Venipuncture Complications and

Preexamination Variables
REQUISTIONS • Visitors and family members should be
• Must still contain all pertinent information for greeted in the same manner as the patient
patient identification and given the option to step outside.
• Patient ID must be the same with requisition • If they choose to stay, the phlebotomist
and the patient wristband should assess their possible reactions and
may elect to pull the curtain around the bed.
GREETING THE PATIENT • Visitors and family members can
sometimes be helpful in the case of
SLEEPING PATIENTS pediatric or very apprehensive patients.
• should be gently awakened and given time
to become oriented and have their identity UNAVAILABLE PATIENT
verified before the venipuncture is • If patient is missing:
performed o phlebotomist should attempt to
• Blood collection may result in: locate the patient by checking with
o identification errors the nursing station.
o physical injury to the patient • If the sample must be collected at a
o charge of assault and battery particular time
▪ patient can’t give informed o draw blood from the patient in the
consent area to which he or she has been
taken
UNCONSCIOUS PATIENTS o If this is not possible
• should be greeted in the same manner as ▪ nursing station must be
conscious patients notified and the appropriate
o they may be capable of hearing and forms completed so that the
understanding even though they test can be rescheduled.
cannot respond
• nursing personnel PATIENT IDENTIFICATION
o assists phlebotomist
MISSING ID BAND
PSYCHIATRIC UNITS • phlebotomist must contact the nurse and
• nurse assists too request that the patient be banded before
• often ANXIOUS about venipuncture the drawing of blood
• place blood collection equipment away from • nurse’s signature on the requisition form
the patient verifying identification should be accepted
in only emergency situations or according to
PHYSICIANS, CLERGY, VISITORS hospital policy
• In case the physicians, clergy or visitors are • Patients in psychiatric units often do not
present, a phlebotomist may come back wear an identification band.
another time. • Follow strict institutional protocol in all
• phlebotomist should explain the situation special situations.
and request permission to perform the
procedure at that time

Venipuncture Complications and Preexamination Variables

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 UNIDENTIFIED EMERGENCY o exercise,
DEPARTMENT PATIENTS o stress,
• The American Association of Blood Banks o alcohol,
(AABB) requires that the patient be o smoking,
positively identified with a: o time of day, and
o TEMPORARY BUT CLEAR o medications.
DESIGNATION • Physiological variables
▪ attached to the body o affect normal values for test results.
• Some hospitals generate identification o Examples
bands with: ▪ age,
o an identification number, and ▪ altitude, and
o a tentative name (John Doe or ▪ gender
Patient X) • Other patient conditions that may influence
• When the patient identity is known, a laboratory test results:
permanent identification number is o dehydration,
assigned to the patient. o fever, and
• The temporary identification number is o pregnancy
cross-referenced to the permanent number
for patient identification and correlation
of patient and test result information.

***Both the temporary and permanent

identification band must be attached to the
patient and confirmed before blood may be
collected.

IDENTIFICATION OF YOUNG,
COGNITIVELY IMPAIRED, OR PATIENTS
WHO DO NOT SPEAK THE LANGUAGE
• ask the patient’s nurse, relative, or a
friend to identify the patient by name,
address, and identification number or
date of birth.
• Document the name of the verifier.
• This information must be compared with
the information on the requisition and
the patient’s identification band.
• Any discrepancies must be resolved
before collecting the sample.

PATIENT PREPARATION
• Numerous preexamination variables
associated with the patient’s activities
before sample collection can affect the
quality of the sample.
• These variables can include
o diet,
o posture,
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 BASAL STATE • Because of these dietary interferences in
• BEST TIME TO COLLECT BLOOD: laboratory testing, fasting samples are often
o Basal State requested.
▪ Patient has refrained from • Phlebotomist must take note of the
strenuous exercise and has fasting time of the patient.
not ingested food or o If the patient has not, this must be
beverages except water for 12 reported to a supervisor or the nurse
hours [fasting]). and noted on the requisition form.
• Normal Values (Reference Ranges) o prolonged fasting, however, can also
o determined from a normal, alter certain blood tests.
representative sample of volunteers
who are in a basal state POSTURE
o the best comparison of a patient’s • Changes in patient posture from a
results with the normal values can be supine to an erect position cause
made while the patient is in the basal variations in some blood constituents,
state such as:
o This explains why phlebotomists o cellular elements,
begin blood collection in the hospital o plasma proteins,
very early in the morning while the o compounds bound to plasma
patient is in a basal state and why proteins, and
the majority of outpatients arrive in o high molecular weight substances.
the laboratory as soon as the • when a person moves from a supine to an
drawing station opens. erect position and water leaves the plasma,
the concentration of these substances
PREEXAMINATION VARIABLES increases in the plasma.
• Tests most noticeably elevated by the
DIET decreased plasma volume are:
• The tests most affected: o cell counts,
o glucose o protein,
o triglycerides o albumin,
• Serum or plasma may appear cloudy or o bilirubin,
turbid (lipemic) due to the presence of fatty o cholesterol, triglycerides,
compounds o calcium, and
o Lipemia will interfere with many test o enzymes.
procedures o can change for 4-15% within 10
• Certain beverages can also affect minutes after changing from a supine
laboratory tests. position to standing.
o Alcohol Consumption o After returning to the supine position
▪ transient elevation in glucose from the standing, it takes about 30
levels minutes for the analytes to decrease
o Chronic Alcohol Consumption back to the original level.
▪ Affects liver tests • Can double in 1 hour (patients are
▪ increases triglycerides required to be lying down for 30 minutes
o Caffeine before blood collection)
▪ affect hormone levels, o Plasma renin,
o Too much liquid o serum aldosterone, and
▪ hemoglobin and electrolyte o catecholamines

