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Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Cardiovascular and Infusion

Therapeutic Phlebotomy (1.07)

Therapeutic Phlebotomy (1.07) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.07

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
July 10, 2015
Amended April,
2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.07

Original
Revision

Page
1
of 3

Title: Therapeutic Phlebotomy

I. PURPOSE

To perform venipuncture and remove whole blood for therapeutic purposes for the
reduction of blood volume in patient populations with conditions such as
hemochromatosis, polycythemia vera, post kidney transplant, and congenital cardiac
conditions.


II. POLICY

A. An order is required for therapeutic phlebotomy which includes volume of blood
to be drawn and goal for post-phlebotomy hematocrit.
B. Pre-procedure hematocrit must be available before performing the procedure.
C. Performing phlebotomy on both arms is generally accompanied by fluid
replacement.
D. This procedure can be performed by registered nurses working in the UW
Hospital Infusion Center and SOS team who have completed education for
performing this procedure.


III. EQUIPMENT

A. Tourniquet or blood pressure cuff
B. Large-bore (17-18 gauge) safety needle, Needle Fistula Set 17Gx1 inch (UWH
Item ID: 4004305) or 18 gauge peripheral catheter
C. ChloraPrep
D. Alcohol prep pads
E. 2 x 2 sterile gauze
F. Tape
G. Exam gloves
H. Wash cloth, or stress ball (for patient to squeeze)
I. Baxter 500 mL evacuated container with 50-100 mL graduations (UWH Item ID:
9996160)
J. Baxter blood collection set with detached 16 gauge needle or roller clamp
K. Solution transfer set with 27 inch needle adapter (UWH Item ID: 9996095)





Page 2 of 4


IV. PROCEDURE

A. Review order for therapeutic phlebotomy, including volume of phlebotomy
desired or target hematocrit.
1. A recent hematocrit (within 72 hours) is necessary for evaluation prior to
therapeutic phlebotomy. If not available, obtain an order and blood sample
for hematocrit test and send to UWHC Clinical Laboratories.
B. Identify patient according to Hospital Administrative Policy 7.31, Patient
Identification.
C. Explain procedure to patient.
D. Perform hand hygiene according to UWHC Hospital Administrative Policy 13.08,
Hand Hygiene.
E. Follow standard and transmission based precautions according to UWHC
Hospital Administrative Policy 13.07, Standard Precautions & Transmission-
based Precautions (Isolation).
F. Assemble supplies.
G. Document baseline vital signs.
H. Assess upper extremities for venipuncture site. Select large antecubital vein
(preferred). Vein must be large enough to accommodate safety needle or catheter.
I. Prepare venipuncture site as outlined in Nursing Policy 1.23 Continuous
Peripheral Intravenous Therapy.
J. Don non-sterile exam gloves.
K. Attach needle to blood collection tubing, close roller clamp.
L. Perform venipuncture and secure safety needle or catheter.
M. Insert spike end of collection tubing into vacuum bottle. Slowly open roller clamp
of tubing allowing retrograde blood flow into tubing and receptacle (collection set
or evacuated container).
N. Tourniquet or blood pressure cuff should be loosened, but left on to facilitate
flow; a radial pulse must be able to be palpated with the tourniquet in place.
O. Patient may gently squeeze wash cloth or stress ball every 10 seconds to facilitate
flow of blood. Instruct patient not to turn arm or squeeze too hard.
P. Document vital signs during, and at completion of procedure.
Q. Offer patient fluids, such as juice or soda with sugar, during procedure to
counteract volume reduction. (Order required for pediatric patients.)
R. Remove blood - not to exceed 500 mL as measured by bag or bottle graduations.
For pediatric patients, refer to provider order for maximum volume of blood to be
removed.
S. Once procedure is complete, close roller clamp on tubing. Remove the needle
from patient’s arm and activate needle safety feature.
T. Hold pressure to site with 2 x 2 sterile gauze for several minutes or until bleeding
stops. Apply small pressure dressing to site using folded 2 x 2 sterile gauze and
tape.
U. After therapeutic phlebotomy, observe patient for a minimum of 15 minutes. The
patient should initially remain supine or seated, and should not stand or walk
without assistance until stable. Watch for signs of adverse reactions (e.g.
Hypotension, Syncope, Tachycardia). Assess blood pressure and pulse.


Page 3 of 4

1. For inpatient units, SOS RN will provide handoff to bedside nurse when
stable.
2. For infusion center, patient may be discharged when stable.
V. Provide patient with post-procedure instructions.
W. Dispose of phlebotomy specimen by taking the collection set or evacuated
container to the soiled utility room and place in large red biohazard container.
X. Documentation: the nurse performing the procedure should document the
following:
1. Clinical diagnosis
2. Physician
3. Pre-phlebotomy hematocrit
4. Date of therapeutic phlebotomy
5. Volume of phlebotomy
6. Vital signs; before, during, and at completion
7. Complications and treatment
8. Patient's condition post-procedure
9. Patient education provided

V. MANAGEMENT OF REACTIONS DURING THERAPEUTIC
PHLEBOTOMY

A. Deflate the blood pressure cuff/tourniquet, close roller clamp on blood draw line.
B. Summon help. Do not leave patient. Notify MD. Only resume procedure at
discretion of MD.
C. Provider may order intravenous 0.9% normal saline as replacement fluid.
Connect to needle/catheter, or new (second) peripheral intravenous site.
D. If diaphoretic, drop in blood pressure or pulse, or pallor occurs, lower the head
and elevate the legs.
E. Loosen restrictive clothing. Apply cold compresses to forehead and back of the
neck. Monitor blood pressure and pulse.
F. Assess and record blood pressure and pulse periodically until patient recovers.
G. Patients in clinic should be monitored until vital signs are stable and patient feels
comfortable to leave.
H. Note time of symptoms and actions taken for all reactions in clinical record.

VI. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 7.31, Patient Identification
B. Hospital Administrative Policy 13.07, Standard Precautions & Transmission-
based Precautions (Isolation) for Inpatient Settings
C. Hospital Administrative Policy 13.08, Hand Hygiene
D. Nursing Patient Care Policy 1.23, Continuous Peripheral Intravenous Therapy

VII. REFERENCES

A. American Association of Blood Banks (AABB) (2009). Standards of
immunohematology reference laboratories, 6th Ed. American Association of
Blood Banks.


Page 4 of 4

B. Roback, J., Combs, M. R., Grossman, B., & Hillyer, C. (2008). Technical manual
of the American Association of Blood Banks, 16th Ed. American Association of
Blood Banks.
C. Therapeutic Phlebotomy (INS, 2011). Policies and Procedures for Infusion
Nursing. Infusion Nurses Society; Norwood, MA.

VIII. REVIEWED BY

Clinical Nurse Manager, Hematology, Oncology & BMT
Nurse Clinician, Infusion Center
Nursing Patient Care Policy and Procedure Committee, June 2015

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer