reference: pl-415 originated: 11/89 revised: 5/03, 2/05, 2

Reference: PL-415 Originated: 11/89

Revised: 5/03, 2/05, 2/07, 11/08, 7/09, 7/10 of 12

Approval: ____________________________ Chief Executive Officer Date ____________________________ Chief of Staff Date ____________________________

Chief Nursing Officer Date

____________________________ Laboratory Medical Director Date

SADDLEBACK MEMORIAL MEDICAL CENTER Policy/Procedure

SUBJECT: ADULT VENIPUNCTURE AND CAPILLARY PUNCTURE PROCEDURE POLICY: Blood for Laboratory testing must be collected by the most appropriate method for both the test required and for the patient. For general purposes, venous blood samples are preferable to capillary. They allow for multiple and/or repeated hematological and chemical examinations upon a single blood sample. PROCEDURE: THE MOST IMPORTANT STEP IN THE PERFORMANCE OF A VENIPUNCTURE IS PATIENT IDENTIFICATION! See the SMMC Patient Identification Procedure PC-008 The SMMC barcode identification system is to be utilized whenever possible in the locations where it has been implemented. This system is a patient identification system. The patient’s ID band is scanned, the phlebotomist confirms the patient’s ID by section 1.2 listed below, then collects the specimen. Once the specimen is collected, the phlebotomist enters the appropriate information about the collection and the labels are then printed at the bedside. These labels must be checked that they contain all of the required data for that patient’s specimen and are then immediately applied to the specimen containers. This barcode scanning system is not a label maker. If labels are printed, the orders are status’d as collected as if the person using the system performed the complete patient –sample identification and the lab will expect the specimens to be sent to the lab at that time. If an RN from a unit that does not have the Lattice device needs labels for blood samples they will be collecting, they can call the lab and request the lab to send the labels up to them via the tube system (At the Laguna Hills Campus) or they may use the addressograph or computer generated labels. They must then follow the identification verification steps listed below.

1. PATIENT APPROACH/IDENTIFICATION

1.1 Hospital badges must be visible to the patient.

Reference: PL - 415 of 12

1.2 As you enter the patient’s room, check for any patient isolation or precautions, which may require masks, gown, etc or restrictions on either arm for performing phlebotomies.

1.3 Identify yourself and provide an explanation that the MD has ordered some lab tests and that you are there to obtain a blood specimen. If the patient wants to know what specific tests are ordered, give the patient the name of the tests. If the patient wants further explanation of the purpose of the tests, the RN or MD can provide the explanation.

1.4 Always wash your hands prior to touching the patient or assembling supplies. You can wash your hands in the sink with soap and water or use the foam or gel cleansers.

1.5 If utilizing the SMMC Barcode scanning device:1.5.1 Double click onto the patient’s name and room number in the Lattice to bring up the

screen where you are ready to scan the patient’s armband. The patient’s name and Date of Birth (DOB) is listed on this screen.

1.5.2 Positively identify the patient by asking the patient to state his or her full name and their date of birth. If patient is unable to state their name or their date of birth, ask a family member or caregiver to state the patient’s full name and DOB if possible. 1.5.3 Compare the information stated by the patient, caregiver or relative with the

information in the Barcode device. If the information does not match, DO NOT CONTINUE WITH THE VENIPUNCTURE. Verify that the information on the armband matches the information that the patient stated and that the information on the armband is correct. If it is not correct, notify the RN in charge of the patient. Do not draw until the armband has been verified or corrected. 1.5.4 Scan the patient’s armband. If the armband does not scan, notify the RN that the armband needs to be replaced before the patient can be drawn.

1.5.5 If, when you scan the armband, the Lattice device makes an unusual noise or alarm, check if there are any error codes before going forward with the venipuncture.