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• National Institutes of Health • Short-term exercise
o patients be lying or sitting for 5 o muscle contents are released into
minutes prior to blood collection for the blood
lipid profiles to minimize the effects o Anaerobic glycolysis and metabolic
caused by posture. changes interfere with laboratory
• The increase is most noticeable in patients results
with disorders such as congestive heart o elevates the enzymes associated
failure and liver diseases that cause with muscles (AST, CK, LD) and the
increased fluid to remain in the tissue. WBC count because WBCs attached
• When inpatient and outpatient results are to the venous walls are released into
being compared, the physician may request the circulation
that an outpatient lie down before sample o The values usually return to normal
collection. within several hours of relaxation in a
healthy person; however, skeletal
EXERCISE muscle enzymes, aldosterone, renin,
• Moderate or strenuous exercise affects and angiotensin may be elevated for
laboratory test results by: 24 hours.
o INCREASE: • Prolonged exercise INCREASES
▪ creatinine, o muscle-related waste products (AST,
▪ fatty acids, CK, and LD)
▪ lactic acid, o hormones
▪ aspartate aminotransferase o (remain more consistently elevated)
(AST),
▪ creatine kinase (CK), STRESS
▪ lactic dehydrogenase (LD), • Stress INCREASES:
▪ aldolase, o adrenal hormones
▪ hormones (antidiuretic ▪ cortisol
hormone, catecholamines, ▪ catecholamines),
growth hormone, cortisol, o WBC counts
aldosterone, renin, ▪ Elevated WBC counts return
angiotensin), to normal within 1 hour.
▪ bilirubin, • Stress DECREASES:
▪ uric acid, o serum iron
▪ high-density lipoprotein (HDL), • Severe anxiety
and o Causes hyperventilation
▪ white blood cell (WBC) count o may cause acid-base imbalances
and o increased lactate and fatty acid
o DECREASE levels
▪ arterial pH and PCO2
• The effects of exercise depend on: ***For an accurate WBC count, discontinue
o the physical fitness and muscle mass blood collection from a crying child until
of the patient, after the child has been calm for at least 1
o the strenuousness and intensity of hour.
the exercise, and the
o time between the exercise and blood
collection
• Vigorous exercise = temporary activation
of coagulation factors and platelet function.
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 SMOKING PREGNANCY
• Immediate Effects of Nicotine • caused by the physiological changes in the
o increases in: body including increases in plasma volume
▪ plasma catecholamines, • increased plasma volume may cause a
▪ cortisol, dilutional effect and cause
▪ glucose, o LOWER:
▪ blood urea nitrogen (BUN), ▪ RBC counts,
▪ cholesterol, and triglycerides ▪ protein,
• Glucose and BUN ▪ alkaline phosphatase,
o increase by 10 percent ▪ estradiol,
• Triglycerides ▪ free fatty acids, and
o increase by 20 percent ▪ iron values.
• Chronic Smoking o HIGHER:
o INCREASES: ▪ erythrocyte sedimentation rate
▪ hemoglobin, ▪ coagulation factors II, V, VII,
▪ red blood cell (RBC) counts, VIII, IX, and X
▪ mean corpuscular volume
(MCV), OTHER FACTORS INFLUENCING PATIENT
▪ immunoglobulin (Ig) E. TEST RESULTS
o DECREASES: • medical conditions:
▪ IgA, IgG, and IgM o shock,
▪ (lowering the effectiveness of o malnutrition,
the immune system) o fever,
o burns, and
ALTITUDE o trauma
• In high-altitude areas (where there are • MALNUTRITION
reduced oxygen levels), o INCREASED
o 5,000 to 10,000 feet above sea level. ▪ ketones,
o INCREASED: ▪ bilirubin,
▪ RBC counts ▪ lactate, and
▪ hemoglobin (Hgb) and ▪ triglycerides
▪ hematocrit (Hct) o DECREASED
▪ note information if the patient ▪ glucose, cholesterol,
traveled from another ▪ thyroid hormones,
geographical area ▪ total protein, and
▪ albumin
AGE AND GENDER • FEVER
• change in body composition o INCREASE
• Hormone levels vary with age and gender. ▪ insulin, glucagon, and cortisol
• Higher in males (than females): • ENVIRONMENTAL FACTORS
o RBC, Hgb, and Hct o Location, temperature and humidity,
• Normal reference ranges are established o Acute exposure to heat
for the different patient age and gender ▪ causes sweating, leads to:
groups • dehydration
• age and gender of the patient should be • hemoconcentration
present on the requisition

