Chapter 11 Venipuncture Complications. Copyright © 2008 by Saunders, an imprint of Elsevier Inc....

Chapter 11Chapter 11

Venipuncture ComplicationsVenipuncture Complications

Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

Learning ObjectivesLearning Objectives

Explain the procedure to be followed in Explain the procedure to be followed in these situations:these situations:

a. The patient is not in his or her room.a. The patient is not in his or her room.

b. The patient has no identification band.b. The patient has no identification band.

c. The patient is sleeping, unconscious, or c. The patient is sleeping, unconscious, or apprehensive.apprehensive.

d. Clergy or a physician is with the patient.d. Clergy or a physician is with the patient.

e. Visitors are present.e. Visitors are present.

f. The patient cannot understand you.f. The patient cannot understand you.

g. The patient refuses to have blood drawn.g. The patient refuses to have blood drawn.



List at least four sites that must be avoided List at least four sites that must be avoided when collecting blood, and explain why.when collecting blood, and explain why.

Describe techniques that can be used to help Describe techniques that can be used to help locate a vein.locate a vein.

Discuss limitations and precautions to be Discuss limitations and precautions to be followed if a leg or hand vein is considered for followed if a leg or hand vein is considered for venipuncture.venipuncture.



List at least two situations in which alcohol List at least two situations in which alcohol should not be used to clean the venipuncture should not be used to clean the venipuncture site, and state at least one alternative.site, and state at least one alternative.

Describe four potential problems associated Describe four potential problems associated with tourniquet application.with tourniquet application.

Define syncope, and explain what to do when Define syncope, and explain what to do when a patient experiences this condition during a patient experiences this condition during the collection of blood.the collection of blood.



Describe the actions to be taken if a patient Describe the actions to be taken if a patient has a seizure, complains of nausea or vomits.has a seizure, complains of nausea or vomits.

List three reasons why blood may not flow List three reasons why blood may not flow into a tube, and explain how to prevent or into a tube, and explain how to prevent or correct the problem.correct the problem.



Explain what should be done in the Explain what should be done in the following situations:following situations:

a. An artery is inadvertently punctured.a. An artery is inadvertently punctured.

b. No blood is collected on the first try.b. No blood is collected on the first try.

c. The patient requests something.c. The patient requests something.

d. There is prolonged bleeding from the d. There is prolonged bleeding from the

puncture site.puncture site.



List the causes of a hemolyzed sample and List the causes of a hemolyzed sample and name the test results that may be affected.name the test results that may be affected.

List tests that may be affected by a patient’s List tests that may be affected by a patient’s position.position.

Describe five long-term complications Describe five long-term complications associated with venipuncture, and explain associated with venipuncture, and explain how they can be avoided.how they can be avoided.

State reasons why a sample may be rejected State reasons why a sample may be rejected by the laboratory.by the laboratory.


Venipuncture ComplicationsVenipuncture Complications

Many factors can interfere with blood collection, Many factors can interfere with blood collection, but by knowing what to expect and planning but by knowing what to expect and planning ahead, you will be able to deal with most ahead, you will be able to deal with most complications and you will be better prepared in complications and you will be better prepared in your work as a phlebotomist.your work as a phlebotomist.


Factors That Prevent Access Factors That Prevent Access to the Patientto the Patient

Locating the Patient.Locating the Patient.

- If the patient is not in his room, check at - If the patient is not in his room, check at the nursing station.the nursing station.

- If the patient is in another area and the - If the patient is in another area and the test is stat or timed, go to that area and draw test is stat or timed, go to that area and draw the patient.the patient.


Factors That Prevent Access Factors That Prevent Access to the Patientto the Patient

Identifying the Patient.Identifying the Patient. - The information on the requisition must - The information on the requisition must

match the information on the armband match the information on the armband exactly before drawing blood.exactly before drawing blood.

- Resolve any discrepancy before collecting - Resolve any discrepancy before collecting the specimen.the specimen.

- Do not draw a patient without an - Do not draw a patient without an armband.armband.

- Some facilities may also require a special - Some facilities may also require a special armband for Blood Bank specimens.armband for Blood Bank specimens.


