what should a health care worker do first if a vein collapses during a blood draw?

Has your ED patient ever needed a stat lab and there was no phlebotomist in sight? Have you ever gone to your home health patient's house to get a finger-stick international normalized ratio (INR) and the point-of-care machine stops working? Whether in astute care, long-term care, or home health, most nurses will inevitably find themselves in a position where they have to describe a patient'due south claret via peripheral venipuncture. Nursing schools across the country often include drawing claret from a fundamental line or port in their curriculum, but very few include peripheral venipuncture and phlebotomy basics in the skills checklist.

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In this article, you lot'll learn the practice's and don'ts of phlebotomy, including drawing technique, equipment option, tube additives, drawing order, claret transport, and nursing considerations.

The right equipment

Nurses are accustomed to working with sharps, performing paw hygiene, and using proper protective equipment for invasive procedures. Phlebotomy is no unlike. You should maintain sharps safe, protect yourself and your patient from blood-borne pathogens, and remember the chain of infection at all times. Every bit you gather your supplies, you'll discover that there's a diversity of blood cartoon equipment available. So how do you know what size needle and device are all-time to utilize?

A quick patient assessment should give you the information y'all need to brand the advisable equipment choices. Have a minute to inspect and palpate the patient'south veins. Are they readily visible and close to the surface or are they deeper? Are the veins small and fragile or are they large and supple? The size and condition of the vein are what dictates your decisions when choosing equipment. Also consider that patients may have hardened or sclerotic veins due to I.V. chemotherapy handling or I.5. drug use. These veins should be avoided because they're difficult to puncture and whatever endeavor tin can pb to farther patient injury.

Evacuated tube organization vs. syringe

The evacuated tube system (ETS) is the standard equipment used for routine venipuncture. It consists of a needle device, a tube holder, and an air-evacuated tube. You attach the needle device to the tube holder, insert the needle into the vein, and appoint the tube. The tube holder is a simple plastic appliance that connects the needle to the tube and allows for stabilization of tube engagement during the draw. Once penetrated past the needle, the tube will automatically make full with the correct amount of blood co-ordinate to the amount of vacuum pressure within the tube. When the tube is manufactured, negative pressure is created within it by removing the air. Once the tube is punctured by engaging the tube onto the needle, the negative pressure causes suction to draw the claret into the tube. Easy, right? Non necessarily.

You must consider the size and condition of the vein before defaulting to an ETS. If the vein is small, thin, and fragile, a syringe depict may be the way to go. Past using a syringe and needle to describe the patient'south claret, you lot can control the pressure and speed at which the blood is removed by varying the rate that you pull dorsum on the plunger. A syringe draw is a much more appropriate technique for you to use with veins that easily collapse. Nevertheless, if multiple tubes are needed from a patient, you must also consider how many full milliliters of blood are needed to fill each tube and choose an appropriate size syringe. When you draw using a syringe, y'all complete the process by transferring the blood to the tubes with a Luer-lock transfer device.

Butterfly needle vs. directly multisample needle

When you've selected an ETS to perform a blood describe, you must too consider the size and condition of the vein. For veins that are small, difficult, and close to the surface, such as those on the dorsum of the hand, your all-time option is a butterfly or winged needle fix. A butterfly needle is shorter with a smaller diameter (23 to 25 gauge) and easily controlled. Butterfly needles too have a length of pocket-size, articulate tubing between the needle that accesses the vein and the needle that attaches to the tube holder and accesses the evacuated tube. When you insert the needle into the vein, a blood flashback will exist visible in the tubing, making it easier to recognize that you've accessed the vein.

A direct multisample needle is typically ane to 1.v inches (2.5 to three.8 cm) in length and the gauge ranges from 20 to 22. Multisample needles are the standard choice for routine venipuncture in a patient with normal, healthy veins. If a patient has veins that are particularly fragile, you tin can besides utilize a butterfly needle that's designed to attach to a syringe. Some healthcare personnel choose to utilize a butterfly needle device with every patient because of its size and ease of use. Notwithstanding, this practice is costly because butterfly needles are expensive compared with multisample needles.

Tourniquet

Tourniquets vary in elasticity, width, and length. Ordinarily, a facility will utilize one or 2 types of tourniquets and you won't take much of a choice. Almost facilities are now using latex-free tourniquets, but you should ask your patient almost latex sensitivity if the tourniquet isn't latex-free. There are tourniquets that are longer for obese patients and smaller for pediatric patients and petite adults. The Clinical and Laboratory Standards Constitute recommends single-use tourniquets to avoid hospital-caused infection transmission.

Site clarified

For routine blood draws, 70% isopropyl alcohol or 70% ethyl alcohol is recommended. For routine antisepsis, you can employ a standard alcohol prep pad or alcohol-impregnated swabs. If you're drawing claret cultures, be certain to follow the policy and procedure at your facility. The process typically calls for the use of chlorhexidine or alcohol and povidone-iodine every bit the pare antiseptics. Other antiseptics can be used during a routine blood draw, such as chlorhexidine gluconate or benzalkonium chloride.

Tubes

Why are there then many different types of tubes and what do all of the colors mean? Venipuncture collection tubes are probably the least understood element of phlebotomy by nurses because venipuncture isn't included in nursing curricula. However, using the right type of tube, filling information technology to the right level, and knowing how to handle the tube postdraw are essential for accurate test results.

Although it isn't vital to know the verbal scientific nature of tube additives and types, it'south important to have a general idea of what the additive does and why yous're using it (encounter Commonly used phlebotomy tubes). Tube types are indicated by colors that are universally associated with a certain condiment or tube property. There are ii bones principles to consider: ane) Does this need to be a plasma sample? 2) Does this need to be a serum sample?

The difference between plasma and serum is that plasma contains clotting proteins and serum doesn't. If a test requires a whole blood or plasma sample, such equally a complete blood prison cell (CBC) count, blood depository financial institution test, or stat chemistries, then the tube needs to comprise an anticoagulant additive to forbid clotting. When obtaining a serum sample, such as serum electrolytes or blood urea nitrogen (BUN)/creatinine, the blood needs to clot within the tube before centrifugation and serum collection. In this case, the tube has no additive or contains a jell activator.

Centrifugation is when the tubes are placed in a car that spins at a high number of revolutions per infinitesimal. The spinning action causes the heavier formed elements (blood cells, platelets) to consolidate at the lesser of the tube. The liquid portion of the sample (serum or plasma) is less dense and, therefore, pools in the upper role of the tube, making information technology easier to collect.

Whether your sample is plasma or serum, there are multiple tube types that also accept separator gel present in the bottom of the tube. The separator gel migrates to a position betwixt the formed elements and the plasma or serum during centrifugation. The gel creates a barrier that helps foreclose whole cells from contaminating the serum or plasma sample.

20 steps to successful venipuncture

Any nurse who'due south being introduced to a new skill should accept a skills checklist and be enlightened of the rationale supporting each step. Utilise the following as your guide.

1. Review the order

It's best practice to check the provider'southward gild before drawing the lab(southward). If the lab test ordered doesn't seem appropriate for your patient, don't be afraid to double check with the provider.

ii. Gather the supply tray/cart

If your facility has a phlebotomy tray available with an array of supplies, bring information technology with y'all. Many facilities don't have phlebotomy trays immediately available to nurses. In this case, be sure to assess your patient's veins earlier this step to ensure that you gather the appropriate supplies.

iii. Approach, place, and ready the patient

Explain the procedure to the patient and ask if he or she has had whatsoever difficulty with needles or blood draws. It's best to place a needle phobia ahead of fourth dimension so that patients tin position themselves every bit they prefer. Ask the patient if he or she has a history of fainting during blood draws. If yes, the patient should lie downwards for the procedure.

As with any procedure, medication, or treatment, it's imperative to accurately identify your patient earlier a blood depict. Ask your patient for at least 2 exact identifiers and check them confronting the lab requisition and patient wristband. The most common exact identifiers are total proper name and date of birth. Patient identification may likewise be verified via medical record number or a unique personal identification number. Some facilities may utilize wristband barcode scanning as a method of patient identification.

Table Usually used phlebotomy tubes

This is also a practiced time to verify latex allergies and if your patient followed any prelab instructions such as fasting.

4. Hand hygiene

You should ever perform hand hygiene immediately before performing any invasive procedure. You may employ soap and h2o or an booze-based hand sanitizer.

5. Apply the tourniquet, ask the patient to make a fist, and assess the antecubital infinite

Well-nigh lab draws are performed in the antecubital space of the patient's arm. If at that place isn't a suitable vein in the antecubital space, the back of the patient'due south hand is also acceptable. When drawing from the antecubital space, it's important to palpate each vein to assess how information technology feels and the vein's position. In one case the tourniquet is in place, enquire the patient to make a fist and hold it. Don't accept the patient pump his or her fist because this may cause a change in the claret composition and atomic number 82 to erroneous results.

6. Select a vein, release the tourniquet, and ask the patient to relax his or her fist

The median cubital vein is the first selection for blood draws because information technology has a decreased proximity to arteries and fretfulness in the arm. The more lateral cephalic vein is the 2d selection and the basilic vein in the medial arm is the final choice. The basilic vein lies over a major artery and a nerve in the arm, which increases the risk of patient injury.

7. Cleanse the site

Simply every bit when prepping a site for an I.Five. or injection, you want to use friction and apply 70% isopropyl or ethyl alcohol in concentric circles, moving outward for a full prep expanse of 2.5 to 3 in (6.4 to seven.half dozen cm). You may too utilize benzalkonium or chlorhexidine to prepare the site, using the aforementioned technique. Let the site air-dry completely before venipuncture and be careful not to recontaminate. Don't blow air onto the site, wave your manus over it, or absorb information technology with dry gauze. The air-drying action is what helps decontaminate the site.

8. Apply clean gloves and prepare your equipment

At this point, you've assessed the patient'south arm and selected the all-time vein for venipuncture. Now you demand to decide which technique and equipment are most suitable for your patient (ETS or syringe, butterfly needle or straight multisample needle). Set up the equipment by attaching the tube holder to the needle and selecting the correct tube(s) for the test(s) ordered. Don't uncap the needle at this indicate. It'southward a good thought to accept actress tubes bachelor in instance in that location'south a faulty tube. You should likewise have a piece of gauze and some tape bachelor for immediately after the depict. Past the fourth dimension yous've collected and prepared your equipment, the site should be dry.

ix. Reapply the tourniquet, take the patient make a fist, and uncap the needle

Be sure to carefully reapply the tourniquet and so that you lot don't contaminate the cleansed site. If contamination does occur, yous'll need to resanitize the site. When yous uncap the needle, inspect the bevel for any barbs or defects. If the needle is faulty, replace it.

10. Ballast the vein and insert the needle

Ballast the vein with the thumb of your nondominant manus i to 2 in (2.5 to 5.one cm) beneath the insertion site, being careful non to touch information technology. If you bear upon the insertion site, it must be resanitized. Insert the needle at a 30[degrees]-angle for antecubital veins and a x[degrees]-bending for manus veins. If the vein is deeper in the tissue, you should increase your angle of insertion slightly. If the vein is more superficial, then employ a shallower angle of insertion. Rest the first tube to exist filled in the tube holder at this point, but don't puncture it.

eleven. Establish blood menstruation, have the patient open up his or her fist, and release the tourniquet

If y'all're using a butterfly needle, you'll see claret flashback in the tubing when you lot've accessed the vein. If you're using a directly multisample needle, in that location'south no fashion to meet a flashback of claret when you enter the vein; your judgment on vein access is more by experience and depth of needle insertion. When y'all feel that the vein has been accessed, engage the tube onto the needle and turn the tube a quarter turn to go on it in identify. In one case claret menses is established, you may release the tourniquet. Remember that the tourniquet shouldn't exist on for more than ane infinitesimal because it tin change the claret composition. If you lot're cartoon multiple tubes, information technology'due south acceptable to keep the tourniquet on when you place a new tube as long equally the full tourniquet fourth dimension remains less than i minute.

12. Fill tubes using the correct lodge of describe and mix tubes

Tubes should fill to the appropriate amount automatically considering of the vacuum in each tube. Be sure not to remove the tube before it'due south full because information technology can throw off the additive-to-blood ratio in the tube. When you switch tubes, stabilize the tube holder with your nondominant hand, making sure that you lot don't change the needle insertion depth. This takes practice. When you're removing the filled tube and placing the new tube, apply the two flanges on the side of the tube holder to stabilize information technology and push the new tube onto the needle. ETS tubes are filled in a specific lodge to avoid condiment contamination from tube to tube. Depending on the lab tests being collected, besides every bit facility protocol, yous may be required to collect a "waste" or discard sample as your start tube. This tube is typically white or clear and collects approximately three to v mL of claret to prevent contamination of the sample. A nonadditive ruddy-height tube may likewise be used every bit a discard sample tube.

