Signs and symptoms of nerve injury to the arm include severe, unusual, or shooting pain; tingling; numbness; or a tremor. If the patient complains of any of these during venipuncture, withdraw the needle immediately.undefined#ref4">4 Show Draw specimens for blood cultures before administering antibiotics. Take extra care with a patient who takes medications that increase the risk for bleeding.11 Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions. OVERVIEWAlthough recommendations are that trained phlebotomy personnel collect peripheral blood culture specimens by venipuncture to minimize collection errors, other health care team members may be responsible for specimen collection. Health care team members should be familiar with the organization’s practice and the state’s nurse practice act regarding venipuncture, blood specimen collection, and delegation. A blood culture specimen set requires that 20 to 30 ml of blood be obtained at one time from one location.2 Blood culture specimens should be drawn when the patient is experiencing signs and symptoms of bloodstream infection, including fever or chills, and before the administration of antibiotics to increase the likelihood of obtaining a true-positive result. If the patient has been receiving antibiotics at the time the blood cultures are obtained, the laboratory should be notified because an additive can be applied to the blood culture medium to negate the antibiotic’s effect.13 Typically, two sets of blood cultures are ordered, and each set (Figure 1) contains one aerobic bottle and one anaerobic bottle. Orders regarding the spacing of the specimens may vary among practitioners and organizations. Blood culture specimens are usually drawn using either a needle and syringe or a vacuum-extraction collection system that draws blood into vacuum-sealed blood culture bottles. In both cases, a hollow-bore needle is inserted into the lumen of a patient’s vein to obtain the blood culture specimen. Straight needles from vacuum-extraction collection systems are not used with blood culture bottles. Instead, winged-butterfly needles with a short length of tubing may be approved by the organization for use. Caution should be taken to avoid contaminating the patient’s skin or equipment to minimize the risk of false-positive test results, which can lead to inappropriate antibiotic use. False-positive results may expose patients to additional laboratory tests and increased length of stay. The correct amount of blood required by the laboratory must be extracted into each blood culture bottle to ensure accurate test results and decrease the patient’s risk of anemia.9 If more than one blood specimen is to be drawn during a single venipuncture, specimens for blood cultures should be drawn first to maintain asepsis and prevent contamination with additives from laboratory tubes. Because limited venous access may be a life-threatening complication of venipuncture, maintaining the patient’s vein’s integrity is essential. A patient with veins that may collapse or become injured from the vacuum or a patient whose veins may be difficult to locate because of unusual anatomy, trauma from repeated phlebotomy, or edema may also require an alternative method of blood specimen collection. Vascular visualization technology, such as ultrasound, infrared light technology, or transillumination devices, may be necessary to identify vasculature and can be used for difficult access.5 Tourniquets should be used with caution. If a tourniquet is deemed necessary, the nurse should not apply the tourniquet for longer than 1 minute.9 Prolonged tourniquet application can cause stasis and hemoconcentration.9 Infection control standards require that tourniquets be single use.8 Staphylococcus aureus contamination from reused tourniquets is a common finding.14 Venipuncture can be painful, and the patient may experience anxiety or fear before the procedure. For some patients, just the appearance of a needle is frightening, especially to a pediatric patient. A calm approach and skilled technique may help limit the patient’s aversion to venipuncture. The application of a vapocoolant spray has been shown to be effective in reducing pain during venipuncture.1 Anxiety may be assuaged by communicating with the patient about how to help relieve the patient’s concerns. EDUCATION
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ADDITIONAL READINGSChela, H.K. and others. (2019). Approach to positive blood cultures in the hospitalized patient: A review. Missouri Medicine, 116(4), 313-317. *In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice. Elsevier Skills Levels of Evidence
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