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Although it would be nice to have every blood run as smoothly as simply doing steps 1-18 from the last section, more often than not your patient will come with some kind of challenge. No one's body is the same and so it is important to learn about all the possibilities you may face and learn what to do when presented with some of these challenges. Some of the difficulties you may face might be your own error during the venipuncture. Learning when to correct yourself, when to restart, and when to stop is also important.
Inappropriate Puncture Sites
Inappropriate Puncture Sites
Before you even tie the tourniquet, there are some situations to always consider and avoid::
Edema- An edema is an accumulation of fluids in the tissue. Not only will this make it hard to find a vein in the first place but drawing from tissue with an edema can also lead to inaccurate test results. Sometimes there is no other option, so feel deep. Ask the patient where their veins are for blood draws, they can usually tell you accurately.
Damaged Tissue- Like avoiding tissue with an edema, you also want to avoid damaged tissue. This can include skin that is scarred, busied, burned, or infected.
Sclerosed Veins- Sclerosed veins are scarred veins. They feel like cords-stiff, hard, and tight. This can happen for various reasons. Sometimes elderly patients have veins that thicken from arteriosclerosis. Extensive I.V. drug use for medical reasons, or illegally can also cause scarring. Even multiple venipunctures over years can cause it. It's commonly seen with plasma donors. Avoid these veins.
Tortuous Veins- These are veins that are winding or crooked. They are susceptible to infection and often have impaired blood flow leading to inaccurate test results. Don't poke these.
I.V. Therapy- If a patient has an IV placed in their arm you may draw blood still but you must draw blood from BELOW the IV placement. For example, if the IV is in the forearm, you must draw from the hand. If the IV is in the hand, use the other arm. Never turn off the IV yourself. Ask the attending nurse to stop the IV so that you can draw blood. The IV must be stopped for 2 minutes to draw below the site or 15 minutes if you must draw above the IV site.
Mastectomy- If a patient has had a mastectomy, do not draw from the same arm as the side they had the surgery. For example, if the left breast was removed, avoid using the left arm and draw from the right arm or hand. If they had a double mastectomy, consult a nurse or physician. If your facility allows, draw from the patient's foot. The reason for this is because during the mastectomy procedure, lymph nodes are removed and this interferes with the flow of lymph fluid. This increases the blood level of lymphocytes and waste products normally contained in the lymph fluid. It is the cause for inaccurate results. Usually the patient will tell you if they have had one.
Fistula- A fistula should never be used for venipuncture. It is a surgical connection between arteries and veins and used for dialysis procedures. Patients who have end stage renal failure are treated with hemodialysis. When kidneys aren't performing properly (to clean and filter the blood) a dialysis machine is used to do this. Since there is so much blood flowing in and out of the artery and vein for this process to occur, a fistula is created by sewing the artery and vein together which enlarges the vein as the arterial pressure grows in the vein. It allows for a large needle for the dialysis process.
Arteriovenous Graft- Like the fistula, never perform a venipuncture on an arm with an arteriovenous graft. Similar to a fistula, it is a surgical procedure used to connect a vein and artery for dialysis. A arteriovenous graft connects the vein and artery with a surgical tubing and is often used when forming a fistula was not successful.
Fistula
Edema
Damaged Tissue
Sclerosed Vein
Tortuous Vein
IV Therapy
Arteriovenous Graft
Failure to obtain blood
Failure to obtain blood
You have a patient that comes to you for their blood draw. You sit them down, read their requisition, prepare your materials, ask them all the preliminary questions to be sure they are ready and you tie the tourniquet and find a vein. You clean the site, uncap your needle and insert it. When you put the vacutainer tube in you notice there is no blood flowing into the tube. THIS MOMENT is where most people start to panic. Both the patient and the phlebotomist. It is very important to realize that you have options here and you do not need to abort the mission. Failure to obtain blood WILL happen to you. Know that now and prepare for what you can do to correct this situation. If the patient becomes uneasy, tell them what you are doing and ask them to tell you if they feel any pain that they can't handle.
How to Prevent Missing:
This happens to even highly skilled and experienced phlebotomists. The number one way to avoid missing a vein all together is to find a GOOD one to start with.
Make sure you anchor well. Have the patient in a position that will help them avoid moving their arm once you put the needle in.
Apply the tourniquet as tight as you can without hurting the patient.
When palpating the vein look for a "landmark" or something to help you aim. This can be like a mole, or freckle or hair. Also determine the direction that the vein is going to enter at the right angle. Do not mark your patient with a marker or pen.
Other Reasons for Missing:
Sometimes you don't miss it and it is actually a bad tube. If the tube has lost its vacuum blood won't flow. Be sure to check the expiration dates of the tubes. Check the tube for cracks or damage. Always have backup tubes handy.
