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Beyond the Antecubital
There are a limited number of secondary sites that are acceptable for venipuncture outside of the antecubital area. When posed with the challenge of finding a vein elsewhere, phlebotomists and other healthcare professionals with blood specimen collection responsibilities should carefully consider their options. It is dangerous to assume that all veins are fair game. Drawing from certain sites without an awareness of the anatomy beneath the skin can put the patient at great risk.
The back of the hand often offers a circuitous network of veins accessible for venipuncture. Such veins can be more delicate and smaller in diameter than their antecubital counterparts, leading the collection tubeís vacuum to collapse them before the procedure is complete if a tube holder is being used. Often, a syringe or winged-infusion set coupled with a syringe coupled with a 22 or 23 gauge needle increases oneís chance of success.
Hand veins on geriatric patients are fragile and do not seal around the needle during the draw, leading to swelling and discoloration as a hematoma forms under the pressure provided by the tourniquet. If a hematoma forms during the venipuncture, the tourniquet should be released immediately, the needle removed and adequate pressure applied before bandaging. A second attempt may be made on the other hand, if accessible. Additionally, platelets in geriatric patients are often fewer in number and less functional than those of a younger population. As a result, they can require additional pressure prior to bandaging.
The vein on the lateral aspect (thumb side) of the wrist is also an acceptable site for venipuncture. This vein, often used for IV therapy, can be quite prominent. However, because it is not stationary, it requires firm anchoring to access successfully. This is best accomplished by pulling the skin below the site downward with the thumb of the free hand to prevent the vein from rolling away when the needle is inserted.
The veins on the front (palm side) of the wrist and forearm should never be considered as an alternative site. Tendons and nerves serving the hand are precariously close to the surface of the skin in this area, which accounts for the restriction against drawing from this area in the Clinical and Laboratory Standards Instituteís venipuncture standard.
Veins in the feet and ankle can be acceptable sites for venipunctures in some facilities and on some patients. Keep in mind, drawing from these sites requires physicianís permission as doing so can result in the formation of clots in patients prone to thrombosis or in tissue necrosis in diabetics. Before puncturing foot and ankle veins, become familiar with your facilityís policy on such punctures. If permitted, make sure you obtain physicianís permission. When drawing blood from these sites, avoid drawing directly into the tube through a tube holder adapter. These veins are generally small in diameter and prone to collapse. Regardless of the device, small-bore needles, 22 or 23 gauge, are recommended.
If you are unable to obtain blood from the veins of the antecubital area or secondary sites, capillary punctures can yield enough blood if the tests requested can be performed on minute quantities. Often physicians will pare down the test requests to accommodate a capillary puncture if informed of the difficulty in obtaining venous blood.
When the acceptable sites are not available, phlebotomists often expose their employers to liability should an injury occur. To manage the risk properly, make sure you have a thorough knowledge of the underlying anatomy wherever you choose to insert a needle, and be prepared to defend your choice should an injury occur.
Drawing specimens only from acceptable sites will bring you closer to full compliance with the standards for the procedure and farther from the consequences of poor judgment. Because phlebotomy is such a highly detailed procedure, and because many phlebotomists perform it so effortlessly, itís easy to understand why itís considered the most underestimated procedure in healthcare.
This Month in Phlebotomy Today
Hereís what subscribers to Phlebotomy Today, the Center for Phlebotomy Educationís paid-subscription newsletter currently in its 8th year of publication, are reading about this month:
For subscription rates and to subscribe to Phlebotomy Today, visit www.phlebotomy.com/PhlebotomyToday.html. The current monthís issue will be emailed to you immediately upon subscribing.
