Nurse Aide crosstraining

2.  List the required information on a requisition form.
 Describe correct patient identification and
specimen labeling procedures.
 Describe patient preparation and the variables
that can affect some laboratory tests.

3.  Correctly assemble venipuncture equipment and
supplies.
 Name and locate the three most frequently used veins
for venipuncture, and describe when these sites would
be unacceptable.
 Correctly apply a tourniquet and state why the tourniquet
can be applied for only 1 minute.

4.  List four methods used to locate veins that are not
prominent.
 Describe the different antiseptics used to cleanse the
venipuncture site.
 State the steps in a venipuncture procedure, and
correctly perform a routine venipuncture using an
evacuated tube system.

5.  Demonstrate safe disposal of contaminated
needles and supplies.
 Deliver specimens to the laboratory in a timely
manner.

6.  Recommended step-by-step venipuncture
procedure
 Possible complications

8.  Purpose
◦ Patient identification
◦ Organization of
equipment
◦ Collection of
appropriate
specimens

10.  Name
 Identification number
 Accession number
 Location
 Health-care provider’s name
 Test requested
 Date and time of collection

11.  Patient’s date of birth
 Special collection information
 Special patient information
 Numbers and type of collection tubes
 Status of specimen

12.  Introduce yourself
◦ Begin communication process
◦ Look and listen
 Explain purpose of visit
◦ Informed consent
◦ Patient has the right to refuse–Patient Bill of Rights
 Guilty of assault if patient has the perception that blood collector is
ignoring his or her refusal
 Wake a sleeping patient
 Greet unconscious patients

13.  THIS IS THE MOST
IMPORTANT STEP !
 Written protocol
◦ Hospital inpatients
◦ Outpatients
 Two identifiers

14.  Primary identifier
 Always compare with the
requisition
 Must be worn by the patient
◦ Wrist of older children and
adults
◦ Ankles of newborns
 Do not trust room and bed
signs

15.  Second identifier
◦ Have the patient state full name
◦ CLSI requirement

16.  Primary identifier
◦ Have the patient state full name
 Secondary identifier
◦ Ask additional information
 Date of birth
 Spell name
 Compare unique data with the requisition form

17.  CLSI requires a caregiver or family member to
provide information on patient’s behalf if patient is
unable to before drawing specimen
 Document the name of the verifier
 Drug testing might require photo ID

18.  Unidentified patients
◦ Tagged with temporary number
◦ Tentative name
 Commercial blood bank system
◦ Place additional stickers from ID band on:
 Specimen
 Requisition form
 Units of blood

19.  Reassure the patient
 Explain procedure
◦ Do not explain the purpose of the test!
 Do not say procedure is painless!
 Alert patient to every step of the procedure
 Remind patient to hold still

20.  Basal state
◦ Preferred state
 Fasting
 Activities
◦ Medications
 A variety of both prescription and over-the-counter
medications can influence lab test results

23.  Site is convenient and
supported
◦ Place pillow under arm
◦ Place fist under elbow
◦ Place arm at downward angle
to prevent reflux
 Safety
◦ Patient is sitting or lying down
◦ Remove objects from patient’s
mouth
◦ Be alert for syncope

25.  Place all supplies close to patient
◦ Collection equipment
◦ Antiseptic pads
◦ Gauze
◦ Bandage
◦ Needle disposal system
◦ Examination requisition
form
 Number and type of tubes
 Extra tubes in case of loss of vacuum

26.  Wash hands between patients
 Change gloves between patients

27. Vein location
Increase amount of available blood

28.  Locate tourniquet 3 to 4 inches above site
 Avoid or cover arms with skin conditions
 Avoid arms on the side of a mastectomy
 Do not use a tourniquet for lactate test

29.  Maximum time is 1 minute
 Apply for site selection
 Release for 2 minutes
 Reapply
 Release when blood flows
 Prolonged tourniquet application
◦ Causes hemoconcentration
 Increase in the ratio of certain analytes to plasma
 Biochemical changes take place in the trapped blood