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 DIURNAL VARIATION collecting a sample and note this on
• Diurnal rhythm is the normal fluctuation in the requisition form
blood levels at different times of the day o For example, samples collected
based on a 24-hour cycle of eating and while a patient is receiving a blood
sleeping. transfusion may not represent the
• Blood analytes are released into the patient’s true condition.
bloodstream intermittently. • Medications that are toxic to the liver can
• HIGHEST IN THE MORNING: cause an increase in blood liver enzymes
o Cortisol, and abnormal coagulation tests.
o aldosterone, • Elevated BUN levels or imbalanced
o renin, electrolytes may be noted in patients taking
o luteinizing hormone, medications that impair renal function.
o follicle-stimulating hormone, • Patients taking corticosteroids, estrogens,
o estradiol, or diuretics can develop pancreatitis and
o thyroid-stimulating hormone (TSH), would have elevated serum amylase and
o testosterone, lipase levels
o bilirubin, • Chemotherapy drugs cause a decrease in
o hemoglobin, WBC counts and platelets.
o insulin, • Patients taking diuretics may have elevated
o potassium, calcium, glucose, and uric acid levels, and
o RBC count, and decreased potassium levels.
o serum iron levels • Oral contraceptives can cause a decrease
• LOWER IN THE MORNING: in apoprotein, cholesterol, HDL,
o eosinophil counts, triglycerides, and iron levels
o creatinine, • Aspirin, medications that contain salicylate,
o glucose, and certain herb use can interfere with
o triglyceride, and platelet function or Coumadin anticoagulant
o phosphate levels are lower therapy and may cause increased risk of
• Cortisol and iron levels can differ by 50 bleeding
percent between 8 a.m. and 4 p.m. • The College of American Pathologists
recommends that drugs known to interfere
MEDICATIONS with blood tests should be discontinued:
• changing a metabolic process o 4 to 24 hours before blood tests
• producing interference with test o 48 to 72 hours before urine tests
• IV administration of dyes • Patients taking herbs often do not realize
o radiographic contrast media the side effect of bleeding that can occur.
▪ for kidney testing o When excessive post venipuncture
o fluorescein bleeding occurs, question the patient
▪ used to evaluate cardiac about herbal medications and
blood vessels document this on the requisition.
• analyzing medications = responsibility of
the health-care provider, pathologist, or
clinical laboratory testing personnel
• Phlebotomists
o should be aware of any procedures
being performed at the time they are

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 PATIENT COMPLICATIONS

APPREHENSIVE PATIENTS
• calm the person’s fears (with nurse)
o hold the patient’s arm steady during
the procedure
• commonly in children
• patients in fixed positions
o patients in traction or
o patients in body casts