1.6 If you are NOT using the barcode device: 1.6.1 Before approaching the patient, the phlebotomist should check that all of the labels in His/her hand are all for one patient. All other patient labels should be put in a pocket or drawer of the cart in order to prevent mis-labeling specimens. 1.6.2 Ask the patient to state their full name and their Date of Birth, comparing what the patient states to the labels or requisitions. 1.6.3 Hold the labels or requisitions next to the armband to check that the full name and medical record number (or DOB) on the armband matches the requisitions. 1.6.4 If at any point during this process the information does not match, DO NOT CONTINUE WITH THE VENIPUNCTURE. Compare the information stated by the patient with the labels and the armband. Notify the RN in charge of the patient if the information on the armband does not match what the patient states. Do not draw until the armband has been verified or corrected.

2 VENIPUNCTURE PROCEDURE

2.1 Assemble supplies: 2.1.1 Gloves – once hands are washed and completely dry, put on the gloves. 2.1.2 Tourniquet – a tourniquet is used to increase intravascular pressure, which

facilitates vein palpation and filling of the tubes or syringe. Without tourniquet application, the collector may not be able to prioritize the antecubital veins for safety. When all available veins are considered, collectors are more likely to find antecubital veins that are not in close proximity with the brachial artery or median nerves when the tourniquet is utilized. Tourniquets are disposable and used on one patient only.

2.1.3 Select appropriate blood collection system. (Vacutainer, syringe with needle or syringe with butterfly.)

2.1.4 gauze pads


2.1.5 70% Isopropyl alcohol prep pads 2.1.6 tape or band-aids. 2.1.7 Select appropriate safety needles

2.1.7.1 (usually 21-22G) for that blood collection system (vacutainer vs. syringe). 2.1.7.2 Needles with a small bore (23G or smaller) or very large bore (18G or

larger) are generally avoided with the Vacutainer system because they may cause hemolysis of specimen. (25 gauge butterflies are only used on neonates)

2.1.8 BD Blood Transfer Device 2.1.9 Select the appropriate tubes for the tests ordered. (EACH tube MUST be inspected

for expiration date prior to use. Expired tubes may not be used and MUST be discarded immediately.) 2.1.9.1 Tubes are to be filled in the following order:

2.1.4.1.1 Blood Cultures 2.1.4.1.2 Blue with X marked on it (Discard) if this is the first tube with

vacutainer (this takes out any tissue fluids that can affect the coagulation tests and also insures that air is removed if using a butterfly to ensure that the next blue top tube is filled completely.) 2.1.4.1.3. Blue (Must be completely filled) 2.1.4.1.4 SST (Gold) or Plain Red 2.1.4.1.5 Green (Heparin or PST) 2.1.4.1.6 Lavender

2.1.4.1.7 Pink 2.1.4.1.8 Gray

2.2 Select the most appropriate site for venipuncture: The preferred venipuncture site is the

antecubital fossa, which is the area of either arm that is anterior (in front of) and below the bend of the elbow where a number of large veins lie relatively near the skin’s surface. When antecubital veins are not acceptable or unavailable, veins on the back of the hand or forearm are also acceptable for venipuncture. Veins on the underside of the wrist must not be used, as nerves and tendons are close to the surface of the skin in this area. 2.2.1 Properly position the patient. (Never draw from a standing patient) 2.2.2 Check above the patient’s bed for “Pink Restricted Extremity Alert”. Always check the patient’s arms for pink “Restricted Extremity Alert” armbands by checking both wrists. These armbands indicate that no venipunctures are to be done or that blood pressure cuff or tourniquet should not be applied to that particular arm.

2.2.2.1 If the patient has pink armbands on both arms: 2.2.2.1.1 Perform a fingerstick if the tests are those that can be obtained

utilizing a fingerstick, unless the patient has had mastectomies on both sides. If that is the case the RN/MD should be consulted as to how the blood should be collected.

2.2.2.1.2 If the labs require a venipuncture, consult with the RN to see if the MD has given instructions on obtaining blood for lab tests.

2.2.2.1.3 If not, ensure that the RN will consult with the MD for instructions of how the blood samples will be obtained from the patient.