30.  Other causes
◦ Excessive squeezing
◦ Probing a site
◦ Long-term IV therapy
◦ Sclerosed or occluded veins
◦ Vigorous fist clenching
 Increases cellular elements

31. ◦ Uncomfortable for patient
◦ Obstruct blood flow
◦ No radial pulse
◦ Appearance of petechiae

32. Major vein
Preferred site is antecubital fossa area

33.  Vein of choice
◦ Large, well anchored
◦ Closer to surface
◦ More isolated from
other structures
◦ Least painful–fewer
nerve endings

34. ◦ Located on thumb side
of arm
◦ Second site of choice
◦ Close to the surface
 Use lower angle of needle
insertion (15°)
 Possible blood spurt
◦ May be prominent in
larger patients

35. ◦ Located on the underside of the
arm
◦ Third choice for venipuncture
(H3-A6 recommends using only
as a last resort)
 Least firmly anchored (vein may
“roll”)
 Near brachial artery and median
nerve
 Hematoma formation more likely
 Consider using a syringe for
more control

36.  Apply tourniquet 3 to 4 inches above venipuncture
site
 Have patient form a fist
◦ Do not pump fist
 Causes hemoconcentration
 Only acceptable for blood donations

37. ◦ Feeling is more important
than sight
◦ Probe with index finger,
thumb has a pulse
◦ Push, don’t stroke
◦ Determine: size, depth,
direction
◦ Remember: veins are
spongy, tendons are rigid,
arteries have a pulse

38.  Check both arms
 Listen to patient’s suggestions of
previously successful areas

39.  Massage the arm upward from the
wrist
 Briefly hang the arm down
 Apply heat
 Transilluminator device

40.  Wrists and hands
◦ Apply tourniquet to forearm
◦ Consider a smaller needle, syringe, winged blood
collection set
 H3-A6 states to avoid veins from the underside of
the wrist
◦ Possibility of puncturing the radial or ulnar nerve or artery
 Can cause permanent nerve
damage and inability to open and close
the hand

41.  Require physician approval
 More susceptible to infection and thrombi
 Avoid in patients with diabetes, cardiac
problems, coagulation disorders

42.  Occluded veins
◦ Thrombi
◦ Multiple punctures
◦ Feel hard
◦ Impaired circulation
 Hematomas
◦ Do not puncture hematoma, noncirculation of blood
◦ Draw below hematoma
◦ Use other arm
 Areas with edema
 Areas with extensive burns, scars or tattoos
◦ More susceptible to infection
◦ Decreased circulation
◦ Difficult to palpate

43.  Mastectomies
◦ Lymphostasis
 Increased lymphocytes
 Increased waste products
◦ Patient danger
 Lymphedema
 Infection
 Double Mastectomies
◦ Consult physician
◦ Possibly perform fingerstick
 Never obtain blood from a finger on the side affected by a mastectomy
(CLSI H$A6) without physician-written permission

44.  IV Fluids
◦ Ideally use other arm
◦ Avoid sites of previous IVs for 24–48 hours
◦ Note same arm collection on requisition
◦ Select site below infusion site, caregiver turns off IV for 2 minutes
◦ Preferably use a different vein
◦ Avoid drawing blood at the same time dye for radiological procedure
or blood components are being infused

45.  Fistulas
◦ Renal dialysis patients
◦ Permanent artery-vein connection
◦ Must avoid this arm
◦ Possibility of infection

46.  Cannula
◦ Temporary (external) AV shunt
◦ T-tube connector with diaphragm
◦ Only specially trained personnel can
draw from a cannula

47.  Turn off IV for at least 2 minutes
◦ Discard first 5 mL blood
◦ Collect specimen in a new syringe
◦ Coagulation tests, discard 10 mL
 Second 5 mL can be used for other tests
 Document the type of IV fluid and location on
requisition