Bad placement of the needle is often a reason for a miss. HOLD STILL. Remain calm and don't panic. Anchor your hand and needle. With your free hand feel for the vein again. Feel for where your needle is and where it needs to be. Do not redirect your needle with side to side motions. Remember the needle is sharp and will slice through the tissue, which will cause bleeding and hematomas. To redirect either advance straight forward if the vein is just ahead, or pull the needle back, leaving the bevel still in the skin, pull tot and anchor the vein and restick the vein from the new desired angle with a straight forward jab. Don't go fishing and redirect blindly. If you are in the basilic vein, do not try to redirect as you are close to several nerves and the brachial artery. This would be very painful for the patient.
Other times you have not missed and are in the vein but blood flow is not occuring because the bevel of the needle is against the vein wall. (Imagine putting your hand over a vacuum hose). To fix this, slowly and slightly change the angle of your needle without pushing it forward or pulling it out. If you are in the vein and it corrects, blood will start to fill your tube.
If slightly adjusting the angle of your needle didn't work, you might also be partially in the vein or may have passed all the way through it. This is when it would be appropriate to attempt moving a little forward or a little backward to see if blood flow begins. Patient's call this "digging" and no one likes it. It is best to try a few "adjustments" in case it is a quick fix. If none of the adjustments work, then release the tourniquet, remove the needle and apply pressure with the cotton ball. Give the patient and yourself a moment and inform them you'd like to try a different vein.
Only stick a patient two times. Don't attempt it a 3rd time if you miss. Let another phlebotomist try.
Any needles or tubes used during a draw that was unsuccessful must be disposed of in the sharps container.
Rolling Veins:
"The vein rolled." This is the most common "excuse" you'll hear a phlebotomist use when they miss a vein. Veins can roll, but there are tricks to help prevent this. Rolling is more likely in some veins than others. Superficial veins tend to move a lot more than deeper ones. Deeper ones have more tissue and fat surrounding them which hold them in place better, but also make them hard to find and feel. This is why the median vein is the first choice, when felt, it is easiest to hit without rolling. If you need to use the cephalic or basilic veins, good and proper anchoring techniques will be crucial. Entering quickly will also help avoid the rolling of the vein. If you enter slowly your needle tip will simply slowly push the vein over without puncturing it.
Collapsing Veins:
Some patients will come in with weak, small fragile veins. These are at risk of collapsing or "being blown." The sign for a collapsed vein is usually blood flow that just stops for "no reason". Sometimes this is caused by the vacuum putting too much pressure on the vein and it causes the vein to close up. (Imagine a vacuum attached to a balloon, it sucks the air too quickly and then the balloon walls suck together.) Do not redirect on a collapsed vein. Remove the tourniquet and remove the needle and try again in a different vein. To avoid having it collapse again, use a smaller butterfly needle, smaller tubes or pediatric tubes or use a syringe to pull the blood at a slow and more gentle rate.
Other complications associated with Phlebotomy
Other complications associated with Phlebotomy
Hematoma-Hematomas are the most common phlebotomy complication. Hematomas are bleeding under the skin causing bruising. If the bevel of the needle is not completely in the vein, blood will leak out and cause a hematoma. If you poke through a vein and slightly pull back to correct, the hole from poking through will leak blood and cause a hematoma. When a hematoma begins to form it is pretty obvious. You will see blood forming a bubble under the skin and darken. If you see this happening, stop the blood draw, pull the tourniquet, pull the needle out and apply pressure with gauze or a cotton ball. Use an ice pack if needed. Ice will slow the blood flow and formation of the hematoma.
Fainting- Fainting is also a common phlebotomy complication, but not as frequent as hematomas. Feeling dizzy or faint before, during, or after a blood draw is called Vasovagal Syncope. It happens to about 3% of patients. There are several reasons that this may happen. It may be because of a physical or emotional response to unpleasant stimuli such as pain, fear, or the sight of needles or blood. This reaction causes a sudden loss of blood pressure leading the patient to feeling faint since the brain has momentary lapses of decreased blood flow. If it is the patient's first time getting blood drawn they may be prone to fainting. If they have low diastolic blood pressure, high systolic blood pressure, or act nervous, watch for signs of fainting. It may be helpful to recline or lay them down prior to the draw so you don't have to try to catch them while holding a needle. Signs that a patient may be feeling faint or are about to pass out are: they stop talking, eyes roll, pale faces, sweating all over their body, dizziness, ringing in the ears, blurry vision, nausea, slurred speech, and sometimes convulsing. If you see the start of one of these, open an alcohol swab and put it in front of their nose to inhale. This may help them avoid losing consciousness. If they aren't laying down already, help them to do so. If there is nowhere for them to lay down or recline, have them rest their head on the armchair or on a counter. Don't have them rest their head on their knees as they can tip forward and hit their head on the ground. If they lose consciousness and you have trouble waking them, you can use an ammonia inhalant under their nose. If the patient has asthma do not use this. Otherwise it usually helps a patient regain consciousness.