2.2.2.1.4 Do not draw the patient until the MD instructions are obtained. 2.2.3 Perform hand hygiene and put on gloves before drawing blood, but after

entering the patient’s room (except with isolation patients where the gloves are put on prior to entering the room)

2.2.4 Extend patient’s arm fully.


2.2.5 Place a tourniquet on the patient’s arm by stretching the ends of the tourniquet around the patient’s arm about 3 to 4 inches above the venipuncture site. Tuck in one side of the tourniquet next to the skin, which makes a partial loop with the tourniquet in order to keep it tight. (Do not leave the tourniquet on longer than 1 minute.)

2.2.6 If the patient has any sores on their arm, you can place the tourniquet over the hospital gown or a piece of gauze. You may also use a blood pressure cuff pumped up to 40 mm Hg, but it has the same time limit of 1 minute as the tourniquet.

2.2.7 Typically, a tourniquet is used to aid in the selection of a vein site unless specific tests require that tourniquets not be used (i.e. Lactate). A tourniquet is not necessary if veins are large and easily palpated. However, if only the basilic vein is visible without a tourniquet, one must be applied so the availability of safer veins can be accessed.

2.2.8 Have the patient make a fist, but do not have them pump their fist. 2.2.9 Look for an obvious good vein by palpating with your index finger. The collector’s

thumb should never be used to palpate, because it has a pulse beat. In addition to locating veins, the palpation pressure helps to differentiate veins from arteries, which pulsate, are more elastic, and have a thick wall.

2.2.10 The median cubital vein is usually the easiest to access and is the most comfortable for the patient. (see diagram below)

2.2.10.1 The next choice would be the cephalic vein located more toward the outside portion of the arm.

2.2.10.2 The last choice in the cubital area would be the basilic vein. This is last due to the close proximity of the vein to the median nerve and brachial artery.

2.2.10.3 Other veins on the back of the hand, wrist or arm may be used if there are no other sites available.

2.2.10.4 Veins on the underside of the wrist must not be used, as nerves and tendons are close to the surface of the skin in this area.


2.2.11 Palpate vein and release tourniquet until ready to draw. 2.2.12 The following must be adhered to when assessing and selecting the site for venipuncture:

2.2.12.1 Do NOT draw above an IV site; either select a vein on the opposite arm from the IV or preferably a different vein distal to the IV site. 2.2.11.2 Do not draw from same side as a mastectomy.

2.2.11.3 Do not draw from vein used for dialysis.2.2.11.4 Do not draw from a hematoma 2.2.11.5 Avoid veins that are in close proximity to arteries. If, during the procedure,

accidental arterial puncture is suspected, discontinue the venipuncture immediately. Remove the needle and apply direct forceful pressure to the puncture site for 5 minutes until active bleeding has ceased. Notify the MD or RN and document incident.

2.3 Prepare puncture site: 2.3.1 Swab area with 70% alcohol wipe. Rub the wipe vigorously starting directly over the draw site.If a blood culture is ordered, use a blood culture prep kit following directions in Procedure PL-417 - Blood Culture Collection. 2.3.2 Air dry or wipe dry with gauze. Do not blow on the site. 2.3.3 Reapply the tourniquet. (Do not leave on longer than one minute) If the tourniquet

is left on longer than 1 minute it could cause localized stasis with hemoconcentration and infiltration of blood into the tissue.

3. VENIPUNCTURE TECHNIQUE 3.1 Enter vein:

3.1.1 Prepare the patient by verbally reassuring them to avoid any sudden jerking movements by the patient.

3.1.2 Keep the bevel of needle up before entering the vein. 3.1.3 A well-supported vein is essential. Pull the skin taut over the vessel by

drawing it distally with the thumb of one hand. 3.1.4 Enter in a rapid and smooth fashion at a 15-30 degree angle to the patient's

arm an in direct line with the vein. 3.1.5 Insert the needle through the skin about 1/2 inch below the most prominent

portion of the vein and in a direct line with the vessel. The point of the needle may be directed into the lumen of the vein by palpation.

