1.    Identify the patient.  Outpatients are called into the phlebotomy area and asked their name and date of
       birth.  This information must match the requisition.    Inpatients are identified by their arm band.
       If it has been removed, a nurse must install a new one before the patient can be drawn.

2.    Reassure the patient that the minimum amount of blood required for testing will be drawn.

3.    Assemble the necessary equipment appropriate to the patient's physical characteristics.
4.    Wash hands and put on gloves.

5.    Position the patient with the arm extended to form a straight-line form shoulder to wrist.

6.    Do not attempt a venipuncture more than twice.  Notify your supervisor or patient's physician if

7.    Select the appropriate vein for venipuncture. 
       The larger median cubital, basilic and cephalic veins are most frequently used, but other may be necessary
       and will become more prominent if the patient closes his fist tightly.  At no time may phlebotomists
        perform venipuncture on an artery.  At no time will blood be drawn from the feet.
       Factors to consider in site selection:

            * Extensive scarring or healed burn areas should be avoided
            * Specimens should not be obtained from the arm on the same side as a mastectomy.
            * Avoid areas of hematoma.
            * If an IV is in place, samples may be obtained below but NEVER above the IV site. 
            * Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.
            * Allow 10-15 minutes after a transfusion is completed before obtaining a blood sample.

8.     Apply the tourniquet 3-4 inches above the collection site. 
        Never leave the tourniquet on for over 1 minute.
        If a tourniquet is used for preliminary vein selection, release it and reapply after two minutes.

9.   Clean the puncture site by making a smooth circular pass over the site with the 70% alcohol pad,
       moving in an outward spiral from the zone of penetration.  Allow the skin to dry before proceeding. 
       Do not touch the puncture site after cleaning.

10.    Perform the venipuncture
        A.    Attach the appropriate needle to the hub by removing the plastic cap over the small end of the
                needle and inserting into the hub, twisting it tight.
        B.    Remove plastic cap over needle and hold bevel up.
        C.    Pull the skin tight with your thumb or index finger just below the puncture site. 
        D.    Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and
                enter the vein in one smooth motion.
        E.    Holding the hub securely, insert the first vacutainer tube following proper order of draw into
                the large end of the hub penetrating the stopper.  Blood should flow into the evacuated tube. 
        F.    After blood starts to flow, release the tourniquet and ask the patient to open his or her hand.
        G.   When blood flow stops, remove the tube by holding the hub securely and pulling the tube off
                the needle.  If multiple tubes are needed, the proper order of draw to avoid cross
                contamination and erroneous results is as follows: 
                1.     Blood culture vials or bottles, sterile (yellow top) tubes
                2.     Coagulation tube (light blue top)
                3.     Serum tube with or without clot activator or silica gel (Red or Gold)
                4.     Heparin tube (Green top)
                5.     EDTA (Lavender top)
                6.     Glycolytic inhibitor (Gray top)
         H.    Each tube containing an additive should be gently inverted 5-8 times after being removed from
                the hub.  DO NOT SHAKE OR MIX VIGOROUSLY.
         I.    Place a gauze pad over the puncture site and remove the needle. 
                Immediately apply slight pressure.  Ask the patient to apply pressure for at least 2 minutes. 
                When bleeding stops, apply a fresh bandage, gauze or tape.
        J.     Properly dispose of hub with needle attached  into a sharps container.  Label all tubes with
                patient labels, initials, date and time.

11.    Venipuncture procedure using a syringe:
        A.    Place a sheathed needle or butterfly on the syringe. 
        B.    Remove the cap and turn the bevel up.
        C.    Pull the skin tight with your thumb or index finger just below the puncture site. 
        D.    Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and
               vein in one motion.
        E.    Draw the desired amount of blood by pulling back slowly on the syringe stopper.
        F.    Release the tourniquet.
        G.    Place a gauze pad over the puncture site and quickly remove the needle. 
               Immediately apply pressure.  Ask the patient to apply pressure to the gauze for at least 2 minutes. 
               When bleeding stops, apply a fresh bandage, gauze or tape.
        H.    Transfer blood drawn into the appropriate tubes as soon as possible using a needleless BD
               Vacutainer Blood Transfer Device, as a delay could cause improper coagulation.
               Gently invert tubes containing an additive 5-8 times.
        I.    Dispose of the syringe and needle as a unit into an appropriate sharps container.

12.    Blood Culture Collection
        A.    Obtain the collection kit from Microbiology:
                1. Adult: One aerobic, one anaerobic bottle to be taken from single site and med-prep kit
                2. Infants: One BacT/Alert Pedi-Bact bottle
                3. Keep bottles away from light
        B.    Proper skin disinfecting is essential to reduce contamination.  Using universal precautions:
                1. Following palpation, cleanse the skin.
                2. Concentrically clean the site with chloraprep (chlorhexidine gluconate 2% and isopropyl
                alcohol 70%) all in one step.
                3. Allowing the disinfectant to dry provides maximum effectiveness of the disinfectant.
                4. Should further palpation be necessary, disinfect the gloved finger.
        C.    Blood culture bottles must be kept at room temperature before being inoculated.
                Remove the plastic flip top from the blood culture bottle(s) and disinfect with 70%
        D.    Obtain the required volume of blood, but do not overfill.
                1.    Adults = 10 ml of blood for each bottle
                2.    Infants = up to 1-4 ml of blood
        E.    Specimens may be drawn using the Blood Collection Adapter System (Direct Draw)
                or by needle or syringe.
        F.    Do not vent the bottles

13.    Infant/Child Phlebotomy
        A.    Confirm the patient's identification
        B.    Secure patient to Papoose apparatus for stabilization if child is unable to sit upright
               on their own.
        C.    Assemble the required supplies
        D.    Select the collection site and proceed as routine phlebotomy.  If the child is old enough,
               collect blood as in an adult.

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