Barriers to Communicating Barriers to Communicating With the PatientWith the Patient

Sleeping or Unconscious Patient.Sleeping or Unconscious Patient.

- - Never draw blood from a sleeping Never draw blood from a sleeping patient.patient.

Gently wake patient before proceeding.Gently wake patient before proceeding.

- - Follow the procedure and talk to an Follow the procedure and talk to an unconscious patient. They may still be able unconscious patient. They may still be able to hear you even if they cannot respond.to hear you even if they cannot respond.



Presence of a physician or clergy.Presence of a physician or clergy.

- Unless it is a stat or timed test, return at - Unless it is a stat or timed test, return at another time and document. another time and document.

- If the test is stat or timed, announce - If the test is stat or timed, announce yourself and wait for permission to enter.yourself and wait for permission to enter.



Presence of Visitors.Presence of Visitors.

- Greet visitors as you would the patient.- Greet visitors as you would the patient.

- You may ask them to step out while you - You may ask them to step out while you collect your specimen.collect your specimen.

- Sometimes family may be helpful if the - Sometimes family may be helpful if the patient is a child.patient is a child.



Apprehensive Patients.Apprehensive Patients.

- Good communication skills can help to put a - Good communication skills can help to put a nervous patient at ease.nervous patient at ease.

- If you suspect that you may still have - If you suspect that you may still have difficulty, ask for assistance from a family difficulty, ask for assistance from a family member or nursing staff.member or nursing staff.



Language Problems.Language Problems. - For non-English speaking patients, you - For non-English speaking patients, you

may need a translator.may need a translator. - You may also demonstrate to the patient - You may also demonstrate to the patient

what you are going to do. what you are going to do. - If the patient extends his arm, you will - If the patient extends his arm, you will

know that he understands what you need to know that he understands what you need to do.do.



Patient Refusal.Patient Refusal.- - According to the Patient Bill of Rights, the According to the Patient Bill of Rights, the

patient does have the right to refuse.patient does have the right to refuse.- - Try to find out the reason for the Try to find out the reason for the

refusal.refusal.- - Tell the patient the tests are needed for Tell the patient the tests are needed for

treatment.treatment. - - If the patient still refuses, report to the If the patient still refuses, report to the

nurse and your supervisor, and nurse and your supervisor, and document.document.


Problems in Site SelectionProblems in Site Selection

Occluded (Blocked) or Sclerosed Veins.Occluded (Blocked) or Sclerosed Veins.

- - Veins will feel hard and have no bounce.Veins will feel hard and have no bounce.

- These veins may be susceptible to - These veins may be susceptible to infection or produce erroneous test results infection or produce erroneous test results because of impaired blood flow.because of impaired blood flow.



Hematomas.Hematomas. - Can be caused by going through the vein, - Can be caused by going through the vein,

having the bevel only partially in the having the bevel only partially in the vein, vein, or by failure to apply enough pressure or by failure to apply enough pressure

post puncture.post puncture. - Hematomas can obstruct blood flow and - Hematomas can obstruct blood flow and

thereby alter test result if the specimen thereby alter test result if the specimen is is collected from that area.collected from that area.



Edematous Tissue.Edematous Tissue. - The arm may be swollen due to the - The arm may be swollen due to the

accumulation of tissue fluid or from an IV accumulation of tissue fluid or from an IV that has infiltrated into the tissues.that has infiltrated into the tissues.

- Collection here can alter test result due to - Collection here can alter test result due to contamination with tissue fluid.contamination with tissue fluid.

Burns and Scars.Burns and Scars. - These sites are susceptible to infection - These sites are susceptible to infection

and may be painful to the patient and and may be painful to the patient and difficult to penetrate.difficult to penetrate.



Mastectomies.Mastectomies.

- Collection on the side of the mastectomy - Collection on the side of the mastectomy can cause lymphostasis or an can cause lymphostasis or an

accumulation of lymph fluid if a tourniquet accumulation of lymph fluid if a tourniquet is used on that arm.is used on that arm.

- The patient has increased risk of an - The patient has increased risk of an infection.infection.



