OBTAIN A BLOOD SPECIMEN USING A VACUTAINER

081-833-0032

Conditions: Necessary materials and equipment: blood specimen tubes, constricting band, vacutainer adapter, vacutainer needles, disinfectant pads, sterile 2 x 2 gauze sponges, betadine or alcohol, adhesive bandage strips, protective pad, labels, and gloves.

Standards: Obtained a blood specimen without causing injury to the patient or violating aseptic technique.

Performance Steps

1. Verify the request to obtain a blood specimen. Select the proper blood specimen tube for the test to be performed.

2. Label the blood specimen tube with the information necessary to identify the patient.

3. Perform a patient care handwash.

WARNING: Gloves should be worn for self-protection against transmission of contaminants whenever handling body fluids.

4. Assemble the vacutainer adapter, the needle, and the blood specimen tube.

a. Inspect the needle for nicks or barbs. Replace the needle if it is flawed or dull.

b. Insert the rubber stoppered end of the specimen tube into the vacutainer holder and advance the tube until it is even with the guideline.

NOTE: The needle is now partially imbedded into the stopper. If the tube is pushed beyond the guideline, the vacuum of the tube may be broken.

5. Identify the patient.

a. Ask the patient his or her name and compare the name to the bed card and identification band or tags.

b. If the specimen is being obtained from an outpatient, identify the patient by asking his or her name and comparing the name with the medical records or the laboratory request.

NOTE: Ask the patient about allergies to such things as iodine or alcohol.

6. Explain the procedure and purpose for collecting the blood specimen to the patient.

7. Position the patient.

a. Assist the patient into a comfortable sitting or lying position.

WARNING: Never attempt to draw blood from a standing patient.

b. The patient should be positioned so the arm is well supported and stabilized by using a pillow, table, or other flat surface.

c. Place a protective pad under the elbow and forearm.

8. Expose the area for venipuncture.

9. Select and palpate one of the prominent veins in the bend of the arm (antecubital space).

a. The first choice is the median cubital vein. It is well supported and least apt to roll.

b. The second choice is the cephalic vein.

c. The third choice is the basilic vein. Although it is often the most prominent, it tends to roll easily and makes venipuncture difficult.

WARNINGS: 1. Avoid veins that are infected, irritated, injured, or have an IV running distal to the proposed venipuncture site. 2. Do not use the vacutainer to draw blood from small or fragile veins, because this can cause the vein walls to collapse. Use a needle and syringe instead.

10. Prepare the sponges for use.

a. Open the betadine or alcohol and 2 X 2 gauze sponge packages.

b. Place them within easy reach (still in the packages).

11. Apply the constricting band with enough pressure to stop venous return without stopping the arterial flow (a radial pulse will be present).

a. Wrap latex tubing around the limb approximately 2 inches above the proposed venipuncture site.

b. Stretch the tubing slightly and pull one end so that it is longer than the other.

c. Form a loop with the longer end and draw the loop under the shorter end so that the tails of the tubing are turned away from the proposed site.

NOTE: If a commercial band is used, wrap it around the limb as in step 11a and then secure the band by overlapping the Velcro ends.

d. Instruct the patient to form a fist, clench and unclench several times, and then hold the fist in a clenched position.

12. Palpate the selected vein lightly with the index finger, moving an inch or two in either direction so that the size and direction of the vein can be determined. The vein should feel like a spongy tube.

13. With a disinfectant soaked pad, cleanse the area around the puncture site using an outward circular motion.

CAUTION: After cleansing the skin, do not repalpate the area.
WARNING: Do not leave the constricting band on for more than 2 minutes.

14. Prepare to puncture the vein.

a. Grasp the vacutainer unit and remove the protective needle cover.

b. Position the needle directly in line with the vein. Using the free hand, grasp the patient's arm below the expected point of entry.

c. Place the thumb of the free hand approximately 1 inch below the expected point of entry and pull the skin taut toward the hand.

15. Puncture the vein.

a. Place the needle, bevel up, in line with the vein and pierce the skin at a 15 to 30 degree angle.

b. Decrease the angle until the needle is almost parallel to the skin surface. Direct it toward the vein and pierce the vein wall.