The society of draw is as follows:

* calorie-free yellow-sterile tubes (blood cultures)

* light bluish-coagulation tubes

* cerise-serum tubes with or without clot activator

* gold-serum tubes with or without separator gel

* green-heparin tubes with or without separator gel

* lavender, purple, pink-ethylenediamine tetraacetic acid, or EDTA, tubes

* gray-glycolytic inhibitor tubes.

Each tube needs to be mixed by inverting information technology a sure number of times. It'due south important not to invert tubes too speedily or you may cause hemolysis of the claret cells, which tin pb to erroneous lab results. Most tubes are inverted 8 times. Red and golden tubes are inverted five times and light blueish tubes are inverted four times.

thirteen. Identify gauze, remove the needle, and employ pressure to the site

Place gauze lightly over the site just before withdrawing the needle and then that when you remove the needle, you lot tin apply firsthand pressure. At this signal, you may ask the patient to agree pressure with the gauze. If the patient is unable, then you must complete this step. Hold the pressure for at least 2 minutes. If the patient is receiving anticoagulant therapy, such as heparin or warfarin, concord the pressure for v minutes.

14. Discard the collection unit of measurement

Engage the needle'southward safe device immediately after withdrawing it from the patient'due south arm and place the needle/tube holder unit in the sharps container. Under no circumstances should you remove the needle from the tube holder before disposal because it increases your run a risk of a needle stick.

15. Label the tubes

Many facilities have computer-generated labels for tubes. If this is the example at your facility, verify the characterization data, identify your initials/time/date on the characterization, and use the label to the tube. If you're filling out the entire characterization, include the patient'south last name and starting time initial, his or her engagement of nativity, your initials, the time, and the date.

16. Implement special handling

If the lab you drew requires special handling, such equally placing the tube in an water ice slurry or wrapping it in foil to protect it from light, at present'southward the time to exercise so. If you aren't certain of special treatment for a sample, call the lab and inquire. It's ameliorate to clarify than to repeat a blood describe because of mishandling a sample.

17. Check the patient's arm and apply a bandage

Assess the insertion site for connected bleeding or bruising. If the site isn't actively haemorrhage, then apply a pressure level cast with gauze and tape. If the site is still haemorrhage, continue to concur force per unit area and recheck the site in a few minutes.

18. Dispose of materials and clean up

Follow your facility'due south policy for disposal of items with blood on them. Also throw away the tourniquet and whatever other used materials.

19. Remove your gloves, perform hand hygiene, and thank the patient

Remove and throw away your gloves, so perform hand hygiene with soap and water or sanitizing gel. You should also give thanks your patient, communicate any symptoms to report, and let him or her know that the provider will discuss any abnormal lab values. If you used a phlebotomy tray or cart, remove it from the room and sanitize it per facility policy.

twenty. Send specimens to the lab

Follow your facility's policy for lab sample transport. If this is a stat lab or the sample requires special handling, it may exist most efficient to bring the sample to the lab yourself. Be sure to proceed the tubes upright and away from excessive motility during send to reduce the run a risk of prison cell hemolysis.

Facilitating authentic results

The preanalytical phase of blood specimen collection and lab value conclusion is everything that happens from the time the test is ordered to the time the sample is analyzed. At that place are multiple considerations during this phase. Granted, nurses don't have control over all preanalytical risks and concerns, but there's a lot you tin can do to minimize erroneous lab results and assistance decrease the likelihood of a second blood depict. After the results are obtained, it's imperative to ensure provider communication of their significance to the patient.

Timing

Depending on what lab test is ordered, you need to verify that information technology'due south the correct time to draw the lab. For example, when a drug's top and trough levels are tested, make sure that you're cartoon the acme level later the correct dosage and at the high point of the drug'due south pharmacologic summit. You should verify the peak time in a drug reference before the depict. The trough is drawn only before a dose assistants; usually, the third or quaternary because this is when serum drug levels are at their everyman.

Burns, scars, tattoos, and damaged veins

You lot should avert these areas for several reasons. Any area of the peel that's newly burned or injured may be painful for the patient and there'due south an increased risk of infection. Areas that have healed after an injury, including tattoos, may accept significant scar tissue and impaired circulation that can crusade erroneous results. Tattoos can also hibernate underlying bruising or hematomas and frequently patients don't desire a blood depict through a tattoo. Damaged veins from frequent claret draws, I.Five. drug use, or frequent I.V. placement tin become hardened (sclerosed) and difficult to puncture.