Avoid any areas of disruption in the skin such Avoid any areas of disruption in the skin such as open lesions, rashes, recent tattoos, or as open lesions, rashes, recent tattoos, or incompletely healed stitches.incompletely healed stitches.

These sites should be avoided because the These sites should be avoided because the patient is at increased risk of infection.patient is at increased risk of infection.


Difficulty in Finding a VeinDifficulty in Finding a Vein

Always check both arms.Always check both arms. Massage the arm from the wrist to the elbow.Massage the arm from the wrist to the elbow. Dangle the arm in a downward position.Dangle the arm in a downward position. Apply heat – use an infant heel warmer.Apply heat – use an infant heel warmer. Rotate the wrist to check the cephalic vein.Rotate the wrist to check the cephalic vein. Use a blood pressure cuff.Use a blood pressure cuff. Use an alternate site such as the hand, foot Use an alternate site such as the hand, foot

or leg with butterfly or winged infusion set or leg with butterfly or winged infusion set (WIS).(WIS).


Hand Collection Using a WISHand Collection Using a WIS

Courtesy of Zack Bent. From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals. Philadelphia, Saunders, 2006.



Position the patient’s hand and apply the Position the patient’s hand and apply the tourniquet.tourniquet.

From Bonewit-West K: Clinical Procedures for Medical Assistants, 6th ed. Philadelphia, Saunders, 2004.



Insert the needle.Insert the needle. - - Choose the largest and straightest vein.Choose the largest and straightest vein. - - Anchor the vein with your nondominant Anchor the vein with your nondominant

hand.hand. - - Insert the needle into the vein using the Insert the needle into the vein using the

wings in an “up” position, bevel up with wings in an “up” position, bevel up with a a 10 to 15 degree angle.10 to 15 degree angle.



A flash of blood will appear in the tubing A flash of blood will appear in the tubing when the vein is entered.when the vein is entered.

Gently thread the needle into the lumen of the Gently thread the needle into the lumen of the vein to stabilize.vein to stabilize.

Hold the needle in place with one hand while Hold the needle in place with one hand while using the other to handle the tubes.using the other to handle the tubes.





Collect the sample.Collect the sample.

Courtesy of Zack Bent. From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals. Philadelphia, Saunders, 2006.



Finish the collection.Finish the collection.

- - Release the tourniquet when the first Release the tourniquet when the first tube tube is filled.is filled.

- - Remove the needle and activate the Remove the needle and activate the safety device.safety device.

Attend to the patient.Attend to the patient.

- - Apply direct pressure to the puncture Apply direct pressure to the puncture site. site.





Dispose of the WIS into a sharps container.Dispose of the WIS into a sharps container.

- - If using the ETS, dispose of the If using the ETS, dispose of the assembly assembly intact.intact.

- - If using a syringe, use a needleless If using a syringe, use a needleless transfer device to transfer the sample transfer device to transfer the sample

and and then dispose of the assembly intact.then dispose of the assembly intact.


Problems Associated With Problems Associated With Cleaning the SiteCleaning the Site

Patients allergic to alcohol may require the Patients allergic to alcohol may require the use of povidone iodine (water based) or use of povidone iodine (water based) or chlohexidine gluconate.chlohexidine gluconate.

Alcohol cannot be used to clean the skin for a Alcohol cannot be used to clean the skin for a blood alcohol test.blood alcohol test.

Do not use povidone iodine for dermal Do not use povidone iodine for dermal punctures because it may elevate test results.punctures because it may elevate test results.


Problems Associated With Problems Associated With Tourniquet ApplicationTourniquet Application

HemoconcentrationHemoconcentration – alteration in the ratio of – alteration in the ratio of cellular elements in the blood.cellular elements in the blood. - - Plasma and smaller elements filter into Plasma and smaller elements filter into the tissues when the tourniquet is on the tissues when the tourniquet is on longer longer than one minute which leaves a than one minute which leaves a concentration of larger elements in the concentration of larger elements in the blood.blood. - - Increased values are seen in proteins, Increased values are seen in proteins, RBCs, enzymes, iron, calcium, potassium, RBCs, enzymes, iron, calcium, potassium, and lactic acid.and lactic acid. - - Can also be caused by fist pumping, Can also be caused by fist pumping, occluded veins, or dehydration.occluded veins, or dehydration.