FAINTING (SYNCOPE)
• loss of consciousness caused by
insufficient blood flow to the brain
• involuntary nervous system
o regulates heart rate and blood
pressure malfunctions in response to
a trigger that causes a vasovagal
reaction
o the heart rate suddenly drops
o blood vessels in the legs dilate
causing blood to pool in the legs and
lower blood pressure
• Triggers:
o sight of blood,
o having blood drawn,
o fear of bodily injury,
o standing for long periods of time,
o heat exposure, and
o exertion
o ↑ can cause vasovagal syncope
• Other conditions:
o postural hypotension,
o dehydration,
o low blood pressure,
o heart disease,
o anemia,
o hypoglycemia, and
o neurological disorders.
• Symptoms (before fainting):
o paleness of the skin,
o hyperventilation,
o lightheadedness,
o dizziness, nausea,
o a feeling of warmth, or cold, clammy
skin
o The phlebotomist must be aware of
these symptoms and monitor the
Venipuncture Complications and Preexamination Variables
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 patient throughout the entire SEIZURES
venipuncture procedure. • Rare occurrence
• Apprehensive patients and fasting patients • Steps to do:
may be prone to fainting o tourniquet and needle should be
• It is sometimes possible to detect such removed
patients during vein palpation because their o pressure applied to the site, and
skin feels cold and damp. o help summoned
• phlebo should ask the patient about history • Restrain the patient only to the extent that
of blood collection failure or fainting injury is prevented.
• If a patient begins to faint during the • Do not attempt to place anything in the
procedure, immediately remove the patient’s mouth.
tourniquet and needle, and apply pressure • Any very deep puncture caused by sudden
to the venipuncture site. movement by the patient should be
• In the inpatient setting, notify the nursing reported to the physician.
station as soon as possible. • Document the time the seizure started and
• In the outpatient area, make sure the stopped according to institutional policy.
patient is supported and that the patient
lowers his or her head. ***In both a syncope or seizure situation,
• The phlebotomist must watch the patient notify the designated first-aid–trained
carefully as patients have a tendency to fall personnel immediately
forward while fainting and can easily slip out
of the phlebotomy chair. PETECHIAE
• Ask the patient to take deep breaths. • small, nonraised red hemorrhagic spots
• If possible, lay the patient flat and loosen (petechiae)
tight clothing. • will show prolonged bleeding following
• Cold compresses applied to the forehead venipuncture
and back of the neck will help to revive the • indication of a coagulation disorder
patient. o low platelet count or
• Outpatients who have been fasting for o abnormal platelet function.
prolonged periods should be given • Additional pressure should be applied to the
something sweet to drink (if the blood has puncture site following needle removal.
been collected) and required to remain in
the area for 15 to 30 minutes. ALLERGIES
• All incidents of syncope should be • occasionally allergic to alcohol, iodine,
documented following institutional policy. latex, or the glue used in adhesive
bandages
***Patients frequently mention previous • use alternate antiseptics, paper tape or self-
adverse reactions. If these patients are adhering wrap (Coban), and nonlatex
sitting up, it may be wise to have them lie products
down before collection. It is not uncommon
for patients with a history of fainting to faint VOMITING
again. • before, during, or after blood collection
• Nauseated? instruct the patient to breathe
***According to the CLSI standards, the use deeply and slowly and apply cold
of ammonia inhalants may be associated compresses to the patient’s forehead
with adverse effects and is not
recommended.
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• If the patient vomits, stop the blood over the patient’s gown or to cover the area
collection and provide the patient with an with gauze or a dry cloth before application.
emesis basin or wastebasket and tissues. o If possible, another area should be
• Give an outpatient water to rinse out his or selected for the venipuncture.
her mouth and a damp washcloth to wipe o Consider routinely using latex-free,
the face. single-use tourniquets.
• Notify the patient’s nurse or designated
first-aid personnel. HEMOCONCENTRATION
• Clinical and Laboratory Standards Institute
ADDITIONAL PATIENT OBSERVATIONS (CLSI) set the limit on tourniquet application
• notify the nursing station time to be 1 minute
• presence of vomitus, urine, or feces; o “tourniquet should be released as
• infiltrated or removed IV fluid lines; soon as the vein is accessed”
• extreme breathing difficulty; and ▪ However = releasing the
• possibly a patient who has expired. tourniquet as soon as blood
begins to flow into the first
PATIENT REFUSAL tube can sometimes result in
• patients have the right to do this the inability to fill multiple
• phlebotomist can stress to the patient that collection tubes.
the results are needed by the health-care • Prolonged tourniquet time causes
provider for treatment hemoconcentration because the plasma
• discuss the problem with the nurse, who portion of the blood passes into the tissue,
may be able to convince the patient to which results in an increased concentration
agree to have the test performed of protein-based analytes in the blood.
• If the patient continues to refuse, this • Tests most likely to be affected are those
decision should be written on the requisition measuring large molecules, such as:
form and the form should be left at the o plasma proteins and lipids,
nursing station or the area stated in the o RBCs, and
institution policy. o substances bound to protein such as
▪ iron, calcium, magnesium, or
***Carefully listen to the patient and o analytes affected by hemolysis,
observe the patient’s body language. The including:
patient has the right to refuse to have his or ▪ potassium, lactic acid, and
her blood drawn. The phlebotomist may be enzymes.
guilty of assault if the patient perceives that • Tourniquet application and fist clenching
his or her refusal is being ignored. are not recommended when drawing
samples for lactic acid determinations.
TOURNIQUET APPLICATION • Other causes of hemoconcentration:
• a blood pressure cuff is sometimes used to o excessive squeezing or probing a
locate veins that are difficult to find. site,
o 40 mmHg o long-term IV therapy,
o Too much pressure affects the flow o sclerosed or occluded veins, and
of arterial blood. o vigorous fist pumping (Box 10-2).
• When dealing with patients with skin • Repeated fist pumping:
conditions or sensitivity and open sores, it o INCREASE the blood potassium
may be necessary to place the tourniquet level 1 to 2 mmol/L

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• Prolonged tourniquet application can • Other techniques used by phlebotomists to
INCREASE enhance the prominence of veins include:
o Hemoglobin by: o massaging the arm upward from the
▪ 3% (>1 min.) wrist to the elbow,
▪ 7% (>3 mins.) o briefly hanging the arm down, and
▪ can mislead health-care o applying heat to the site for 3 to 5
providers in diagnosing minutes
anemia • TOURNIQUET = remove after 1 minute.
o Cholesterol by: Many phlebotomists forget removing the
▪ 2-5% (2 mins.) tourniquet especially during palpation of
▪ 10-15% (>5 mins.) hard-to-palpate veins.
• If no palpable veins are found in the
***According to the CLSI standard H3-A6, antecubital area, the wrist and hand should
tourniquet use is recommended unless it be examined
interferes with test results, such as lactate. o veins in these areas are smaller
o may be necessary to change
equipment and use a smaller needle
with a syringe or winged blood
collection set or a smaller evacuated
tube
o Wrist veins must be tightly anchored
as they tend to roll to the side easily.
o Veins on the underside of the wrist
should never be used because
nerves, tendons, and the ulnar and
radial arteries lie close to the veins
and can be injured if accidentally
punctured
o Nerve damage caused by drawing
SITE SELECTION on the underside of the wrist may
• a high percentage of patients have veins cause a patient to lose his or her
that are not easily located, and the ability to open or close the hand.
phlebotomist may have to use a variety of • Veins in the legs and feet
techniques to locate a suitable puncture site o when veins in the arms or hands are
• Many patients have prominent veins in one unsuitable
arm and not in the other; o They should be used only with
• therefore, checking the patient’s other arm physician approval.
should be the first thing done when a site is o Leg or foot veins are more
not easily located susceptible to infection and the
• Patients with veins that are difficult to locate formation of thrombi (clots),
often point out areas where they remember particularly in patients with:
previous successful phlebotomies. ▪ diabetes,
o Palpation of these areas may prove ▪ cardiac problems, and
beneficial and is also good for patient ▪ coagulation disorders.
relations.
• Never be reluctant to check both arms and
to listen to the patient’s suggestions.
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 o sites contaminated with alcohol or
iodine, or
o anticoagulant carryover between
tubes