Editorís Personal Note Now Available to Non-Subscribers
For years, one of the most popular features of our flagship newsletter, Phlebotomy Today, has been the editorís On a Personal Note column. Always off topic, past subjects have discussed the merits of eating at the sink, the challenges of raising chickens, and how the editorís mother stopped the daily pilfering of his lunch box when he was in first grade with a well-placed dog food sandwich. Often spiritual, frequently whimsical, and occasionally poignant---as was the account of his fatherís death last October---On a Personal Note never fails to move or entertain those who rely on it for their monthly dose of diversion. Now, itís available to subscribers and non-subscribers alike. (Phlebotomy Today subscribers will continue to have access to it through the newsletter as well.) To read this and all future monthís installments, visit the Center for Phlebotomy Educationís home page at www.phlebotomy.com.
Single Issues of Phlebotomy Today Now Available
The Center for Phlebotomy Education is now making single issues of Phlebotomy Today available for immediate download. Current and back issues, over 80 issues in all spanning back to the first archived issue published in March 2000, are now available for $9.95/issue. Each issue contains one or more feature articles, a phlebotomy Tip of the Month, and more. Each purchase also provides access to the editorís popular ďOn a Personal NoteĒ column. Click here for a complete library of issues.
Featured FAQ: Children in drawing areas
Question:What happens when a parent shows up for lab work and brings their small child with them? I am talking about the parent who insists their child accompanies them. If there is another parent or guardian along, we are asking them to wait in the lobby. If not, I am putting another phlebotomist in the room to watch the child. What are other hospitals doing? Are there references you can refer me to so I can officially address this matter?
Response:Facilities that I have experience with don't have a policy against a parent bringing their child into the outpatient drawing area. Nor do they assign another phlebotomist to watch the child. The child remains under the supervision of the parent. But there are several things to be concerned about here. Sharps containers should be well out of reach of all children. Then thereís always the potential for the child to reach for the needle while itís going into the mother's arm. Mothers need to make sure they instruct their child not to interfere or to explore the supplies and equipment of the drawing area. Arranging the area so that things are out of reach is an added precaution.
In the event an unruly child causes the parent to be injured, or if the child is injured in the drawing station, one may have liability for injuries from acts that can be reasonably anticipated. But because I have never heard of any such incidents, one could argue that a child lunging for the needle is not something that could be reasonably anticipated. Not legal advice, but that's my take.
One final thought: There may be some benefit to having a child witness the collection. If the child sees how simple the procedure is and that it brought no discomfort to the parent, they are likely not to be apprehensive when they have to have their own blood drawn.
Each month, PT--STAT! will publish one of the hundreds of phlebotomy FAQs in the growing database of questions and answers available in Phlebotomy Central, the members-only section of the Center for Phlebotomy Education's web site. For information on joining Phlebotomy Central, visit www.phlebotomy.com/PhlebotomyCentral.html.
Specimen Collection Safety: Sharps Containers
Treating an accidental
Some things money canít buy; for accidental needlesticks, thereís prevention.Seal and discard sharps containers long before they overflow. Most sharps containers are labeled or scored with a line that indicate the unit is about 75% full and should be discarded. Continuing to add additional contaminated sharps into the device increases the risk of an accidental needlestick. When sharps containers are filled to capacity, not only is the collector who uses the container at risk, but all co-workers who use the device subsequently are at risk.
Healthcare professionals who find overfilled sharps containers in their facility should not attempt to seal the hazard, but bring the risk to the attention of a manager or supervisor who can oversee its safe disposal and take the necessary steps to prevent such a hazard from occurring again. Sometimes disciplinary measures are required to fully protect the staff from future carelessness.
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Copyright 2007, Center for Phlebotomy Education, Inc. All rights reserved. Newsletters may contain links to sites on the Internet owned and operated by third parties. The Center for Phlebotomy Education, Inc. is not responsible for the availability of, or the content located on or through, any such third-party site. Information in this document is provided "as is," without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability, fitness for a particular purpose and freedom from infringement. The user assumes the entire risk as to the accuracy and the use of this document. We will not be liable for any damages of any kind arising from the use of this information, including, but not limited to direct, indirect, incidental, punitive, and consequential damages.