Allowtheareatothoroughlyairdry.Alcohollysesredbloodcellsandcancauseintensestingingtothepatient.
NEVERblowonitorwavesomethingoversitetohastendrying.

Visualizewhatyouaregoingtodoandbeginbystretchingdownwardbelowvenipuncturesitewithoppositehandtoanchorthevein
andlimitmovement.Insertneedlewiththebevelfacingup,directlyoverandparalleltothevein,enteritimmediatelyadjacenttothe
vein.Insertneedlewithbevelupatabout1530anglesothattheneedlepenetrateshalfwayintothevessel.Greaterthan1530may
allowtheneedletopuncturethroughthefarwallofthevein.HoldtheneedlesteadyandengagetheVacutainertube.Avoidrotatingthe
needleforthiswilldamagethevesselwall.MovetheVacutainertubedownintothebarrelsothatthetubeispunctured.

Bloodisdrawnintotubesbyvacuum.MostVacutainertubesarenonsterileandhaveadditives.Thetubewillceasedrawingblood
whenitsvacuumisexpired(i.e.whenthetubeisfilled).Alwayshavenexttubeready.Rememberthatmultipletubesofbloodcanbe
drawnatthisonevenipuncturesitewithoutrestickingthepatient.

Anchorthebarrel/holdersecurelywhileremovingthefilledtubeandinsertthenexttube.WhenbloodflowsintothelastVacutainer
tube,releasethetourniquetandhavepatientrelaxhand.

Removeneedlefromskin.Oncetheneedleisout,forhemostasis,applyfirmpressureandholdasterile2x2coveringoversitewhile
armisoutstretchedorraised,neverbendarm.Applyfirmpressuretositeuntilbleedingstops,atleast34minutes.Dressthesitewith
gauzeandtapeoraBandaid(askaboutallergiespriortoapplyingdressing.NEVERRESTICKTHESAMESITE!!

RemoveVacutainertubefromtheholderpriortoneedleremoval.Discardtheneedleinapunctureresistantsharpscontainer.Be
suretogentlyagitatealltubesbytiltingthembackandforthtoensureadequatemixingofbloodwithadditiveagent.Ifmultipletubesare
drawncarefullyinverttubsandmixasrequiredforeachspecifictube.*Donotvigorouslyshaketubesasyoumaylysecells!Placetubes
inorderofdrawnearbytoconfirmthatsampleswerenotcontaminated.Cleananybloodspillagewithappropriatecleaningagent.

LabelallVacutainertubesaccordingtofacilityprocedure.Encloseinbiohazardcontainer.Checkonpatientagainandtheapplied
dressing.Makesurepatientisfeelingfineandshowsnosignsofvertigo,lightheadednessordiscomfort.

VI USINGASYRINGE

SyringesareusedwhenthepatientsveinsaresmallorfragileandVacutainertubesmaycausetheveinstocollapse.Theuseofasyringe
allowsforgreatercontrol.TheprocedureforusingasyringegenerallyfollowsthesamestepsastheVacutainerprocedure.The
exceptionsareasfollows:adifferentsampledraworder,theaspirationofbloodintothesyringeandthetransferofbloodintothevacuum
tubes.

Theorderofdrawisasfollows:
1. Bloodcultures,usingonlyiodineforskinprep.
2. Lightbluetoprequiresfulldrawofsample,usesincludecoagulationtestssuchasprotimeandprothrombin
3. Lavendertoprequiresdrawinvertatleast8timesslowlytopreventclottingandplateletclumping,usesinclude
hematology,bloodbank
4. Greentop
5. Graytoprequiresafulldrawtopreventhemolysis,usesincludelithiumlevel,sodiumheparin,glucose
6. Redtopchemistries,immunology,serology,bloodbank.
Thecleansingofthesite,siteselection,palpationandentryintotheveinarethesameaswhenusingaVacutainersystem.
Oncetheneedleisinthevein,pullbackgentlyonthesyringeplunger.Usingthesyringetobraceagainstyou,fillthesyringewiththe
desiredamountofbloodneededforthetubes.Releasethetourniquetandcompletethedressingprocedureusingthesametechniqueas
youdidfortheVacutainersystem.

Whentransferringthebloodfromthesyringetothetubesremovetheneedlefromthesyringeandreplaceitwithan18or19gauge
needle.Takeextremecaretopuncturethetubesintherightorderandallowthetubestofillbyusingthepressureofthevacuumtube.
DONOTUSETHEPLUNGERTOFILLTHETUBES.Continuewiththesamelabelingprocedureandensuringthestatusofthepatient
beforeallowingthemtoleave.
VII. USINGANINFUSIONSETORBUTTERFLY

AnIVinfusionsetorbutterflycanbeusedforvenipuncturewhendrawingfromahandorafootorfromaverysmallordifficult
vein.TheprocedureforcleansingthesiteisthesameasforuseofasyringeorVacutainer,althoughsitesnowincludethehandandthe
foot.Theinsertionoftheneedleshouldbeatalesseranglethanforeitheroftheothermethods.Theimportancewiththeinfusionsetis
totakecarewiththeneedleandnotmissthevein.