DAMAGED VEINS
• Veins that contain thrombi / Veins subjected
to numerous venipunctures:
o often feel hard (sclerosed)
o should be avoided as they may be
blocked (occluded) and have
impaired circulation.
• Chemotherapy patients,
• chronically ill patients, and
• illegal IV drug users may have hardened
veins.
• Probing or using a lateral needle direction
when redirecting the needle also can cause
vein damage.
• Areas that appear blue or are cold may also
have impaired circulation

HEMATOMA
• indicates that blood has accumulated in the
tissue surrounding a vein during or following
venipuncture
• Puncturing into a hematoma is not only
painful for the patient but will result in the
collection of old, hemolyzed blood from the
hematoma rather than circulating venous
AREAS TO BE AVOIDED blood that is representative of the patient’s
• possibility of decreased blood flow, current condition.
infection, hemolysis, or sample • If a vein containing a hematoma must be
contamination used, blood should be collected below the
• Sample contamination affects the integrity hematoma to ensure sampling of free-
of the specimen causing invalid test results. flowing blood.
• The laboratory personnel may not know that
contamination has occurred and
consequently can report erroneous test
results that adversely affect overall patient
care.
• Incorrect blood collection techniques that
cause contamination include blood
collected from
o edematous areas,
o hematoma areas,
o IV area,

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 EDEMA o It may be possible to perform the
• sample will be contaminated with tissue tests from a fingerstick with a
fluid and yield inaccurate test results. physician’s permission.
• Edema may be caused by:
o heart failure, ***Most mastectomy patients have been told
o renal failure, never to have blood drawn from the
o inflammation, or infection. affected side. Make sure they receive
o IV fluid infiltrating into the appropriate reassurance in cases of a
surrounding tissue double mastectomy.

BURNS, SCARS, AND TATTOOS OBESITY

• susceptible to infection. • Veins on obese patients are often deep and
• decreased circulation and can yield difficult to palpate.
inaccurate test results. • Often, the cephalic vein is more prominent
• Veins in these areas are difficult to palpate and easier to palpate.
and penetrate. • A blood pressure cuff may work better as a
• Tattooed areas tourniquet when a vinyl or latex tourniquet is
o contain dyes that can interfere in too short.
testing • It is important to not probe to find the vein
as that can be painful to the patient and
MASTECTOMY cause hemolysis by destroying red blood
• Applying a tourniquet to or drawing blood cells that can alter test results.
from an arm located on the same side of • Using a syringe with a 11⁄2-inch needle may
the body as a recent mastectomy can be offer more control.
harmful to the patient and produce
erroneous test results. IV Therapy
• Removal of lymph nodes in the mastectomy • phlebotomist encounters patients receiving
procedure: IV fluids in an arm vein.
o interferes with the flow of lymph fluid • Whenever possible, blood should then be
(lymphostasis) drawn from the other arm because the
o increases the blood level of sample maybe contaminated with IV fluid.
lymphocytes and waste products • If an arm containing an IV must be used for
normally contained in the lymph fluid. sample collection, the site selected must be
• Patients are in danger of developing below the IV insertion point and preferably
lymphedema in the affected area, and this in a different vein.
could be increased by application of a • CLSI recommends having the nurse turn off
tourniquet. the IV infusion for 2 minutes, the
• The protective functions of the lymphatic phlebotomist then may apply the tourniquet
system are also lost, so that the area between the IV and the venipuncture site
becomes more prone to infection. and perform the venipuncture.
• blood should be drawn from the other arm. • Document the location of the venipuncture
• DOUBLE MASTECTOMY (right or left arm) and that it was drawn
o physician should be consulted as to below an infusion site.
an appropriate site, such as the • Certain “add on tests” may not be
hand. acceptable from this sample.

