UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: BONE MARROW BIOPSY
Effective Date: June, 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Hematology and Oncology Clinic
Reviewed May 2008 May 2009 May 2013
PURPOSE: To provide guidelines for assisting with a Bone Marrow Biopsy at the University of Wisconsin Medical
Foundation (UWMF) Hematology and Oncology Clinic.
POLICY: The clinical staff will utilize the following guidelines to assist the provider with a bone marrow
biopsy at UWMF Hematology and Oncology Clinic.
SUPPLIES: Bone marrow biopsy kit, sterile gloves, yellow gown, non-sterile gloves One sterile multi-dose
vial of 1% 10mg/ml lidocaine, alcohol swabs
Several sterile 4X4 gauze dressings, one sterile 2x2 gauze dressing
One bottle of alcohol, spinal needle, extra sterile 22g needles, bandage Scissors, ammonia
inhalant, Provider’s order, Patient’s record
1. Check provider’s order and clarify any inconsistencies.
2. Contact GML #417-7840
NOTE: Be sure to include instructions as to what the lab should be collecting.
3. Wash hands and gather equipment.
4. Fill out paperwork (lab form and consent form).
5. Introduce yourself, identify the patient and provide privacy.
6. Explain the procedure to the patient.
7. Allow patient to read and sign consent form, then sign the consent form as a witness.
8. Offer patient a hospital gown, and make patient comfortable
9. Assist patient to side-lying or prone depending on provider preference.
10. When GML/hematology and patient are ready, notify provider.
11. Comfort patient throughout the procedure.
12. Assist provider (as needed). i.e. using sterile technique hold bottle of lidocaine, with label facing provider,
so provider may extract additional lidocaine (f needed).
1. Put on gloves – if not applied from step 13.
2. Cleanse patient with alcohol and apply a dry dressing to the biopsy area.
(See Dry Dressing Policy)
3. Assisted patient to sitting position, offer fluids and assist with dressing (if needed).
4. Remove gloves and wash hands.
5. Assess for lightheadedness, gather vital sign if lightheaded.
6. Patient may stand/walk when steady.
7. Provider will instruct patient to keep bandage on for specified amount of time – NOTE: usually 12-24
hours without getting it wet.
8. Discharge Instructions:
Patient instructed to call if any green/yellow drainage, swelling, redness, fever and/or warmth is noted at
bone marrow biopsy site.
May take Tylenol for pain. If pain increases, patient should phone the clinic.
9. Biohazard materials should be disposed of in proper containers.
10. Room must then be disinfected with dispatch i.e. all surfaces, exam table, etc.
11. Make sure supplies are stocked, if anything is low - reorder.
12. Document in the patient’s record:
Date and time of procedure and how the patient tolerated the procedure.
WRITTEN BY: Amanda Motl, R.N., Oncology Clinic
REVIEWED BY: Nina Jones, Registered Nurse - Oncology
Oncology Department Date
Medical Director Date