3.1.6 Immediately upon entering the venous channel, push a vacutainer tube onto the adapter and blood will usually appear. With syringe, exert a slight pull on the plunger to check whether the needle is in the vein. Care must be taken not accidentally withdraw the needle while pulling back the plunger and NOT to pull too hard, which could cause hemolysis of the red cells or collapse of the vein. Now advance the needle a short distance further into the lumen of the vein.

3.1.7 If multiple tubes are drawn, remove the tube as soon as the blood flow stops and insert the next tube into the holder. Collect the tubes in the order as listed in section 2.1.9.1.

3.1.8 Mix tubes with anticoagulants gently, but IMMEDIATELY after removing tube from the vacutainer. (Anticoagulated tubes mix 8-10 times to avoid platelet clumping and to insure mixture with anticoagulant. All tubes with clot activators mix 5 times to initiate clotting). The phlebotomist can mix one tube while the other tube is filling, when using the vacutainer system.

3.1.9 Release the tourniquet as soon as possible. (Do not leave on longer than one minute.) Discard tourniquet.


3.2 Withdrawing from the vein: 3.2.1 After the tourniquet has been released, remove the tube from the

Vacutainer leur needle first before removing the needle from the arm. (Follow proper procedure using safety needle devices.)

3.2.2 Fold gauze over the puncture site and apply pressure. 3.2.3 After pressure has been applied, make a pressure bandage using the

gauze and micropore tape to help ensure that the bleeding has stopped. 3.2.4 Notify patient that they can remove the tape after about 30 minutes. 3.2.5 For Outpatients which have had coagulation testing, self adherent Coban

wrap can be used as a substitute for tape.

3.3 Use of Safety needle - “ECLIPSE Blood Collection Needle” (B-D Vacutainer)3.3.1 Holding the colored shield and cap together, twist and remove the white

protective end cap. 3.3.2 Screw needle onto the holder. (This is the “Leur” end of the needle). 3.3.3 Pull the pink needle shield back toward the needle holder. 3.3.4 Twist and pull the needle cap straight off. 3.3.5 Perform the venipuncture. 3.3.6 Immediately after removing the needle from the patient activate the pink

safety shield by firmly pushing forward on the pink safety shield with your finger and lock it into place. This should be done by the hand holding the needle and holder.

3.3.7 DO NOT attempt to snap the safety shield into place on the patient’s arm, bed or any solid surface. Point the needle away from patient.

3.3.8 Discard the Eclipse safety needle with the holder attached into an appropriate sharps container.

3.3.9 Be careful not to stick your finger into the needle holder with the Leur end of the vacutainer needle. The rubber sheath covering the leur end of the needle is NOT a safety shield.

3.4 Use of Safety butterfly needle – “BD Push Button Blood Collection Set”

3.4.1 After unwrapping the set from the packaging, pull the tubing and stretch it tautly to take out the bends in the tubing from when it was packaged. It is helpful to stretch the tubing starting at one end and pull as you slide along the tubing stretching it tautly.

3.4.2 Attach it to either the syringe or the leur adapter and holder. 3.4.3 Perform the venipuncture. 3.4.4 Immediately upon completion of collection with the butterfly set apply light

pressure to the site and withdraw the needle by pushing the button. The needle will pull into the sheath from the arm and insure that the needle is hidden to protect from any possible needle stick.

3.4.5 Discard the used blood collection set (with holder) carefully. The “Leur” end, which is attached to the vacutainer holder, is NOT shielded.

3.4.6 If a syringe is used, disconnect the blood collection set and discard in a sharps container, then attach the syringe to a BD Blood transfer device to following protocols listed below:

3.5 Use of the BD Blood Transfer device – When blood is obtained using a syringe,

the blood transfer device must be used to transfer the blood into the tubes. The syringe with a needle should NEVER be used to transfer blood into a tube because there is such a high risk of a needlestick.


3.5.1 Remove from the package.

3.5.2 Once blood is obtained in the syringe, activate the safety device and remove the needle or blood collection set, immediately discard in a sharps container and attach the blood transfer device.

3.5.3 Obtain the selected tubes and holding the syringe on top with the transfer device at the bottom.

3.5.4 Insert the tube into the transfer device pushing the rubber stopper onto the shielded needle. The blood will come into the vacuum tube automatically. It is important to hold the tube in the holder at a 45 degree angle to prevent the blood from dropping to the bottom of the tube. By holding it at an angle the blood will run down the wall of the tube preventing hemolysis or other preanalytic damage to the blood.

3.5.5 Never press on the syringe plunger to force the blood into a tube.This could cause blood to spray out of the syringe connection causing accidental exposure to the user. It can also cause hemolysis.

4. SPECIMEN LABELING 4.1 See Laboratory Specimen Submission Clinical Policy #PL-404.

Label specimen AFTER blood is collected, but BEFORE leaving the patient’s bedside. Blood should never be left unlabeled. It should be immediately labeled at the bedside. If label printer fails, the required data listed below must be hand written with required information listed below on all of the tubes prior to leaving the bedside. Once the specimens are labeled it is good practice to compare all tubes match each other and then hold them next to the patients’ armband to verify that the specimen label matches the armband.

4.2 Label all tubes with the following information at the bedside: 4.2.1 Patient's Full name 4.2.2 Patient's medical record number (Financial number can be used in

computer downtime -- Date of Birth can be used for outreach patients). 4.2.3 Initials of person collecting specimen or phlebotomists’ computer ID

number 4.2.4 Time/Date of collection 4.2.5 A pre-printed label can be used for identification provided all of the above information is on it; if not, hand write the missing information onto the label.

5. HINTS FOR ACCURATE VENIPUNCTURE

5.1 Tightly apply tourniquet in close proximity (3-4 inches) to the vein used. The farther away the tourniquet, the less efficient it works in a particular vein.

5.2 For best results, have the patient lie down in a horizontal position with the arm hanging down. NEVER have patient standing or sitting on a stool. If the patient faints, they must be well supported.

5.3 Use an indirect light at a 45-degree angle to highlight the veins. Direct light tends to obscure veins.

5.4 For a difficult venipuncture, a tight tourniquet is usually more effective than a loose one. Don't have the tourniquet too tight, so that it will be uncomfortable for the patient. Don't keep tourniquet on for longer than one minute.

5.5 Insert needle in smooth and rapid fashion. Check needle bevel for burrs before entry. 5.6 Correction for Incomplete Venipuncture (See diagrams page 8)

5.6.1 If the vein had not been entered, blood will not flow into the tube or syringe. 5.6.2 An incomplete venipuncture may cause the tube to fill slowly or partially. Move the

needle slightly up or down. The tube may also have lost vacuum. 5.6.3 If blood flow begins and stops, the needle may have passed through both vein walls,

and is embedded in tissue. Slowly withdraw the needle until blood flows again.


5.6.4 If there is repeated failure to enter the vein, excessive pain or beginning formation of a hematoma, release the tourniquet promptly, withdraw the needle and apply pressure to the wound. When bleeding stops, apply a pressure bandage.

5.6.5 If suction pulls the vein wall into the bevel of the needle, rotate the needle, or move it slowly up or down.

5.6.6 If the vein collapses, apply pressure above the puncture site with the index and middle fingers, then release. The vein will fill up and the blood flow should continue.

5.6.7 If you are unable to draw the patient after two attempts, notify the nurse that another phlebotomist will be returning to attempt the draw.

5.6.8 Never draw blood from a patient's leg or ankle without the prior permission of the Physician. Permission is to be documented either in the patient’s electronic medical record or on the requisition.

5.6.9 Laboratory personnel are NEVER to draw a patient from any type of line. 5.6.10 Never return a draw to the lab, which can be completed by capillary micro methods.

6. DRAWING FROM ARMS WITH IV’S 6.1 When a patient has an IV, the opposite arm should be used whenever possible.6.2 Alternatively, the arm with the IV can be used if a venipuncture site is selected below

(distal to) the IV site and select a different vein that the IV is in. 6.3 Drawing Above (proximal to) an IV site Not recommended. Should only be used after all other options have been exhausted.

6.3.1 Notify nurse to stop the IV for at least 2 min. 6.3.2 Select a vein other than the one use for the IV for venipuncture. 6.3.3 Withdraw first 5 cc of blood and discard tube. 6.3.4 Obtain next blood specimen for tests requested. 6.3.5 Nurse needs to turn IV on after the blood specimen has been obtained. 6.3.6 Record on the request form that the specimen was obtained above an IV site.


7. DIFFICULT VEINS 7.1 Rolling veins: Secure vein at TWO points, pulling area taut to immobilize vein. 7.2 Collapsing veins: Apply pressure above puncture site with index and middle finger, then

release. If this does not work, use syringe. 7.3 Superficial veins: Use syringe with a smaller needle (23 gauge) or safety butterfly

needle. 7.4 "Sure" vein that does not produce: If it feels like a vein, but no blood enters the tube,

and the patient feels pain; you have probably entered a tendon. Remove the needle and look for another vein.

7.5 Use warm soaks to stimulate blood flow. 7.6 Rub selected site for venipuncture vigorously with 70% alcohol to stimulate blood flow. 7.7 Tap veins with fingers to increase blood flow. 7.8 Use hand veins with a syringe or butterfly needle when all else fails.

DO NOT SELECT FEET FOR VENIPUNCTURE SITE (ESPECIALLY ON OLDER PATIENTS). There is too great a chance of thrombophlebitis (inflammation of wall of a vein with an accompanying clot at the site). Any draw performed on a foot must have MD approval prior to draw.

If patient refuses to allow you to draw them, notify RN or Charge RN. If, after speaking with the RN, the patient continues to refuse, cancel the test in LIS, footnoting the name of the RN that was notified. Appropriately document that the patient refused.

8. DRAWING FROM HEPARIN/SALINE LOCKS OR ARTERIAL LINES

Laboratory personnel are never to draw a patient from any type of line. 8.1 Notify nurse (the nurse will draw the blood from the line) 8.2 Provide the nurse with a syringe in order to remove 5 ml of the heparin-blood mixture or

IV fluid-blood mixture. Discard this specimen. 8.3 Provide the nurse with a new syringe, remove the amount of blood needed for the tests

and place into the appropriate tubes, following the fill order for syringe draws. (See section 2.2.7.2.)

8.4 If a vacutainer adapter is available for the heparin lock, then vacutainers can be used for the collection of the blood samples. In this case, discard the first tube collected (at least 5 ml.)

8.5 Make sure if you see the RN/MD collect the blood, to scan the patient’s armband with the Lattice and record the RN’s name and select phleb + RN line draw for method of collection in the barcode scanning device.

8.6 If RN is not available to draw at that time, the tubes may be left for the RN to collect at a later time. NEVER print labels from the barcode scanning device unless you see the blood being drawn. Labels are never applied to tubes until the specimen is obtained. Cerner Labels can be printed and sent to the unit from the lab if requested.

9. AGE SPECIFIC CONSIDERATIONS

9.1 Pediatrics 9.1.1 Refer to PL-416 for infant blood collection. Any requests for phlebotomy on

pediatric patients should be referred to the Laboratory. 9.2 Adults

9.2.1 Can generally tolerate the usual types of adhesives. 9.2.2 Provide for privacy to the extent possible. 9.2.3 Reassure patient. 9.2.4 Attempt to answer patient’s questions without attempting to explain why the

physician has ordered the tests or what the tests will be used for.


9.3 Geriatrics Due to the especially delicate nature of the veins and skin of the geriatric patients, the following methods should be used to provide quality care and preserve the veins and skin of these patients.

9.3.1 Be extra careful about patient identification. Elderly patients may be confused or hard of hearing. Ask them “What is your name”, not, “Are you Mrs.--------“. ALWAYS check the patient’s armband. Always address elderly patients by the last name, such as “Mr. or Mrs. LAST NAME”, never by the first name only.

9.3.2 Carefully examine all your options for a good, not damaged vein before trying to stick the patient.

9.3.3 Examine and evaluate the condition of your patient for any sign of thin skin, small or thin veins, previous hematoma, multiple bruises, or any other possible damage.

9.3.4 If the condition of the venipuncture site is normal, use 22 gauge safety needles.

9.3.5 If the condition of the skin or the veins is not favorable, use a 23 gauge safety butterfly needle.

9.3.6 Hold the skin very tautly from below the vein. (Elderly patients may lack collagen around the veins so they will not be anchored securely.)

9.3.7 Apply direct pressure to the venipuncture site immediately following the removal of the needle.

9.3.8 Continue applying pressure YOURSELF until the bleeding is stopped. (Elderly patients may not have the strength to apply sufficient pressure themselves.)

9.3.9 Use micropore surgical tape (paper material) to prevent any skin irritation or discomfort.

9.3.10 Elderly patients require respect and consideration. A calm and reassuring manner may make the difference between a successful venipuncture with a good specimen and an unsuccessful, unpleasant experience.

9.3.11 Provide for privacy to the extent possible and be sensitive to the patient’s modesty.

10. BLOOD CULTURE COLLECTION PROCEDURE

Employees will follow procedure PL-417 to perform a Blood Culture collection. 11. IMMEDIATE GENERAL COMPLICATIONS

11.1 Seizures If this occurs during a phlebotomy, release tourniquet and remove needle immediately. Call for assistance immediately while applying pressure to venipuncture site without completely restricting patient's movement. Do not attempt to put anything into the patient's mouth. Protect patient from injuring his/her head.

11.2 Fainting (Syncope)11.2.1 Not due to blood loss. Occurs more often with outpatients than inpatients. 11.2.2 If patient admits to a history of fainting or a feeling of "light headedness,” have the

patient lie down before the procedure begins. 11.2.3 If patient begins to feel faint during procedure:

11.2.3.1 Release tourniquet and remove needle immediately. 11.2.3.2 Have patient lower head and breathe deeply. 11.2.3.3 Loosen collar or tie if possible. 11.2.3.4 Apply cold compress to forehead and/or back of neck.


11.2.4 Notify pathologist or nurse if patient does not come around within a moment. 11.2.5 Can sometimes be avoided if patient's attention is diverted.

11.3 Nausea 11.3.1 Reassure patient. 11.3.2 Instruct patient to breathe slowly and deeply. 11.3.3 Apply cold compress to forehead and/or back of neck. 11.3.4 Provide patient with emesis tray if needed.

11.4 Pain

11.4.1 If a patient complains of a shooting, electric-like pain, or tingling or numbness proximal or distal to the puncture site, terminate the venipuncture and remove the needle immediately. Repeat the venipuncture in another site if needed.

11.4.2 Document the incident and notify the RN in charge of the nurse or if the patient is an outpatient, notify a supervisor/manager, who will arrange for a pathologist to evaluate the patient.

12. CAPILLARY PROCEDURE

12.1 Obtain the appropriate supplies 12.1.1 Microtainer Safety Flow Lancets 12.1.2 70% Isopropyl alcohol prep pads 12.1.3 Clean, dry gauze pads (2x2). 12.1.4 Microtainer tubes

12.2 Perform hand hygiene and put on gloves. 12.3 Follow proper identification steps listed above. 12.4 The finger should be warm to ensure good circulation of blood. If it is cold, warm the

finger with a heel warmer or partially fill a glove with warm water, tie off the top and surround the finger with the glove.

12.5 Cleanse the fingertip with an alcohol wipe and wipe with dry gauze. 12.6 In general, use the patient’s ring finger unless it has already been used too often. Hold

the patient’s finger in one hand and the skin puncture device in the other. Apply gentle pressure to the fingertip to draw the skin taut. DO NOT SQUEEZE.

12.7 Touch the end of the skin puncture device to the lateral aspect of the patient’s fingertip, aligning the direction of the blade with the finger, then push the “trigger” to release the spring-loaded lancet. (do not cut across the finger)

NOTE: The puncture is made along the lateral aspect of the finger to avoid any callous formation.

12.8 With a dry gauze pad, wipe off the first drop of blood as it wells up on the finger.

12.9 Gently squeeze the finger starting at the base of the finger towards the tip of the finger In order to help the blood flow from the puncture site at the tip of the finger. Do not squeeze only at the tip as this will stop the flow of the blood out of the tip of the finger and will push tissue juices to mix with the blood.

12.10 Collect the desired specimens, ensuring that the capillary tubes are mixed as they are collected if they contain anticoagulant. This can be done by tapping the microtainer tube at the bottom.

12.11 Apply a sterile, dry gauze pad to the wound and hold until the bleeding stops. Cover with a small bandaid.

12.12 Label all specimens according to Section 4.2. 12.13 Ensure the lancet is disposed in a sharps container and all other supplies are

disposed of properly. 12.14 Remove and discard gloves. 12.15 Wash hands before leaving the patient room.


13. COMMENTS FOR CAPILLARY PUNCTURE 13.1 The fingertip is the preferred site of puncture since the microtainers can be use with

greater ease and accuracy. Hair on the ear lobe may interfere by causing clumping of the cells.

13.2 Do not use the finger on a hand that has been hanging over the side of the bed, since it may be congested. Edematous or cyanotic areas should not be used . 13.3 The finger should be dried prior to puncture, for the blood will not well up on a finger that

is moist. Furthermore, the alcohol may hemolyze the red cells or coagulate the blood proteins, causing cell clumping and erroneous values.

13.4 If bleeding fails to occur following a finger puncture, it is usually due to an inadequate puncture and the procedure MUST be repeated. NEVER squeeze the finger, since tissue fluid squeezed from the wound will dilute the blood specimen and render it useless for examination.

13.5 A milking motion is the most effective in pushing the blood to the tip of the finger. 14. REFERENCES:

• CLSI Standard H3-A6, October, 2007. • Phlebotomy Handbook; 8th edition; by Diana Garza, Kathleen Becan-McBride, • Becton-Dickenson product support (www.bd.com), June 2009.

Reviewed/Approved by: Steve Geidt, Chief Executive Officer Cheryl Jacob, Chief Operating Officer Vivian Mendoza, M.D., Laboratory Medical Director – Laguna Hills Campus Shih-Jwo Huang, M.D., Laboratory Medical Director – San Clemente Campus Hugo Folli, Executive Vice President, Ancillary Services Cheryl Dilbeck, Director, Laboratory Services Georgene Groover, Manager, San Clemente Campus Originated: 11/89 Revised by/Date:

J. Johansen 3/15/01 J. Johansen 3/27/03 J. Johansen 1/13/05 J. Johansen 11/11/06 J. Johansen 10/4/08 J. Johansen 4/22/09 J. Johansen 5/29/09 J. Johansen 6/10/09 J. Johansen 6/9/10 APPROVAL BOX:

Medical Executive Committee 1990, 1991, 1992,1993, 1994, 1995, 1996, 6/01, 3/03, 2/05, 2/07, 01/09, 9/09, 7/10

Board of Directors 1996, 6/01, 3/03, 2/05, 2/07, 01/09, 9/09, 7/10

Central Partnership Council 6/01, 3/03, 1/05, 1/07, 11/08, 7/09, 6/10

http://www.bd.com/

reference: pl-415 originated: 11/89 revised: 5/03, 2/05, 2

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