Blood Extraction (Vacutainer, Syringes, Butterfly) Procedure

1. Before entering patient room, assemble all equipment

A. Equipment for collecting blood
 Laboratory sample tubes for blood collection (sterile glass or plastic tubes with
rubber caps, vacuum extraction blood tubes, or glass tubes with screw caps).
EDTA tubes are preferred
 Blood sampling systems (Needle and syringe system, vacuum extraction system
with holder, winged butterfly system (vacuum extraction) or winged butterfly
system
 Tourniquet (single-use)
 Skin antiseptic solution: 70% isopropyl alcohol
 Gauze pads
 Adhesive bandage
 Tray for assembling blood collection tools
 Rack for holding blood tubes
 Durable marker for writing on laboratory sample
B. Assemble equipment for preventing infections
 For Hand Hygiene: use Alcohol-based hand rubs OR Clean, running water, Soap
Disposable (paper) towel
 Personal Protective Equipment (PPE)
 For waste management materials: Leak-proof and puncture resistant sharps
container and proof infectious waste bags
2. Perform hand hygiene
3. Put on Personal Protective Equipment (PPE)
4. Prepare room.
 Put infectious waste bags and leak-proof and puncture resistant sharps
container into patient room and make sure they are ready for use.
 Place all blood collection equipment in a place that is easy to access.
5. Identify and prepare the patient.
 Introduce yourself to the patient and explain what you will do with the blood
sample and why.
 Make sure that this is the correct patient from whom you wish to take the
blood sample
6. Select the site, preferably at the bend of the elbow.
 Palpate the area; locate a vein of good size that is visible, straight and clear.
 The vein should be visible without applying a tourniquet
7. Apply a tourniquet around the arm.
 Tie approximately 4–5 finger widths above the selected site.
 Ask the patient to form a fist so that the veins are more prominent.
8. Disinfect the area where you will put the needle.
  Use 70% isopropyl alcohol. Wait 30 seconds for the alcohol to dry. DO NOT
touch the site once disinfected.
9. When using vacuum extraction system with holder, insert the blood collector tube into
the holder.
 Avoid pushing the collector tube past the recessed line on the needle holder or
you may release the vacuum

10. Anchor the vein by holding the patient’s arm and placing a thumb BELOW the place
where you want to place the needle.
 DO NOT touch the disinfected site. DO NOT place a finger over the vein to guide
the needle.
11. Perform the blood draw.
 Enter the vein swiftly at a 30 degree angle.
 Line up the needle with the vein. Make sure the bevel is up
12. When blood starts to flow, ask patient to open his/her hand
13. Once sufficient blood has been collected (minimum 5ml), release the
tourniquet BEFORE withdrawing the needle
14. Withdraw the needle gently.
 Give the patient a clean gauze or dry cotton wool ball to press gently on the site.
 Ask the patient NOT to bend the arm.
15. Remove blood collector tube from holder and put into rack.
16. Put needle into leak-proof and puncture resistant sharps container.
17. Stop the bleeding and clean the skin.
 Do not leave patient until bleeding has stopped.
 Put an adhesive bandage on the site, if necessary.
18. Put items that drip blood or have body fluids on them into the infectious waste
bag.

19. Ask the designated assistant to approach the patient room, without entering.
 This person should have gloves on. This person should come close to you holding the
open plastic leak-proof packaging container.

20. The person who has collected the blood sample should put the wrapped tube of
blood into the plastic leak-proof packaging container for transport to the
respective laboratory.
 Be careful not to touch outside of leak-proof plastic tube with gloves.
21. Remove Personal Protective Equipment (PPE) and do Handwashing.
 IV Cannulation and Infusion

Pre-Catheterization or Preparation

1. Review Physician’s Order

A physician’s order is necessary to initiate IV therapy. The physician’s order should include:
 Type of solution to be infused
 Route of administration
 Exact amount (dose) of any medications to be added to a compatible solution either
hourly or 24-hour volume
 Rate of infusion
 Duration of infusion or the time over which the infusion is to be completed
 Physician’s signature

2. Observe Hand Hygiene Procedures

Indications for handwashing and hand antisepsis:

