The Venipuncture From an Arm Vein

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22 So You’re Going to Collect a Blood Specimen: An Introduction to Phlebotomy Hospitalized patient not in bed Have the patient sit at a small table where the elbow can be placed on a hard surface, or in a position in which the arm can be placed across the bed. If necessary, put a small pillow or a roll of towels under the extended arm to support it. Outpatient/ambulatory patient Ask the patient to sit in a chair designed for phlebotomy or at a small table where the elbow is placed across a hard surface. This will ensure that there is sufficient support for the arm. This support will help prevent the patient from pulling the arm back when the needle is inserted into a vein. For infants or small children, have a second individual, such as a parent, hold the arm of the child firmly so that the arm will not jerk suddenly when the needle is inserted into the vein. Home visits Tourniquet Pillow Follow the same principles outlined above. Do not place your equipment on or near food. Ensure patient safety since there may not be any help available if the patient faints (see pages 36–37). Some patients may have fragile bones or restrictions to phlebotomy sites due to recent surgeries. Make certain to obey any signage that warns the phlebotomist against potential injuries to the patient from phlebotomy. Hospitalized patient in bed Make sure the patient is in a position where the arm is easy to access for venipuncture. Place the blood collection tray where it is readily available but is not in danger of being upset by the patient. Never put your equipment on the patient’s bed. Never label tubes prior to collection. Never leave any equipment in the room. Before phlebotomy, always ask patients if they are taking anticoagulants or if they have an inherited blood clotting problem. Patients who are taking medicine to prevent their blood from clotting (ie, anticoagulants such as coumadin, heparin, or aspirin) or patients who have inherited a blood clotting abnormality (eg, hemophilia) may continue to bleed from the punctured vein. If this bleeding is not stopped, blood may accumulate within the tissues of the arm, specifically in the enclosed area of the arm that surrounds the muscle. This bleeding can lead to compartment syndrome, a condition in which the blood accumulates in a contained space within the arm such that the pressure produced can interfere with blood flow and may injure the muscle. This is a rare but very serious complication and requires an emergency surgical procedure to open the compartment, relieve the pressure, and stop the bleeding.
Never attempt venipuncture on a standing patient. Patients sometimes faint during or after venipuncture. A standing patient might suddenly collapse. So You’re Going to Collect a Blood Specimen: An Introduction to Phlebotomy 23 Selecting the vein for venipuncture Whenever possible, a blood specimen should not be obtained from an extremity when an IV is running (see page 31) or when dermatitis (skin inflammation) is present over the vein. If the patient has had a mastectomy with lymph nodes removed from the underarm area, a physician’s authorization is required prior to performing phlebotomy on the involved extremity. The patient may offer specific information about arm preference, and it is important for you to listen to their specific needs. Follow any special instructions of the ordering physician or laboratory. Inspect the preferred arm first. If it appears good, attempt to draw from this arm. You may be able to see the vein. Veins appear blue and are slightly raised above the skin surface. Veins may be more difficult to see in obese people. Gloves can be put on at this point or they can be put on just before the venipuncture. Consult your institution’s policy/procedure and follow the established guidelines. Always wash your hands or use an alcohol-based hand rub before you glove, and wear new, properly fitting gloves. Never tear or remove the tip of the finger of the glove for any reason. Attach an unused sterile needle to the needle holder and assemble the necessary blood collection tubes. Always have extra evacuated tubes close at hand in case problems are encountered with the original tubes. Apply the tourniquet about 3 inches above the elbow, or midway between the elbow and shoulder. z The tourniquet must be applied with enough tension to compress the vein, but not the artery. (An artery carries blood into the area, and if the tourniquet is too tight, blood flow will slow or stop.) z If appropriate, have the patient form a fist to make the veins more prominent, thus aiding in identification of the vein. There must not be any hand “pumping,” which can alter some analyte concentrations. Asking the patient to clench their fist repeatedly has been reported to be a common error in phlebotomy practice. z Have the patient keep their hand closed until blood is flowing freely into the tube, and then ask the patient to open their hand. z Some special tests may require that blood be collected without a tourniquet. Consult your phlebotomy manual or ask your supervisor for information. z Do not leave the tourniquet on for more than 1 minute while you search for a vein. If more than 1 minute passes, release the tourniquet for at least 3 minutes. Then, reapply the tourniquet. Inspect and palpate the area to find a vein. Prolonged obstruction of blood flow by the tourniquet (ie, tourniquet in place for longer than 2 to 3 minutes) changes some test results. Always palpate or feel for the vein, even when the vein is seen. This procedure gives you practice in finding deeper, unseen veins. The vein will feel like an elastic tube that “gives” under the pressure of your finger. Arteries pulsate, so make certain the structure you feel is not pulsating.
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The Venipuncture From an Arm Vein

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