NOTE: A faint "give" will be felt when the vein is entered and blood will appear in the hub of the needle.

(1) If the venipuncture is unsuccessful, pull the needle back slightly (not above the skin surface) and attempt to pierce the vein again.

CAUTION: If the needle is withdrawn above the skin surface, quickly release the constricting band and stop the procedure. Begin again with a new needle.

(2) If the venipuncture is still unsuccessful, release the constricting band, place a gauze sponge lightly over the site, quickly withdraw the needle, and immediately apply pressure to the site.

(3) Notify the supervisor before attempting to enter another vein.

c. Instruct the patient to unclench the fist.

16. Collect the specimen.

a. Single specimen sample.

(1) With the dominant hand, hold the vacutainer unit and the needle steady.

(2) Place the index and middle fingers of the free hand behind the flange of the vacutainer and ease the tube as far forward as possible. Blood will enter the tube.

WARNING: If the unit and needle are not held steady while pushing in the tube, the needle may either slip out of the vein or puncture the opposing vein wall.

(3) After the tube is approximately two-thirds full of blood or the flow of blood stops, prepare to withdraw the needle.

b. Multiple specimen samples (multiple tubes).

(1) Follow steps 16a(1) and 16a(2) for collecting a single specimen.

(2) Remove the first tube and insert another tube into the vacutainer.

(3) Repeat this procedure until the desired number of tubes are filled or blood stops flowing.

(4) Release the constricting band using the nondominant hand.

(5) After the last tube is approximately two-thirds full of blood or the flow stops, prepare to withdraw the needle.

NOTE: If the blood flow starts to slow down between samples, remove the constricting band.

17. Withdraw the needle.

a. Release the constricting band by pulling on the long, looped end of the tubing or pulling the Velcro fasteners open.

WARNING: Never withdraw the needle prior to removing the constricting band because this will cause blood to be forced out of the venipuncture site with resulting blood loss and/or hematoma formation.

b. Place a gauze sponge lightly over the venipuncture site.

c. Keeping the patient's arm fully extended, withdraw the needle smoothly and quickly. Immediately apply firm manual pressure over the venipuncture site with the sponge.

d. Instruct the patient to elevate the arm slightly and keep the arm fully extended. Continue to apply firm manual pressure to the site for 2 to 3 minutes.

18. Remove the specimen tube from the vacutainer.

a. Replace the protective cover over the needle.

NOTE: Dispose of the uncapped needle IAW local SOP.
WARNING: If accidentally punctured by a used needle, force the puncture site to bleed, wash it thoroughly, and report the incident to your supervisor immediately.

b. Pull the tube from the vacutainer.

c. If the tube contains an anticoagulant, gently invert the tube several times to mix it with the blood.

19. Apply an adhesive bandage strip to the venipuncture site after the bleeding has stopped. Adhesive bandage strips do not take the place of pressure and therefore, are not applied until the bleeding has stopped.

20. Provide for the patient's safety and comfort.

a. Remove the protective pad.

b. Assist the patient to assume a comfortable position.

21. Dispose of and/or store the equipment.

a. Collect all the equipment and remove it from the area.

b. Place the used gauze sponge, alcohol or betadine sponge, and the protective pad in the trash receptacle.

c. Store the constricting band and vacutainer adapter IAW local SOP and dispose of the needle and syringe IAW local SOP.

22. Remove the gloves.

23. Perform a patient care handwash.

24. Complete the laboratory request.

a. Patient identification.

b. Requesting physician's name.

c. Ward number, clinic, or dispensary.

d. Date and time of specimen collection.

e. Test(s) requested.

f. Specimen source--blood.

g. Remarks. Write in the admission diagnosis or the type of surgery in this section.

h. Complete the "urgency" box. (Routine, today, preop, STAT, or ASAP.)

NOTE: There are many lab request slips which are used for requesting specific blood tests. All slips must be checked for the minimum information, as given.

25. Forward the specimen to the laboratory.

a. Attach the lab request to the specimen tube(s) with a rubber band or paper clip.