Hemoconcentration- Hemoconcentration is when there is an increased proportion of formed elements (platelets, red blood cells and white blood cells) to plasma. This is caused by the tourniquet being left on too long. Avoid letting the tourniquet be on longer than two minutes. You won't be able to see this complication until the blood tube is centrifuged. Lab techs might ask for a redraw to run the test.
Petechiae- Petechiae are tiny red dots that appear on the skin from the tourniquet being tied too tightly or left too long. This is a result of capillaries rupturing.
Phlebitis- Phlebitis occurs when a vein becomes inflamed from repeated venipuncture.
Thrombus- A thrombus is a blood clot. With phlebotomy these occur usually when there is not enough pressure applied after withdrawal of the needle.
Thrombophlebitis- Thrombophlebitis is when you have an inflamed vein and a clot formed.
Septicemia- Septicemia occurs when an infection enters the body and is introduced by venipuncture.
Trauma-Trauma to the tissue occurs when probing/fishing or "slide slicing" with the needle.
tips to make difficult draws easier
tips to make difficult draws easier
Blood draws are not easy and require skill and training. According to CLSI, 5% of blood draws are unsuccessful. So here are some tips to help you have the best success possible.
General Tips
Warm the site before poking it. This will increase the blood flow to the area.
Use alcohol swabs while palpating. The wetness will make the skin cold and shrink slightly exposing the veins more making them easier to feel.
Tighten the tourniquet (but not too tight). Often the tourniquet is just too loose.
Lower the arm below the heart, use gravity.
Be sure the patient is hydrated. Offer them water and have them drink for 15-20 minutes before drawing them.
Have the patient flex, extend their arm out tight or rotate their wrists to feel different angles.
Palpate in different directions.
If looking for a deeper vein, have the patient relax their arm and slightly bend it upwards while you feel. This works to feel veins with some patients.
If attempting a hand vein, place the alcohol swab over the vein and then (after warning the patient) flick the vein 3 or 4 times. This will cause it to grow and bulge. Don't injure your patient by flicking too hard.
Bariatric Patients- Obese patients can be challenging to find a vein on. Check the cephalic vein.
Geriatric Patients- Elderly patients may have tender, fragile skin and rolly veins. Use a butterfly needle and good anchoring.
Needle Phobic Patients- Patients with legitimate fears of needles can be difficult as they flinch and withdraw easily. Fear can lead to fainting. It can also cause decreased blood flow. Use smaller needles (tell them this, it helps ease their minds), lay them down, don't have them look, distract them with conversation or their phones. Don't show them the needle or the blood or tubes. Some prefer you don't talk about the blood draw and not to tell them when you are about to poke. Invite them to have someone there to support them.
Unstable Patients- An unstable patient may be someone combative, impaired, handicapped, or psychologically unstable. Bottom line, be prepared to react by releasing the tourniquet and removing the needle, activating the safety and applying pressure if possible. Always protect yourself. If you are uncomfortable with a patient you are not required to draw them. Talk to another phlebotomist or supervisor for assistance. If the patient has a caretaker with them, ask advice for how to make the draw a success. Let them help you get the patient comfortable.
Pediatric Patients- Pediatric patients can be tricky! They are very reactive and usually take a lot of coaxing. Explain what you need to do simple. Do a mock walk through with a parents arm or a stuffed animal. Show them the sticker, candy or toy they get when they finish. Leaving the cap on the needle do a pretend draw on them before the real one. Distract them with a show or book or something else to look at. It is often helpful to have the parent hold them and hold their arm down. If there is another phlebotomist available to help secure the arm for the draw that is recommended. Use a butterfly needle. Usually children have a good median cubital vein. Heel stick may be performed on infants. If you have cooling or numbing spray you can spray that on before performing the venipuncture. Be ready to redirect quickly as kids are wiggly. The better anchoring and securing you do the better.
Drug Users- Drug users usually have very scarred and damaged veins. They can usually tell you exactly where they are though. Try to enter the vein above or below the scarring.
Post Cancer Treatment- Like drug users, repeated poking will cause scarred and hardened veins. They may also be smaller and harder to palpate. Since they have had it done a lot, you can always ask them where a good vein is to draw from.
Sleeping Patients- Don't draw blood from a sleeping patient. It can startle them and mess you up and also cause inaccurate test results. Always wake them first. Shake/tap the bed and say their name. Don't shake them.
Pediatric draws.pdfRETURN TO THE GOOGLE CLASSROOM AND DO THE PRACTICE WORKSHEET.
For more information and references on the reading material found in Section 5: Venipuncture Problems, click the link below. Test questions will be based on the reading in the sections and not from more information found in external references and website links.
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