Mastectomy or breast and upper extremity surgeries

The removal of lymph nodes or impaired lymph circulation can cause not but an imbalance in blood composition, but also put a patient at increased risk for infection and lymphedema. Performing venipuncture on a patient'due south mastectomy side is the last resort and you should consult the patient'southward healthcare provider first.

I.5. sites or venous admission devices

You should avert venipuncture on the extremity with an established I.Five. or other venous admission device, such every bit a peripherally inserted central catheter (PICC) line. I.V. fluids and saline locks can lead to erroneous lab results, and you as well run the risk of damaging or dislodging the device with tourniquet placement. If a patient has an I.5., saline lock, or PICC line that tin't be used for claret draws, the best option is to perform the venipuncture on the opposite extremity. If the patient has I.V. access in both arms, turn off any I.V. fluids for a minimum of ii minutes and draw the sample from a site below the level of the I.V.

Edematous sites and obesity

Sites that are bloated from an injury or I.V. infiltrate may be contaminated with increased tissue fluid or take contradistinct blood composition. Swelling in the arm or obesity can go far difficult to locate a viable vein for venipuncture. If the patient is obese, apply a longer tourniquet or extra-large BP cuff too avoid patient discomfort.

Tourniquet application

Believe it or non, tourniquet application is one of the well-nigh important steps in proper venipuncture. You should place a tourniquet 3 to 4 in (seven.6 to 10.2 cm) in a higher place the site, tying it tight enough to dull venous blood flow and loose plenty non to impede arterial claret period. Necktie the tourniquet using a quick release knot, with the ends pointed abroad from the venipuncture site and the loop pointed toward the site. If the ends are pointing toward the insertion site, they can easily get in the way and cause contamination. Call back, yous shouldn't leave the tourniquet in place for more than than 1 infinitesimal. Also, never identify a tourniquet over a wound or astute injury. It's perfectly adequate to place a sleeve or towel under the tourniquet to protect the patient from skin tears and discomfort. This should be a fundamental nursing intervention when you're drawing claret from an older developed patient with fragile peel.

Learning curve

As hospitals and other care centers decentralize ancillary services, nurses are being called on more ofttimes to draw claret. Transitional and home care nurses often perform phlebotomy procedures, but rarely receive adequate pedagogy to do and so. Procedural errors during the preanalytical phase are largely responsible for inaccurate lab results that lead to the need for boosted blood draws or improper treatment. All the same, in that location's little room in nursing curricula to add more skills content. This leaves phlebotomy as a topic for standing education. Take the initiative to brainwash yourself about proper phlebotomy techniques and equipment earlier you're asked to draw blood.

retention jogger

To remember the society of draw, think "End low-cal carmine stay, green low-cal go."

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twenty steps to a successful blood depict checklist

cheat sail

* Review the guild

* Get together the supply tray/cart

* Approach, place, and prepare the patient

* Perform hand hygiene

* Use the tourniquet, ask the patient to brand a fist, and assess the antecubital infinite

* Select a vein, release the tourniquet, and ask the patient to relax his or her fist

* Cleanse the site

* Apply make clean gloves and prepare your equipment

* Reapply the tourniquet, have the patient brand a fist, and uncap the needle

* Ballast the vein and insert the needle

* Constitute blood flow, have the patient open his or her fist, and release the tourniquet

* Make full tubes using the correct order of describe and mix tubes

* Identify gauze, remove the needle, and employ pressure to the site

* Discard the drove unit

* Label the tubes

* Implement special handling

* Check the patient's arm and apply a bandage

* Dispose of materials and clean upwardly

* Remove gloves, perform manus hygiene, and thank the patient

* Transport specimens to the lab

on the web

Center for Phlebotomy Educational activity:http://world wide web.phlebotomy.com

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Clinical and Laboratory Standards Constitute:http://www.CLSI.org

Mayo Clinic:http://www.mayomedicallaboratories.com/index.html

National Phlebotomy Association:http://www.nationalphlebotomy.org/

REFERENCES

Source: https://www.nursingcenter.com/ce_articleprint?an=00152258-201607000-00008

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