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• It is preferred, however, that a dermal • The devices must be flushed with heparin
puncture be performed to collect the sample or saline periodically and after use to
if possible. prevent blood clots from developing in the
• The first 5 mL of blood drawn must be line.
discarded, because it may be • The first 5 mL of blood drawn must be
contaminated with IV fluid. discarded from either device.
o A new syringe is then used for the • It is not recommended to collect blood
sample collection. through these devices for coagulation
• If a coagulation test is ordered, testing because residual heparin can affect
o additional 5 mL (total of 10 mL) of test results.
blood should be drawn before • Only specifically trained personnel are
collecting the coagulation test authorized to draw blood from heparin and
sample saline locks.
o IV lines are frequently flushed with
heparin CANNULAS AND FISTULAS
o This additional blood can be used for • Patients receiving renal dialysis have a
other tests if they have been permanent surgical fusion of an artery and
requested. a vein called a fistula in one arm
• Collections from an IV site are usually o should be avoided for venipuncture
performed by the nursing staff to ensure o infection-prone
proper care of the site. • Accidental puncture of the area around the
• Whenever blood is collected from an arm fistula can cause prolonged bleeding.
containing an IV line, the type of fluid and • The dialysis patient also may have a
location of IV must be noted on the temporary external connection between the
requisition form. artery and a vein formed by a cannula that
• Avoid collecting blood at the same time dye contains a special T-tube connector with a
for a radiological procedure or a unit of diaphragm for drawing blood.
blood is being infused. • Only specifically trained personnel are
• Avoid drawing blood from the site of a authorized to draw blood from a cannula or
previous IV for 24 hours after the IV was fistula.
disconnected. • Be sure to check for the presence of a
fistula or cannula before applying a
***Inappropriate collection of blood from an tourniquet to the arm, because this can
arm containing an IV is a major cause of compromise the patient.
erroneous test results. Unless the sample is
highly contaminated, the error may not be CLEANSING THE SITE
detected. • blood cultures and ABGs require stronger
antiseptic than isopropyl alcohol
HEPARIN AND SALINE LOCKS • The most frequently used solutions are:
• Heparin or saline locks are winged infusion o 70% alcohol
sets connected to a stopcock or cap with a o povidone-iodine
diaphragm that can be left in a vein for up to o tincture of iodine
48 hours to provide a means for o chlorhexidine gluconate for persons
administering frequently required who are allergic to iodine
medications and for obtaining blood o benzalkonium chloride (Zephiran
samples. Chloride)

Venipuncture Complications and Preexamination Variables

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• Alcohol should not be used to cleanse the
site before drawing a sample for blood
alcohol level test.
• Thoroughly cleansing the site with soap and
water will ensure the least amount of
interference.

TECHNICAL COMPLICATIONS

• the bevel of the needle may be resting

against the upper or lower wall of the vein,
obstructing blood flow
• this occurs because the angle of the needle
is incorrect
o too shallow
▪ cause the needle to lay
against the upper wall of vein
o too steep
▪ cause the needle to lay
FAILURE TO OBTAIN BLOOD against the lower wall of the
vein
NEEDLE POSITION • NOT BEVEL UP before insertion
• can be corrected by slight movement of the o obstruct blood flow into the needle
needle • Removing the evacuated tube and rotating
• The patient must then be repunctured when the needle a quarter of a turn will allow
it may not have been necessary. blood to flow freely into a new evacuated
tube
***Failure to keep the holder steady by
bracing the hand against the patient’s arm
may cause the needle to be pushed through
the vein or pulled out of the vein when
tubes are being changed.

BEVEL AGAINST THE WALL OF THE VEIN

NEEDLE TO DEEP
• too steep (greater than 30 degrees) angle
• while advancing the evacuated tube onto
the tube stoppering needle when the holder
is not firmly braced against the skin
• may penetrate through the vein into the
tissue
Venipuncture Complications and Preexamination Variables
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• Blood can leak into the tissues, forming a cause a vein to collapse and stop blood
hematoma. flow
• Gently pulling the needle back may produce • Using a smaller evacuated tube may
blood flow remedy the situation.
o If it does not, another puncture must
be performed, possibly using a
syringe or winged blood collection
set.

NEEDLE TOO SHALLOW

• too shallow (less than 15 degrees) angle
• needle may only partially enter the lumen of
the vein, causing blood to leak into the
NEEDLE BESIDE THE VEIN
tissues, forming a hematoma
• A frequent reason for the failure to obtain
• Slowly advancing the needle into the vein
blood occurs when a vein is not well
may correct the problem.
anchored before the puncture.
• If a hematoma appears under the skin,
• The needle may slip to the side of the vein
remove the tourniquet and needle
without actual penetration (“rolling vein”)
immediately and apply pressure to the site.
• Gentle touching of the area around the
o Continuing to draw the sample may
needle with the cleansed gloved finger may
result in injury to the patient and a
determine the positions of the vein and the
sample contaminated with tissue
needle, and allow the needle to be slightly
fluid and hemolysis
redirected.
• To avoid having to repuncture the patient,
withdraw the needle until the bevel is just
under the skin, reanchor the vein, and
redirect the needle into the vein.
• Movement of the needle should not include
vigorous probing because this is not only
painful to the patient but also enlarges the
puncture site so that blood can leak into the
tissues and form a hematoma or cause an
accidental nicking of an artery.

