by Dennis Ernst • June 12, 2018
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The newly revised venipuncture standard released by the Clinical and Laboratory Standards Institute in April, 2017 is the most comprehensive revision in the document's history. With over 140 new mandates, facilities have a lot of changes to implement. This series discusses one or more substantive changes each month.
One of the most critical aspects of performing a venipuncture is post-venipuncture care. Bruising is not only unsightly and impacts patient satisfaction, but hematomas can cause permanently disabling injuries when they exert pressure on nearby nerves. The committee that revised the CLSI venipuncture standard instituted a comprehensive rewrite of the section on caring for the venipuncture site.
While the popular standard always instructed collectors to "observe for hematoma," prior to this version the document never defined what "observe" really meant. Merely lifting the gauze for a millisecond would suffice. However, a quick peek won't alert the collector to a site that is still bleeding. Worse yet, it would be impossible to know if a hematoma is forming. As a result, a patient could be bandaged too quickly, and continue to bleed into the tissue, causing not only an unsightly bruise, but inflict a permanent nerve injury from the pressure of a subcutaneous hemorrhage. Yet technically the standard would have been followed.
The standard now instructs healthcare professionals to observe the site for hematoma formation by watching the skin for at least 5-10 seconds. That should be enough time to detect the telltale mounding of the skin at the puncture site, which indicates blood is leaking from the vein into the tissue. If observed, or if blood is seen pooling on the skin, the standard requires additional pressure to be applied until the bleeding has stopped. At least five minutes of additional pressure is required if bleeding from the brachial artery is suspected, and the nursing staff and physician must be notified.
The revision continues to forbid patients from being allowed to bend their arm up after the draw as a substitute for direct pressure. Neither cotton nor rayon balls can be used for applying pressure, only clean gauze.
Cooperative patients can be allowed to apply direct pressure. However, it is the responsibility of the collector to ensure pressure is adequate in order to prevent bruising and any bleeding into the tissue that could lead to complications. If necessary, collectors must provide adequate pressure themselves if patients are unable.
When the collector is sure bleeding has stopped---both superficially and subcutaneously---the site can be bandaged, preferably with a hypoallergenic bandage or wrap. The patient should be instructed to leave the bandage on for at least 15 minutes, and cautioned against using the arm with exertion for several hours.
Editor's note: Readers are urged to obtain their own copy of the standard as soon as possible and begin implementing all new provisions immediately. The document, Collection of Diagnostic Venous Blood Specimens (GP41-A7), is the standard to which all facilities will be held if a patient is injured during the procedure or suffers from the consequences of an improperly performed venipuncture. It can be obtained from CLSI or the Center for Phlebotomy Education, Inc.
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To serve you better, we have prepared the following information and instructions to answer any questions you may have about the development of a hematoma after a blood collection.
What is a Hematoma?
A hematoma is a swollen or raised area at the venipuncture site resulting from the leakage of blood into the tissues.
What Will Happen to the Hematoma?
In the next few days, the blood will be absorbed by the body. The blood will surface to the skin causing a bruised appearance. As the bruise is healing, it will turn a yellowish-green in color and then gradually fade.
What Can I Do?
Below are a few steps you can take to help the healing process and/or make your arm feel more comfortable:
- Leave the pressure dressing on for at least 8 hours.
- Do not take aspirin or ibuprofen for 72 hours
- Avoid lifting heavy objects with the arm
- Apply ice packs, wrapped in a cloth, to the affected site for approximately 20 minutes one or more times during the first 24 hours following the formation of the bruise or hematoma.
- You may apply warm, moist compresses to the site for 20 minutes one or more time during the second 24 hours after the collection.
- If you notice any of the following complications notify your doctor immediately and report the problem to us.
- Discoloration of the hand
- Additional swelling
- Generalized pain or discomfort of the arm
- Throbbing of the arm
- Numbness in the arm
Once again, thank you for allowing us to provide you with this service.
If you have any questions or concerns, please contact: Jennifer Holland, MT (ASCP), Kentucky Clinic Lab Supervisor
859-323-4608
3910 Washington Parkway Idaho Falls, ID 83404
208-529-8330
Fax: 208-523-3318
2001 S. Woodruff, Suite 15B Idaho Falls, ID 83404
208-529-8330
Fax: 208-523-3318
444 Hospital Way Building 100, Suite 224 Pocatello, ID 83201
208.529.8330 ext. 346
Fax 208-497-2098
Henry's Fork Plaza859 S Yellowstone Hwy #3202 Rexburg, ID 83440
208.529.8330 ext. 670
Fax: 208-497-2098
Time to Read:
About 2 minutes
This information will help you know what to do after your therapeutic phlebotomy (fleh-BAH-toh-mee) procedure. Therapeutic phlebotomy is a blood draw that’s done to treat a medical problem, such as having too much iron in your blood. With therapeutic phlebotomy, more blood is drawn than during a regular blood draw. Your doctor will decide how much blood will be drawn based on the reason you’re having the procedure. If you can, it’s helpful to drink more liquids than usual before your therapeutic phlebotomy procedure. Aim to drink 8 to 10 (8-ounce) glasses of liquids for 1 day before your procedure. You will sit in a chair in the treatment area for your procedure. During your therapeutic phlebotomy procedure, a nurse will use a needle connected to a blood collection bag to draw a certain amount of your blood. After the right amount of blood is drawn, the nurse will remove the needle and place a pressure bandage (bandage that wraps around your arm) over the needle site (the place on your arm where the needle was). You may feel lightheaded or dizzy after your therapeutic phlebotomy procedure. To help keep this from happening: If you feel lightheaded or dizzy, sit down and place your head between your knees. You can also lie down flat and raise your feet and legs slightly. For example, you can rest them on a couple of pillows. You may have discomfort, bleeding, swelling, or bruising at your needle site. Follow the guidelines below to help with these side effects. Bruises may spread around your needle site and take about 7 to 10 days to go away.What to Expect During Your Procedure
Instructions After Your Procedure
Caring for Your Needle Site
Guidelines for managing discomfort
Guidelines for managing bleeding
Guidelines for managing swelling
Guidelines for managing bruising
Call Your Healthcare Provider’s Office if You Have:
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