NOTE: Ensure that the lab requests and blood tubes are appropriately labeled with infectious warning labels IAW local SOP.

b. Arrange for the specimen to be sent to the lab or transport the specimen to the lab IAW local SOP.

26. Perform a patient care handwash.

27. Record the procedure on the appropriate form.

 

Performance Measures

GO

NO GO

1. Selected the proper blood specimen tube.

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2. Labeled the blood specimen tube.

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3. Performed a patient care handwash.

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4. Assembled the vacutainer unit, needle, and blood specimen tube.

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5. Identified the patient.

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6. Explained the procedure and purpose for collecting the blood.

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7. Positioned the patient.

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8. Exposed the venipuncture site.

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9. Selected and palpated the vein.

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10. Prepared sponges for use.

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11. Applied the constricting band.

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12. Palpated the selected vein.

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13. Cleaned the venipuncture site.

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14. Prepared to puncture the vein.

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15. Punctured the vein.

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16. Collected the specimen.

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17. Withdrew the needle.

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18. Removed the specimen tube from the vacutainer.

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19. Applied an adhesive bandage strip to the site.

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20. Provided for the patient's safety and comfort.

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21. Disposed of and/or stored equipment.

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22. Removed the gloves.

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23. Performed a patient care handwash.

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24. Completed the laboratory request.

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25. Forwarded the specimen to the laboratory.

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26. Performed a patient care handwash.

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27. Recorded the procedure on the appropriate form.

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28. Did not violate aseptic technique.

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29. Did not cause further injury to the patient.

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Evaluation Guidance: Score each soldier according to the performance measures in the evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all performance measures to be scored GO. If the soldier fails any step, show what was done wrong and how to do it correctly.

References

Required

Related

None

BASIC NURSING

 

 

INITIATE AN INTRAVENOUS INFUSION

081-833-0033

Conditions: You have performed a patient care handwash. Necessary materials and equipment: IV injection set, IV solution, needle or catheter-over-needle, constricting band, antiseptic sponges, 2 x 2 gauze sponges, tape, IV stand or substitute, armboard, and gloves.

Standards: Initiated an intravenous infusion without causing further injury or unnecessary discomfort to the patient. Did not violate aseptic technique.

Performance Steps

1. Identify the patient and explain the procedure.

a. Ask the patient's name.

b. Check the identification band against the patient's chart, as appropriate.

c. Explain the reason for IV therapy.

d. Explain the procedure and caution the patient against manipulating the equipment.

e. Ask about any known allergies to such things as betadine or medication.

f. Reassure the patient that this is a common procedure.

2. Select and inspect the equipment for defects, expiration date, and contamination.

a. IV fluid of choice (check doctor's orders, as appropriate). Discard containers that have cracks, scratches, leaks, sedimentation, condensation, or fluid which is not crystal clear and colorless.

b. IV injection set.

(1) Spike, drip chamber, tubing, and needle adapter. Discard them if there are cracks or holes or if any discoloration is present.

(2) Tubing clamp. Ensure that the clamp releases and catches.

(3) Needle or catheter-over-needle. Discard them if they are flawed with barbs or nicks.

NOTE: Place the stand to the side of the patient and close to the IV site.

3. Prepare the equipment.

a. Clamp the tubing 6 to 8 inches below the drip chamber.

b. Remove the protective covers from the spike and from the outlet of the IV container.

CAUTION: Do not touch the spike or the outlet of the IV container.

c. Insert the spike into the container.

(1) If using a bag, push the spike firmly into the container's outlet tube.

(2) If using a bottle, push the spike firmly through the container's diaphragm.

CAUTION: If no vacuum release sound is heard when puncturing bottled solution, discard the solution. Bagged solution makes no vacuum release sound.

d. Hang the container at least 2 feet above the level of the patient's heart, if possible.

NOTE: An IV bag container may be placed under the patient's body if there is no way to hang it.

e. Squeeze the drip chamber until it is half full of the IV fluid.

f. Prime the tubing.

NOTE: Ensure that all air is expelled from the tubing.

(1) Hold the tubing above the level of the bottom of the container.

(2) Loosen the protective cover from the needle adapter to allow the air to escape.

(3) Release the clamp on the tubing.