PetechiaePetechiae – small, non-raised red spots on – small, non-raised red spots on the skin of a patient with a capillary wall or the skin of a patient with a capillary wall or platelet disorder.platelet disorder.

- - Make to apply extra pressure post Make to apply extra pressure post draw.draw.

Tourniquet Too TightTourniquet Too Tight – patient will complain – patient will complain of numbness or tingling in arm.of numbness or tingling in arm.

- - Loosen tourniquet and begin again.Loosen tourniquet and begin again.



Latex AllergyLatex Allergy

- - All patients must be asked whether they All patients must be asked whether they have a latex allergy.have a latex allergy.

- Use nonlatex gloves and tourniquets.- Use nonlatex gloves and tourniquets.

- Use nonlatex bandages.- Use nonlatex bandages.


Complications During CollectionComplications During Collection

Syncope (fainting)Syncope (fainting) - - Remove tourniquet and needle Remove tourniquet and needle immediately, apply pressure and immediately, apply pressure and document.document. - - Do not leave the patient; call for help.Do not leave the patient; call for help.

SeizuresSeizures - - Remove tourniquet and needle Remove tourniquet and needle immediately, apply pressure and immediately, apply pressure and document.document. - - Do not leave the patient; call for help.Do not leave the patient; call for help. - - Do not put anything in the patient’s Do not put anything in the patient’s mouth mouth so as to cause an injury.so as to cause an injury.



PainPain

- - Warn the patient prior to stick.Warn the patient prior to stick. Nausea and Vomiting (Emesis)Nausea and Vomiting (Emesis)

- - Provide a wet washcloth and emesis Provide a wet washcloth and emesis basin.basin.

Hematoma Hematoma – swelling of tissue around site as it – swelling of tissue around site as it fills with blood.fills with blood.

- - Remove tourniquet and needle Remove tourniquet and needle immediately, apply pressure and a cool immediately, apply pressure and a cool compress.compress.



Lack of Blood FlowLack of Blood Flow - - Can be caused by a defective tube, Can be caused by a defective tube,

missing the vein, or improperly missing the vein, or improperly positioned positioned needle.needle. - - Intermittent flow indicates improperly Intermittent flow indicates improperly

positioned needle or a collapsed vein.positioned needle or a collapsed vein. - - Always try to reposition or try a new Always try to reposition or try a new tube tube before aborting the draw.before aborting the draw.



Defective Evacuated TubesDefective Evacuated Tubes

- - Always examine tubes for cracks and Always examine tubes for cracks and have spares easily accessible.have spares easily accessible.

Improperly Positioned NeedleImproperly Positioned Needle

- - Corrective action must be taken to Corrective action must be taken to reposition the needle so that the patient reposition the needle so that the patient does not need to be stuck again.does not need to be stuck again.



The bevel is stuck to The bevel is stuck to the vein wall. the vein wall. Slightly rotate the Slightly rotate the needle.needle.



The needle has The needle has passed through both passed through both sides of the vein. sides of the vein. Slowly pull back on Slowly pull back on the needle and the needle and watch for the blood watch for the blood to come into the to come into the tube.tube.



The needle is not The needle is not advance far enough advance far enough into the vein. Slowly into the vein. Slowly advance the needle advance the needle and feel for the give and feel for the give of the vein and of the vein and watch for blood to watch for blood to appear into the tube.appear into the tube.



The vein was missed The vein was missed completely. Remove completely. Remove the tourniquet, pull the tourniquet, pull the needle out the needle out slightly, palpate to slightly, palpate to relocate the vein, relocate the vein, and redirect the and redirect the needle.needle.



Collapsed Vein Collapsed Vein – too much vacuum on a – too much vacuum on a small vein.small vein. - - Use smaller tubes or try with a syringe.Use smaller tubes or try with a syringe.