Infusionsetscomeindifferentsizesofneedlesandtheappropriateonefortheadult,childordifficultveinshouldbeselected.

Asyringeshouldbeattachedtothesetandcaretakennottouseexcessivesuctionfromthesyringeasthebloodisdrawnslowly
andcarefully.Theinfusionsethasaplasticwingswhichareattachedtoashortlengthofflexibleplastictubing,whichisthenattached
toeitherasyringeoratesttube.Bloodwillbevisibleinthetubingandthiswillallowforeasyaccessbysyringeassoonastheneedleis
inthevein.Fillsyringewithappropriateamountofbloodandreleasethetourniquet.Attachaneedleandtransferbloodtothe
appropriatetubesusingthesameorder,asyouwouldforasyringeblooddraw.

Whenusingasafetyinfusionset,slidethesafetycoverovertheneedleanddiscardtheset.Topreventanaccidentalrestick
withtheinfusionsetneedle,holdthebaseoftheneedleorthewingsasyouremovetheneedleorthewingsasyouremovetheneedleand
donotletgooftheneedlebaseuntilitisbeingplacedinthebiohazardsharpscontainer.

VIII.PITFALLS
1. Ifbloodisnotobtained,changethepositionoftheneedlecarefullybymovingitforwardorbackward.Alsoconsideradjusting
theangleoftheneedle.
2. Watchforformationofahematoma.Stoptheprocedureifahematomaoccurs.
3. Ifbloodstopsflowingintothevacuumtube,theveinmayhavecollapsed.Resecurethetourniquettoincreasevenousfilling.
Ifthisisnotsuccessful,removetheneedle,takecareofthepuncturesiteandredrawatanothersite.
4. Neverdrawfromathrombosedorscarredvein.Thrombosedveinslackresilience,feelcordlikeandrolleasy.
5. Neverattemptvenipunctureinanartery.Arteriespulsate,areveryelastic,andhaveathickwall.Ifyouseebrightredblood,
becautious,removethetourniquet,carefullyremovetheneedleandapplyfirmsteadypressureforatleast10minutes.
6. NeverdrawaboveanIVsite.Thefluidmaydilutethespecimen,socollectfromtheoppositearm.
7. Donotusealcoholforpreppingthesitewhendrawingabloodalcoholsample.
8. Neverdrawoverscarsoranewtattoosites.Itisdifficulttopuncturethescartissueandoneshouldnotcomeincontactwith
theinflamedtattoosite.
9. Edematousextremitieswithswollentissuealtertheresults.
10. Neverleaveatourniquetonformorethantwominutes.Thiscancausehemoconcentrationofnonfilterableelements.The
hydrostaticpressurecausessomewaterandfilterableelementstoleavetheextracellularspace.
11. Makesurethevenipuncturesiteisdry.
12. Whenusingasyringeavoiddrawingtheplungerbacktooforcefully.

IX.COMPLICATIONS
Thereareanumberofcomplicationsthatcanoccurwhenperformingvenipuncture.Thesecomplicationsincludeinfectionatthe
site,thrombosis,lacerationofthevein,andhemorrhageorhematomaatthesiteofthepuncture.Theriskofcomplicationsisincreased
withrepeatedpunctureatanysite.

Themostcommoncomplicationsarehemorrhageorhematomaatthesiteofpuncture.Thisoccurswhenbloodleaksintothe
tissuesafternickingorpenetratingthedistalwalloftheveinduringneedleinsertion.Useofthecorrectangleofneedleinsertioncan
minimizethisproblem.Also,takeyourtimeanddonotrapidlyinserttheneedle.Asmallergaugeneedlealsodecreasestheriskof
hemorrhageorhematoma.Ifahematomadoesdevelop,removethetourniquet,removetheneedleandmaintainpressureonthesiteforat
least10minutes.

Syncopecanoccurwhenperformingavenipuncture.Removethetourniquet,removetheneedle,applypressuretothesite,fix
withtapeandlaythepatientdown.Applyappropriatemeasurestowakethepatient.Thisisonereasonwhythebestpositionfor
performingvenipunctureishavingthepatientsupine.

VENIPUNCTURESUMMARY

I. Takeafewminutestobecomefamiliarwithyourpatient
A. Checkpatientidentification;makesureyouhavetherightpatient.
B. Makesurethepatienthasfollowedprelabinstructionpriortodrawingblood(i.e.fastingbeforebloodglucoseorlipid
profile).
C. Discusspatientspreviousexperiencewithvenipuncture(i.e.fainting,vomiting,etc).
 D. Explaintheprocedureandthattheremaybeinitialstingingandoccasionalbruising.
E.Answeranyquestionsthepatientmayhave.
REMEMBER:Painandbruisingareindirectlyproportionaltoyourpopularity!