(4) Gradually lower the tubing until the solution reaches the end of the needle adapter.

(5) Clamp the tubing.

(6) Retighten the needle adapter's protective cover.

(7) Loop the tubing over the IV stand or holder.

g. Cut several pieces of tape and hang them in a readily accessible place.

4. Select the infusion site.

a. Put on gloves for body substance isolation.

b. Choose the most distal and accessible vein of an uninjured arm or hand.

c. Avoid sites over joints.

d. Avoid veins in infected, injured, or irritated areas.

e. Use the nondominant hand or arm, whenever possible.

CAUTION: Do not use an arm that may require an operative procedure.

f. Select a vein large enough to accommodate the size of needle/catheter to be used.

5. Prepare the infusion site.

a. Apply the constricting band.

NOTE: When applying the constricting band, use soft-walled latex tubing about 18 inches in length.

(1) Place the tubing around the limb, about 2 inches above the site of venipuncture. Hold one end so that it is longer than the other, and form a loop with the longer end.

(2) Pass the looped end under the shorter end of the constricting band.

NOTE: When placing the constricting band, ensure that the tails of the tubing are turned away from the proposed site of venipuncture.

(3) Apply the constricting band tight enough to stop venous flow but not so tightly that the radial pulse cannot be felt.

(4) Tell the patient to open and close his or her fist several times to increase circulation.

CAUTION: Do not leave the constricting band in place for more than 2 minutes.

b. Select a prominent vein.

NOTES: 1. Wet the area with germicide to facilitate palpation of the vein with the fingertips. Touch the distended vein with the fingertips and estimate tissue support. 2. If the vein rolls, select another vein.

c. Tell the patient to close his or her fist and keep it closed until instructed to open the fist.

d. Clean the skin over the selected area with 70% alcohol or betadine, using a firm circular motion from the center outward.

e. Allow the skin to dry and discard the gauze.

f. Put on gloves for self-protection against transmission of contaminants.

6. Prepare to puncture the vein.

a. Pick up the assembled needle and remove the protective cover with the other hand.

(1) Ensure the needle is bevel up.

(2) Place the forefinger on the needle hub to guide it during insertion through the skin and into the vein.

b. Position yourself so as to have a direct line of vision along the axis of the vein to be entered.

7. Puncture the vein.

CAUTION: Keep the needle at the same angle to prevent through-and-through penetration of the vein walls.
NOTE: You may position the needle directly above the vein or slightly to one side of the vein.

a. Draw the skin below the cleaned area downward to hold the skin taut over the site of venipuncture.

b. Position the needle point, bevel up, parallel to the vein and about 1/2 inch below the site of venipuncture.

c. Hold the needle at a 20 to 30 degree angle and insert it through the skin.

d. Decrease the angle of the needle until it is almost parallel to the skin surface and direct it toward the vein.

e. Move the needle forward about 1/2 inch into the vein.

8. Confirm the puncture.

NOTE: A faint "give" will be felt as the needle enters the lumen of the vein.

a. Check for blood in the flash chamber. If successful, proceed to step 9.

b. If the venipuncture is unsuccessful, pull the needle back slightly (not above the skin surface) and attempt to pierce the vein again.

c. If the venipuncture is still unsuccessful, release the constricting band and tell the patient to open and relax his or her clinched fist.

(1) Place a sponge lightly over the site and quickly withdraw the needle.

(2) Immediately apply pressure to the site.

d. Notify your supervisor before attempting a venipuncture at another site.

9. Advance the needle or the catheter.

a. Grasp the hub and advance the needle into the vein up to the hub.

b. If using the catheter-over-needle, grasp the hub and with a slight twisting motion fully advance the catheter.

c. While continuing to hold the hub, press lightly on the skin over the needle or catheter tip with the fingers of the other hand.

NOTE: This prevents the backflow of blood from the hub.

d. If using a catheter-over-needle, remove the needle from inside the catheter.

10. Remove the protective cover from the needle adapter on the tubing. Quickly and tightly connect the adapter to the catheter or needle hub.

WARNING: Do not allow air to enter the blood stream.