Inadvertent Arterial PunctureInadvertent Arterial Puncture - - Noted because of pulsating, bright red Noted because of pulsating, bright red

blood.blood. - - Apply pressure for at least 5 min. or Apply pressure for at least 5 min. or until until bleeding has stopped.bleeding has stopped. - - Log the specimen in as “arterial” Log the specimen in as “arterial” because because some test values will be altered.some test values will be altered.



Failure to Collect on the First Try Failure to Collect on the First Try

- The guidelines allow for a 2- The guidelines allow for a 2ndnd attempt. attempt.

- - Use a clean needle and tube.Use a clean needle and tube.

- Try the other arm or go below 1- Try the other arm or go below 1stst attempt.attempt.

- If you have tried twice, call for another - If you have tried twice, call for another phlebotomist to help.phlebotomist to help.


Problems in CompletingProblems in Completing the Procedure the Procedure

Patient RequestsPatient Requests

- - Refer any patient requests to the nurse.Refer any patient requests to the nurse. Prolonged BleedingProlonged Bleeding

- Bleeding should stop within 5 min. - Bleeding should stop within 5 min.

- - Patients on anticoagulants may bleed Patients on anticoagulants may bleed longer and require more pressure.longer and require more pressure.


Factors That Affect Sample IntegrityFactors That Affect Sample Integrity

Hemolysis – the destruction of RBCs, Hemolysis – the destruction of RBCs, resulting in release of hemoglobin and resulting in release of hemoglobin and cellular contents into the plasma.cellular contents into the plasma.

- - The serum or plasma will appear red.The serum or plasma will appear red.

- - Many test values will be altered.Many test values will be altered.

- - The lab will have to ask for a redraw. The lab will have to ask for a redraw.


Causes of HemolysisCauses of Hemolysis


Tests Affected by HemolysisTests Affected by Hemolysis


Factors That Affect Sample IntegrityFactors That Affect Sample Integrity

Patient Position Patient Position

- - The physician may request that a The physician may request that a patient patient lie down for specimen collection.lie down for specimen collection.

Reflux of AnticoagulantReflux of Anticoagulant - - backflow of blood from the tube out the backflow of blood from the tube out the

needle if the last tube is not released needle if the last tube is not released before withdrawing needle.before withdrawing needle.


Tests Affected by Patient PositionTests Affected by Patient Position


Long Term Complications Associated Long Term Complications Associated With VenipunctureWith Venipuncture

AnemiaAnemia - - Follow your facility’s policy on frequency Follow your facility’s policy on frequency

and amount of blood that can be drawn.and amount of blood that can be drawn. Nerve DamageNerve Damage

- - Remove the needle immediately if the Remove the needle immediately if the patient has any numbness or tingling.patient has any numbness or tingling. - - Use the basilic vein as last resort.Use the basilic vein as last resort.

InfectionInfection - - Follow aseptic procedures.Follow aseptic procedures. - - Patients should leave bandage on for at Patients should leave bandage on for at least 15 min. post puncture.least 15 min. post puncture.


Causes of HematomasCauses of Hematomas

Excessive probing to obtain blood.Excessive probing to obtain blood. Failure to insert needle into vein.Failure to insert needle into vein. Inserting needle through the vein.Inserting needle through the vein. Failure to remove tourniquet before Failure to remove tourniquet before

withdrawing needle.withdrawing needle. Inadequate pressure after needle removal.Inadequate pressure after needle removal. Bending the elbow while applying pressure.Bending the elbow while applying pressure.


Compartment SyndromeCompartment Syndrome

A condition in which pressure within the A condition in which pressure within the tissue prevents blood from flowing freely.tissue prevents blood from flowing freely.

Causes swelling, pain and may result in Causes swelling, pain and may result in permanent nerve damage.permanent nerve damage.

Pain, burning, and numbness may be Pain, burning, and numbness may be followed by paralysis distal to the puncture followed by paralysis distal to the puncture site.site.


Specimen RejectionSpecimen Rejection


Specimen RecollectionSpecimen Recollection

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Chapter 11 Venipuncture Complications. Copyright © 2008 by Saunders, an imprint of Elsevier Inc....

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