***CLSI recommends to never move the

COLLAPSED VEIN needle in a lateral direction to access the
basilic vein because of the close proximity
• Using too large an evacuated tube or
of the brachial artery and antebrachial
pulling back on the plunger of a syringe too
cutaneous nerve.
quickly creates suction pressure that can
Venipuncture Complications and Preexamination Variables
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FAULTY EVACUATED TUBE • Errors in technique that can cause injury
• faulty evacuated tube include:
o manufacturer error, o blind probing,
o age of the tube, o selecting high-risk venipuncture sites
o dropping and cracking the tube, or (underside of the wrist, basilic vein),
o accidental puncture when o employing an excessive angle of
assembling the equipment needle insertion (greater than 30
• Won’t permit blood flow to the tube even if degrees),
needle is in the vein o lateral redirection of the needle,
o a new tube should be used. o excessive manipulation (jerky
• Occasionally an evacuated tube will lose its movements) of the needle, and
vacuum if the needle bevel moves out of o movement by the patient while the
the skin during venipuncture. needle is in the vein
o This will be detected by a splash of • nerve compression injury
blood into the tube and sometimes a o pressure from a hematoma,
hissing sound before the blood flow infiltrations of IV fluid, or a tourniquet
stops. that is on for too long or too tight
o Swelling and numbness may occur
***Remember always to have extra tubes 24 to 96 hours later
within reach. • Symptoms Rx:
o cold ice pack initially and then warm
COLLECTION ATTEMPTS compresses to the area.
• If the second puncture is not successful, the • Document the incident and direct the
same phlebotomist should NOT make patient to medical evaluation if indicated,
another attempt. according to facility policy
• Following hospital policy, the phlebotomist
should notify the nursing station and IATROGENIC ANEMIA
request that another phlebotomist perform • Iatrogenic anemia pertains to a condition of
the venipuncture. blood loss caused by treatment.
• An anemia can occur when large amounts
***Never attempt to stick a patient unless a of blood are removed for testing at one time
vein can be seen and/or felt. or over a period of time.
• This is especially dangerous for infants and
NERVE INJURY the elderly.
• Temporary or permanent • Removal of over 10 percent of a patient’s
• may result in loss of movement to the arm blood can be life-threatening in these
or hand and the possibility of a lawsuit patients.
• most critical permanent injury • Collecting the minimum amount of blood,
o damage to the median antebrachial monitoring collection orders for duplicate
cutaneous nerve requests, and the avoidance of redraws can
• occur when a nerve is nicked reduce excessive blood collections.
• patient may experience a shooting pain,
electric-like tingling or numbness running up HEMOLYZED SAMPLES
or down the arm or in the fingers of the arm • Hemolysis may be detected by the
used for venipuncture presence of pink or red plasma or serum
• Rupture of the red blood cell membrane
releases cellular contents into the serum or

Venipuncture Complications and Preexamination Variables

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 plasma and produces interference with 11. Performing venipuncture before the
many test results so that the sample may alcohol is allowed to dry
need to be redrawn. 12. Collecting blood through different
• Hemolysis that is not visibly noticeable may internal diameters of catheter and
be present and will affect test results of connectors
analytes such as potassium and lactic acid. 13. Partially filling sodium fluoride tubes
14. Readjusting the needle in the vein
(probing) or using occluded veins