 Wash hands with either a non-antimicrobial soap and water or an antimicrobial soap
and water when hands are visibly dirty or contaminated with blood or other body fluids.
 If hands are not visibly soiled, use an alcohol-based hand rub to avoid routinely
contaminating hands in all other clinical situations.
 Decontaminate hands before having direct contact with patients
 Do not wear artificial fingernails or extenders when having direct contact with patients
at high risk
3. Gather Equipment
 Prepare and gather the equipment’s needed for starting the IV. Always check for the
fluid’s expiration date.
 Inspect solution container for integrity.
 Glass containers. Hold up to light to look for cracks, clarity, particulate contamination,
and expiration date.
 Plastic containers. Squeeze to check for pinholes, clarity, particulate contamination, and
expiration date.
 Inspect administration set
 Choose the appropriate set: vented or nonvented
 Gather venipuncture and dressing supplies
 Catheter (22 g, 20 g most common)
 Dressing (gauze)
 Tape: 1-inch paper
 Prepping solution
 Gloves 2×2 gauze
4. Patient Assessment and Psychological Preparation
 It’s important to also prepare the patient on the procedure.
 Introduce self and verify the client’s identity.
 Provide privacy
 Explain the procedure to the client. A venipuncture can cause discomfort for a few
seconds, but there should be no discomforts while the solution is flowing.
 Evaluate the patient preparedness for IV procedure by talking with patient before
assessing veins

PATIENT INFORMATION TO CONSIDER

 Patient’s medical diagnosis.

 History of chronic disease that places patient at risk for complications.
 History of vasovagal reactions during venipuncture or when blood is seen.
 Has the patient had vascular access devices?
 Will the patient be going home with the catheter?
 If cultural barrier exists, take more time; speak slowly and distinctly but not louder. Use
pictures. Keep messages simple, and use interpreter to improve communication.
 Assess both arms and hand prior to choosing appropriate vein.
 Choose the lowest best site for size catheter being inserted and type of therapy the
patient will receive.
 Assess for any allergies (e.g., to tape or povidone-iodine)
 Vital signs for baseline data
 Skin turgor
 Allergy to latex, tape or iodine
 Bleeding tendencies
 Disease or injury to extremities
 Status of veins to determine appropriate venipuncture site
5. Site Selection and Vein Dilation

There are several factors you need to consider before initiating venipunctures:

 Type of solution to be infused. Hypertonic solutions and medications are irritating to

vein.
 Condition of vein. Use soft, straight, bouncy vein; if you run your finger down the vein
and it feels like a cat’s tail — avoid! Avoid veins near previously infected areas.
 Duration of therapy. Choose a vein that can support IV therapy for 72–96 hours.
 Patient age. Elderly and children need additional time for assessment and management
of insertion.
 Patient activity. Ambulatory patients using crutches or walker need catheter placement
above the wrist.
  Presence of disease or previous surgery. Patients with vascular disease or dehydration
may have limited venous access. If a patient has a condition causing poor vascular
return (mastectomy, stroke), the affected side must be avoided.
 Presence of shunts or graft. Do not use the arm or hand that has a patent graft or shunt
for dialysis.
 Patient receiving anticoagulation therapy. Patients receiving anticoagulant therapy have
a propensity to bleed. Local ecchymosis and major hemorrhagic complications can be
avoided if the nurse is aware of the anticoagulant therapy.
Precautions: Minimal tourniquet pressure; use the smallest catheter that is appropriate
for therapy; use care in removing dressing.
 Patient with allergies. Question regarding allergies to medications, foods, animals, and
environmental substances. Identify the allergens:
 Iodine. Avoid povidone-iodine as skin preparation
 Latex. Set up latex allergy cart

VEIN DILATION TECHNIQUES

Use the techniques below to dilate the vein:

 Tourniquet. Latex or non-latex used most frequently. Placed 6–8 inches above the
venipuncture site. If BP high, move farther from venipuncture site. If BP low, move as
close as possible without risking site contamination.
 Gravity. Position the extremity lower than the heart.
 Fist clenching. Instruct patient to open and close his/her fist.
 Tapping vein. Using thumb and second finger, flick the vein; this releases histamines
beneath the skin and causes dilation. Do not slap the vein.
 Warm compresses. 10 minutes maximum. Do not use microwave!
 Blood pressure cuff. Inflate to 30 mmHg; great for fragile veins.
 Multiple tourniquet technique. Use 2 to 3 latex tourniquets; apply one high on arm and
leave for 2 minutes; apply second at mid arm below antecubital fossa; collateral veins
should appear; apply third if needed.

Tips for selecting veins

 Suitable vein should feel relatively smooth and pliable, with valves well-spaced.
 Start with distal veins and work proximally.
 Veins that feel bumpy (like running your finger over a cat’s tail) are usually thrombosed
or extremely valvular. Veins will be difficult to stabilize in a patient who has recently lost
weight.
 Catheterization or Catheter Insertion

6. Needle Selection
 The smaller the gauge number, the thicker the catheter and the more rapidly medicine
can be administered and blood can be drawn.
 Thicker catheters cause more painful insertion, so it’s very necessary not to use a
catheter that’s larger than you need.
 The tip of the catheter should be inspected for integrity prior to venipuncture.
 Only two attempts at venipuncture are recommended.