49.  Apply 70% isopropyl alcohol
using a circular motion cleanse
from inside to outside
 Allow to air dry, 30–60 seconds
will give maximum bacteriostatic
action
 Avoid wiping off with gauze
 Failure to let alcohol dry causes a
stinging sensation for patient
 Specimen hemolysis

50.  Blood cultures or arterial blood gases
◦ Povidone-iodine
◦ Tincture of iodine
◦ Chlorhexidine gluconate
 Blood Alcohol Collection
◦ Do not cleanse site with alcohol
◦ Soap and water are recommended
◦ Iodine or benzalkonium chloride (Zephiran
Chloride) may be acceptable

51.  Perform while alcohol is drying
 Screw the stopper-puncturing end of
needle into the holder
 Insert first collection tube into the
holder
 Advance tube only to mark on holder

52.  Perform immediately before puncture
◦ Blunt end
◦ Barbed point

53.  Reapply tourniquet
 Confirm puncture site
 Cleanse gloved palpating finger if
necessary
 Place holder in dominant hand
 Place thumb on top, fingers underneath
 After insertion, fingers can be braced on patient’s
arm

55.  Place thumb of nondominant
hand 1–2 inches below site
 Place fingers on back of arm
 Do not anchor above and
below site with thumb and
index finger
◦ Possible accidental self-puncture

57.  Bevel up
 15-to-30 degree angle
 Resistance lessens
when the needle
enters the vein

58.  Nondominant hand
can be used after
vein is entered
 Use flared ends of
holder

59.  Brace the hand
holding the holder
against the patient’s
arm
 Gently twist tubes
on and off the
needle

60.  Mix tubes as they are removed from
the holder needle
◦ Can be done before next tube is inserted
 Remove and mix the last tube before
removing the needle from the vein
◦ Blood will drip from the needle

61.  Remove the tourniquet if still
applied
 Failure to remove can cause a
hematoma
 Patient may relax fist
 Withdraw needle and apply
pressure to gauze at the same
time

62.  Capable patients can apply pressure
using digital pressure
 Arm is raised and outstretched
◦ Do not bend the elbow
 Collector must apply pressure if necessary

63.  Immediately activate
needle safety device
 Dispose in a
conveniently located
sharps container
 NEVER BEND, CUT,
OR RECAP NEEDLE

64.  Label tube before leaving the
patient
 Less chance of tubes being
mixed up
 Use a pen
 Confirm information on
preprinted labels
 Verify correct labeling with the
patient (CLSI H3-A6)

65.  Patient’s name and ID number
 Date and time of collection
 Collector’s initials
 Additional information
◦ Blood bank identification

66.  Check arm before bandaging
 H3-A6 states collector must
observe for hematoma formation
before applying bandage
 Apply hypoallergenic bandage
over gauze for extra pressure
 Self-adhering material
 Patient’s instructions
 Avoid carrying heavy objects
 Remove bandage within 1 hour

67.  Pressure must be applied until bleeding stops
◦ Patients on anticoagulants/aspirin/herb therapy
 Accidental arterial puncture
◦ Collector must apply pressure for 5 minutes or until bleeding has
stopped
◦ Notify nursing staff and physician
 Allergy to adhesive
◦ Avoid use in children under 2 years old

68.  Place in biohazard containers
 Remove gloves
 Wash hands

69.  Return patient’s bed to original position
 Replace bedrails

70. Use designated biohazard
bags/containers

71.  Observe any special handling procedures
 Deliver as soon as possible
◦ No longer than 45 minutes
 Transport in an upright position
◦ Facilitate clotting
◦ Prevent hemolysis
 Complete all required paperwork

72.  Separate serum and plasma from the cells
within 2 hours of collection
o Hemolysis severely affects potassium values
o Cellular metabolism decreases glucose levels

73.  Coagulation specimens for a PTT can remain
at RT for 4 hours; if patient is on unfractionated
heparin, the plasma must be removed from the
cells within 1 hour, test within 4
 PT are stable for 24 hours at RT
 Blood smears from EDTA tubes should be
made within 1 hour of collection.
 Specimen can be refrigerated for up to 4 hours