Factors in processing, handling, or

transporting the sample also can result in
hemolyzed samples and include:
1. Rimming clots
2. Prolonged contact of serum/plasma with
cells
3. Centrifuging at a higher than
recommended speed and with increased
heat exposure in the centrifuge
***Samples collected following vigorous
4. Elevated or decreased temperatures of
probing are frequently hemolyzed and must
blood
be recollected.
5. Using pneumatic tube systems with
unpadded canisters, speed acceleration
***Potassium values are higher in serum
and/or deceleration, excessive agitation
than in plasma due to the release of
potassium from platelets during clotting.
Various patient physiological factors can
cause hemolysis and include:
Errors in performance of the venipuncture
1. Metabolic disorders (liver disease, sickle
account for the majority of hemolyzed
cell anemia, autoimmune hemolytic
samples and include the following:
anemia, blood transfusion reactions)
1. Using a needle with too small a diameter
2. Chemical agents (lead, sulfonamides,
(above 23 gauge)
antimalarial drugs, analgesics)
2. Using a small needle with a large
3. Physical agents (mechanical heart
evacuated tube
valve, thirddegree burns)
3. Using an improperly attached needle on
4. Infectious agents (parasites, bacteria)
a syringe so that frothing occurs as the
blood enters the syringe
REFLUX OF ANTICOAGULANT
4. Pulling the plunger of a syringe back too
• occur when there is blood backflow into a
fast
patient’s vein from the collection tube.
5. Drawing blood from a site containing a
o This can cause adverse reactions in
hematoma
patients.
6. Vigorously mixing tubes
7. Forcing blood from a syringe into an • Keeping the patient’s arm and the tube in a
evacuated tube downward position, allowing the collection
8. Collecting samples from IV lines when tubes to fill from the bottom up, eliminates
not recommended by the manufacturer this problem.
9. Applying the tourniquet too close to the
puncture site or for too long ***To ensure prevention of reflux, blood in
10. Using fragile hand veins the tubes should not come in contact with
the stopper during collection.
Venipuncture Complications and Preexamination Variables
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 REMOVAL OF THE NEEDLE • An alternate site should be chosen for the
***Remember: Proper Needle Disposal repeat venipuncture, or if none is available,
the venipuncture must be performed below
HEMATOMA FORMATION the hematoma
• Improper technique when removing the • The goal of successful blood collection is
needle is a frequent cause of a hematoma not only to obtain the sample but also to
• The skin discoloration and swelling that preserve the site for future venipunctures.
accompanies a hematoma is often a cause
of anxiety and discomfort to the patient and BANDAGING THE PATIENT’S ARM
in severe cases can cause disabling • Bleeding/Coagulation disorder = bleeding
compression injury to nerves. won’t stop even after 5 minutes of pressure
application.
Errors in technique that cause blood to leak • The phlebotomist should continue to apply
or be forced into the surrounding tissue pressure until the bleeding has stopped.
and produce hematomas include: • The nurse should be notified in cases of
1. Failure to remove the tourniquet before excessive bleeding.
removing the needle • For patients who have bleeding problems, a
2. Applying inadequate pressure to the site self-adhering gauze (Coban) can be
after removal of the needle placed over a folded gauze to form a
3. Bending the arm while applying pressure dressing.
pressure
4. Excessive probing to obtain blood ***Never leave the patient until the bleeding
5. Failure to insert the needle far enough has stopped.
into the vein
6. Inserting the needle through the vein COMPARTMENT SYNDROME
7. Selecting a needle too large for the vein • Some patients receiving anticoagulants or
8. Using veins that are small and fragile who have a coagulation disorder
9. Accidentally puncturing the brachial (hemophilia) may continue to bleed large
artery amounts of blood into the subcutaneous
tissue surrounding the puncture site.
• Under normal conditions, the elasticity of • The blood can accumulate within the
the vein walls prevents the leakage of blood tissues of the muscles that surround the
around the needle during venipuncture. arm or hand and cause an increased
• A decrease in the elasticity of the vein walls pressure to build in the area, which can
in older patients causes them to be more interfere with blood flow and cause muscle
prone to developing hematomas. injury.
• Using small-bore needles and firmly • This condition called “compartment
anchoring the veins before needle insertion syndrome” can cause pain, swelling,
may prevent a hematoma in older patients. numbness, and permanent injury to the
• If a hematoma begins to form while blood is nerves.
being collected, • This is a serious condition and would
o immediately remove the tourniquet require a surgical procedure to open the
and needle compartment to relieve the pressure and
o apply pressure to the site for 2 stop the bleeding.
minutes • This syndrome can be prevented by
o A cold compress may be offered to checking the venipuncture site for bleeding
the patient to minimize hematoma
swelling and pain.
Venipuncture Complications and Preexamination Variables
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 and hematoma formation before applying • Bandages should not be opened ahead of
the bandage. time and placed on the table or lab coat.

***Phlebotomists should routinely ask LEAVING THE PATIENT

patients if they are taking blood thinners • Leave the room in the condition in which
(anticoagulant therapy) and take extra care you found it (bed and bed rails in the same
to maintain pressure on the site until position).
bleeding has stopped. o Even if the patient asks you to
change his bed position or his bed
ACCIDENTAL ARTERIAL PUNCTURE platform, do NOT.
• Probing and lateral movement of the needle o Just tell the patient that you will
particularly near the basilic vein are the inform the nurse of the request.
main causes of accidental arterial
punctures. COMPLETING THE VENIPUNCTURE
• usually detected by the appearance of PROCEDURE
unusually red blood that spurts into the • Samples brought to the laboratory may be
tube, the phlebotomist, not the patient, rejected if conditions are present that would
should apply pressure to the site for 5 compromise the validity of the test results.
minutes (10 minutes may be required if the
patient is on anticoagulant therapy). Major reasons for sample rejection are the
• A nick to the artery also can cause following:
compartment syndrome and compression 1. Unlabeled or mislabeled samples
nerve injury due to the accumulation of 2. Inadequate volume
blood in the tissue. 3. Collection in the wrong tube
4. Hemolysis
***The fact that the sample is arterial blood 5. Lipemia
should be recorded on the requisition form 6. Clotted blood in an anticoagulant tube
because some test values are different for 7. Improper handling during transport, such
arterial blood versus venous blood. as not chilling the sample
8. Samples without a requisition form
ALLERGY TO ADHESIVES 9. Contaminated sample containers
• wrap gauze around the arm before applying 10. Delays in processing the sample
the adhesive tape or use paper tape 11. Use of outdated blood collection tubes
• Omitting the bandage in these patients and • Phlebotomists should make sure that none
those with hairy arms is another option, of these conditions exist in the samples
particularly if the patient requests it. they deliver to the laboratory.
• Self-adhering bandages, such as Coban,
may be used.

***Bandages are not recommended for

children younger than 2 years because
children may put bandages in their mouths.

INFECTION
• Instruct the patient to keep the bandage on
for at least 15 minutes post venipuncture to
avoid the possibility of infection.

Venipuncture Complications and Preexamination Variables

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