Size Color Recommended use

14G Orange In massive trauma situations.

16G Gray Trauma, surgeries, or multiple large-volume infusions

18G Green Blood transfusion or large volume infusions.

20G Pink Multi-purpose IV; for medications, hydration, and routine therapies.

22G Blue Most chemo infusions; patients with small veins; elderly or pediatric patients

24G Yellow Very fragile veins; elderly or pediatric patients

7. Don your gloves
8. Site Preparation
 Apply antimicrobial solution, working from center outward in a circular motion for 2-3
inches for 20 seconds. Use enough friction.
 Do not shave site. Shaving can cause micro abrasions; remove hair with scissors or
clippers only.
 Cleanse insertion site with one of the following solutions:
 2% Chlorhexidine gluconate (preferred)
 povidone-iodine
 70% Isopropyl alcohol
9. Insertion of Catheter into Vein
9.1 Place the extremity in a dependent position (lower than the client’s heart).Gravity
slows venous return and distends the veins. Distending the veins makes it easier to
insert the needle properly.
9.2 Apply a tourniquet firmly 15 to 2 cm above the venipuncture site. Explain that it will
feel tight. Tourniquet must be tight enough to occlude venous flow but not so tight
that it occludes arterial flow. Obstructing arterial flow inhibits venous filling. If a
radial pulse can be palpated, the arterial flow is not obstructed.
9.3 Use the non-dominant hand to pull the skin taut below the entry site.
This stabilizes the vein and makes the skin taut for needle entry. It can also make
initial tissue penetration less painful.
9.4 Hold the over-the-needle catheter at a 15-to 30-degree angle with bevel up, insert
the catheter through the skin and into the vein.
Sudden lack of resistance is felt as the needle enters the vein. Jabbing, stabbing or
quick thrusting should be avoided because it may cause rupture of delicate veins.
9.5 Advance the needle catheter approximately 1 cm.
Once blood appears in the lumen or you feel the lack of resistance, lower the angle
of the catheter until it almost parallel with the skin and advance the needle catheter
approximately 1 cm.
9.6 Holding the needle portion steady, advance the catheter until the hub is at the
venipuncture site.
The catheter is advanced to ensure that it, and not just the metal needle, is in the
vein.
9.7 Release the tourniquet.
9.8 Apply pressure.
Put pressure on the vein proximal to the catheter to eliminate or reduce blood
oozing out of the catheter. Stabilize the hub with thumb and index finger of the non-
dominant hand.
9.9 Remove the protective cap from the distal end of the tubing.
Hold it ready to attach to the catheter, maintaining the sterility to the end.
 9.10 Remove the needle.
Carefully remove the needle, engage the needle safety device, and attach the end of
the infusion tubing to the catheter hub.
9.11 Initiate the infusion.
9.12 Tape the catheter. Tape the catheter by the “U” method or according to the
manufacturer’s instructions. Using three strips of tape (about 3 inches long).
9.13 Dress and label the venipuncture site and tubing according to agency policy.
Label should have date on which administration set must be changed. The
venipuncture site should also be labeled with the date and time, and type and
length of catheter.
9.14 Document the relevant data, including assessments.

Post-Catheterization

 Labeling: Insertion site

The venipuncture site should be labeled:
 Date and time
 Type and length of catheter
 Nurse’s initials
 Solution container
 Place a time strip on all parenteral solutions
 Any additives must have a clear label applied to bag
 Equipment Disposal
 Needles and stylets shall be disposed of in non permeable, tamper-proof
containers.
 Dispose of all paper and plastic equipment in a biohazard container.
 Patient Education
 Patient must receive information on all aspects of their care. After catheter is
stabilized, dressing is applied, and labeling complete:
 Inform regarding any limitations of movement or mobility
 Instruct to call for assistance if venipuncture site becomes tender or sore or if
redness or swelling develops
 Advise that site will be checked every shift by the nurse
 Rate Calculation
 Ensure appropriate infusion flow.
 Do not leave patient care environment until rate is calculated and adjusted
accordingly.
 Documentation
 Document the relevant data, including assessments.
 Record the start of the infusion on the client’s chart.
 Include the date and time of the venipuncture
 The gauge and length of the device
 Specific name and location of the accessed vein
 Amount of solution used, including any additives
 Container number
 Flow rate
 Type, length and gauge of the needle or catheter
 Venipuncture site, how many attempts were made and location of each attempt
 The type of dressing applied
 The client’s general response
 Your signature