11. Tell the patient to unclench the fist, and then release the constricting band.

12. Unclamp the IV tubing and adjust the flow rate to keep the vein open (TKO or KVO).

NOTE: A rate of about 30 cc per hour, or 7 to 10 drops per minute using standard drip tubing, is adequate to keep the vein open.

13. Check the site for infiltration. If it is painful, swollen, red, cool to the touch, or if fluid is leaking from the site, stop the infusion immediately.

14. Secure the site IAW local SOP.

a. Apply a sterile dressing over the puncture site, leaving the hub and tubing connection visible.

b. Loop the IV tubing onto the extremity and secure the loop with tape.

c. Splint the arm loosely on a padded splint, if necessary, to reduce movement.

15. Readjust the flow rate.

a. Determine the total time over which the patient is to receive the dosage.

Example: The patient is to receive the dosage over a 3 hour period.

b. Determine the total IV dosage the patient is to receive by checking the doctor's orders.

Example: The patient is to receive 1000 cc of IV fluid.

c. Check the IV tubing package to determine the number of drops of IV fluid per cc the set has been designed to deliver.

Example: The set is designed to give 10 drops of IV fluid per cc (10 gtts/cc).

d. Multiply the total hours (step 15a) by 60 minutes to determine the total minutes over which the IV dosage is to be administered.

Example: 3 hours X 60 min = 180 min.

e. Divide the total IV dosage (step 15b) by the total minutes over which the IV dosage is to be administered (step 15d) to determine the cc of fluid to be administered per minute.

Example: 1000 cc / 180 min = 5.5 cc/min.

f. Multiply the cc/min (step 15e) by the number of drops of IV fluid per cc delivered by the tubing (step 15c) to determine the number of drops per minute to be administered.

Example: 5.5 cc/min X 10 drops/cc = 55 drops/min.
NOTE: Always round drops per minute off to the nearest whole number. If drops per minute equal .5, round up to the next whole number.

16. Prepare and place the appropriate label.

a. Dressing.

(1) Print the information on a piece of tape.

(a) Date and time the IV was started.

(b) Initials of the person initiating the IV.

(2) Secure the tape to the dressing.

b. IV solution container.

(1) Print the information on a piece of tape.

(a) Patient's identification.

(b) Drip rate.

(c) Date and time the IV infusion was initiated.

(d) Initials of the person initiating the IV.

(2) Secure the tape to the IV container.

c. IV tubing.

(1) Wrap a strip of tape around the tubing, leaving a tab.

(2) Print the date and time the tubing was put in place and the initials of the person initiating the IV.

NOTE: Place disposable items in an appropriate receptacle and clean and store equipment IAW local SOP.

17. Recheck the site for infiltration.

18. Perform a patient care handwash.

19. Record the procedure on the appropriate form.

a. Date and time the IV infusion was initiated.

b. Type and amount of IV solution initiated.

c. Drip rate and total volume to be infused.

d. Type and gauge of needle or cannula.

e. Location of the infusion site.

f. Patient's condition.

g. Name of the person initiating the IV.

 

Performance Measures

GO

NO GO

1. Inspected the equipment.

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2. Prepared the equipment.

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3. Identified the patient and explained the procedure.

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4. Selected the infusion site.

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5. Prepared the infusion site.

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6. Prepared to puncture the vein.

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7. Punctured the vein.

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8. Confirmed the puncture.

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9. Advanced the needle or the catheter.

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10. Connected the tubing to the catheter or needle hub.

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11. Released the constricting band.

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12. Unclamped the IV tubing and adjusted the flow rate TKO.

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13. Checked the site for infiltration.

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14. Secured the site.

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15. Readjusted the flow rate.

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16. Prepared and placed the appropriate labels.

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17. Rechecked the site for infiltration.

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18. Performed a patient care handwash.

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19. Recorded the procedure on the appropriate form.

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20. Did not violate aseptic technique.

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21. Did not cause further injury to the patient.

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Evaluation Guidance: Score each soldier according to the performance measures in the evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all performance measures to be scored GO. If the soldier fails any step, show what was done wrong and how to do it correctly.

References

Required

Related

None

BASIC NURSING