II. PREPARATION
A. Knowyourlabstudiesandtheappropriatecorrespondingcolortoptubes.
B. Befamiliarwiththeamountofbloodneededinordertocompleteaparticularlabtest.Thiswillpreventunnecessarysticks.
C. Collectequipment.Youwillrequireantisepticswabs,absorbentcottonspongesorballs,tourniquet,Vacutainerbarrel,test
tubes,18,20or22gaugeneedles(besuretousemultisampleneedleswherepossible).
D. Placeallequipmentwithincomfortablereachingdistance.
E. Washhands.
F. Takethetimetofindagoodvein.Selectaslargeaveinaspossible.Checkantecubitalspacesbilaterally.Ifnoneavailable
startdistallyandworkproximal.Learntouseyoursenseoftouch.Dontrelytotallyonvision.Darkskinanddeepveins
aredifficulttovisualize.DifficultstickssuchasIVDUaskthepatientwhereagoodveincanbefound.
G. Positionyourpatientcomfortably.Ifpossible,laypatientdown.Thistendstorelaxthepatient.

III. PROCEDURE
A. Putongloves!
B. Removeprotectivecoveringfromthreadedhubandscrewneedleintoholder.Placetubeinsidebarrelwithoutpuncturing
topoftubewithneedle
C. Firmlyplacetourniquetproximaltovenipuncturesite.Applyinamannersoitcanberemovedeasily.Neverleaveonmore
thantwominutes.
D. Mayhavepatientpumpfistgentlyorcantapveintomaketheveinmoreprominent.
E. Prepareausingantisepticwipetocleansite.Cleansiteusingacircularfashionfromcentertoperiphery.Repeat.
F. Stretchskindownwardbelowinjectionsitewithoppositehandtoanchortheveinandlimitmovement.
G. Insertneedlewithbarrelatabout30anglesothattheneedlepenetrateshalfwayintothevessel.CompressVacutainertube
downintothebarrelsothattubeispunctured.
H. AsbloodflowsintotheVacutainertubereleasethetourniquetandhavepatientrelaxhand.Ifadditionaltubesarerequired,
donotremoveneedle.Simplyanchorthebarrel/holdersecurelywhileremovingthefilledtubeandinsertthenexttube.
I. Bloodisdrawnintothetubesbyvacuum.MostVacutainertubesarenonsterileandhaveadditives.Thetubewillcease
drawingbloodwhenthevacuumisgone(i.e.whenthetubeisfilled).
J. RemoveVacutainertubefromtheholderpriortoneedleremoval.(Remember,multipletubesofbloodcanbedrawnatthis
onevenipuncturesitewithoutrestickingthepatient).Removeneedlefromskin.Forhemostasis,holdsterilecoveringover
sitewhilearmisoutstretchedorraised.Applyfirmpressuretositeuntilbleedingstops.DresssitewithBainaidornon
sensitizingtape.
K. Besuretogentlyagitatealltubesbytiltingthembackandforthtoensureadequatemixingofbloodwithadditiveagent.*Do
notvigorouslyshaketubesasyoumaylysecells!
L. Carefullydisposeofneedleinappropriatesafetycanister.Cleananybloodspillagewithappropriatecleaningagent.
M. LabelallVacutainertubesaccordingtofacilityprocedure.

HELPFULHINTSFORDRAWINGBLOOD
A. Alwaysinformthepatientaboutwhatyouaregoingtodo.Anxietycancausetheveintospasmorconstrict.This
makesthevenipuncturemoredifficult.
B. Be/appeartobeorganizedandconfident.Thisalsohelpstoallayanxiety.
C. Ifthepatienthashardtofindorcollapsibleveins,try:
1. Keepingtheextremitybelowtheleveloftheheartforafewminutes.Applyingawarmhotbottle
orwarmtoweltotheextremitytopromotevasodilatationfromtheheatORusingabloodpressurecuffasa
tourniquet.Havepatientpumphandwhilethetourniquetisonandwhiletheextremityisstillinadependent
position.Remembernottooccludearterialpressureofthepulse.ORVigorouslyrubbingoverthepossible
puncturesidewithalcoholprepwillsometimesmaketheveinstandup.
2. AvoidtheuseoftheVacutainer.Vacutainersexertexcessivevacuum,whichcancausetheveintocollapse.Usea
syringeandbutterflyneedleandtransferthebloodfromthesyringetothetubes.
3. Whentransferringbloodfromsyringetobloodtube,donotpushplunger;vacuuminthebloodtubewilldrawthe
bloodintothetube.
a. ForCBC,removerubberstopperandtransferthebloodtothetubeandrecap.
b. Acleanneedlethroughtherubbercapwillrecreateasealsothatthecapwillnotpop
off.
4. Manytimesthesmallbluetoptubescontainlittleornovacuum,makingitdifficulttoimpossibletogetbloodwith
aVacutainer.Alwayscarryanextrabluetoptubeinyourpocket.
5. CBCorlavendertoptubeshavepreservativeinthemtokeepthebloodfromclotting.Youmustalwaysgently
rotatethebloodinthetubebeforeputtingitdown.

AclottedCBCtubeisUSELESS!