Improve your venipuncture technique.

Here are some tips, reminders, guidelines and suggestions to help you improve your venipuncture technique.
For nurses who have limited venipuncture experience I recommend first studying the following video which is quite good (although I will discuss some differences in my own practice).

Of course you should consult, and adhere to your own local unit policy and guidelines for this or any other procedure.

Wash your hands.

Before beginning this procedure perform a thorough hand wash.

Identify | Explain | Consent

If you have not yet done so, introduce yourself to the patient and ensure you have their correct identity. Ask for first and last name as well as date of birth checking against their ID bracelet.

Explain the procedure to the patient.
Tell them the short version before you do it and tell them long version as you are doing it (more on this important skill here).
Make sure you also tell them exactly why they need to have blood drawn, what tests are going to be run and roughly how long the results will take to come back.
Finally, ask them if they have any questions.

Having the patient extend their arm or begin squeezing their fist etc is considered an implied consent for this procedure but it is preferable to ask them specifically for permission or simply ask “are you OK with that?”

If you have some form of electronic ID label generator, print them out at this time and check against patients ID. Set them aside ….close by.
You should never stick the patient ID labels to the pathology tubes until they are filled with blood. This increases the risk of errors.
You should also never carry blood filled tubes across to the printer or set them down unattended.

To recap:

  1. print out the labels.
  2. check against patient ID.
  3. fill the tubes.
  4. then attach the labels and complete any additional documentation.

Position | Planning | Preparation.

Ensure the patient is in a comfortable position and that their arm is supported and sloping downwards if possible.

Always ask yourself: if this patient were to have a vasovagal response during the procedure (or otherwise collapses) are they safe from harm? For example: sitting a big beefy tattoo covered man upright on a stool whilst you draw his blood is probably an unwise strategy in my experience.

Importantly, make sure you will also be comfortable during the procedure. Being bent over or at an uncomfortable angle during the draw will decrease your likelihood of success.

Check to see exactly which blood tests have been ordered.
Assemble your equipment and blood tubes taking into consideration:

  • Which tube should you use first?
    See: Order of draw
  • Blood cultures require additional actions, and again there is a specific order in which they should be drawn.
    See:  Blood cultures.
  • Other special orders such as venous gas samples or blood alcohol collection.

Take time to properly set up your equipment for venipuncture as per your hospital protocol.

PPE.

Don your personal protective equipment (PPE).

Namely, gloves and eye protection.
If your patient has been given chemotherapy within the last 7 days further precautions should be used (consult your local policy for advice on this).

Tip: I tend to opt for gloves that are a size smaller than I would usually wear to ensure the glove stretches tight across my fingertips. I find this gives me a better touch sensitivity when palpating the vein. Check for wrinkles on the gloves across your fingertips as these can misleadingly feel like a vein during palpation.

And yes,  you should always be wearing additional eye protection during venipuncture.
Prescription glasses are NOT enough. I have had blood flick up under my glasses and directly into me eyes on two occasions. I now always wear a full face shield when drawing blood (Which I often wear upside down when not using much to the amusement of my colleagues).

Performing the venipuncture.

Select your target vein.

Apply the disposable tourniquet firmly but not too tight (reusable tourniquets are an infection control risk and should not be used)
A good light source will help to visualise your vein but it is your sense of touch that will be most useful. Palpate for the unique ‘spongey firmness’ that a good vein has. You will also want to palpate above and below to get an idea of the direction of that vein so your needle does not enter across it and out the other side.

 

veins in upper arm

Here are some tips to help you when you just can’t find that vein.

As featured in the above video, many hospitals recommend using some sort of vaccuette system consisting of a needle and a plastic tube holder.

Personally,  I would recommend using a butterfly needle (and I usually use an 18fr or green for most adults) attached to the tube holder. I find that if you use a standard needle the movement caused by removing a blood tube from the holder and re-loading a new tube often moves the needle tip out of the vein resulting in a failed venipuncture..

During my preparation I grab a small 3cm length of Transpore tape which I temporarily place on the tourniquet (within easy reach) once it has been applied to the patients upper arm.
During insertion I place the tube holder in the palm of my dominant hand whilst holding the actual butterfly needle between the thumb and first fingers.

The needle enters through the skin bevel up at about a 15-30 degree angle. Let the patient know there is about to be a sharp push. Be confident.

Once I have confirmed the butterfly is in the vein (by seeing a flash-back of blood in the proximal butterfly needle tubing) I grab the tape and gently lay it across the wings of the butterfly, temporarily holding it in place.

Letting go of it with my fingers, I now have the tube holder in my dominant hand and my other hand is free to attach and remove the required blood tubes as they fill. This avoids movement of the needle tip in the vein.

Two caveats to this technique. So use caution:

  1. Butterfly needles cause a high number of occupational exposure injuries. They tend to spring and bounce around on their tubing if not removed carefully.
  2. There is extra air in the tubing of the butterfly which will enter the first tube filled and may affect some tests. For example, it could lead to under-filling of coagulation tubes (where correct volume is important) or introduce extra air into an anaerobic blood culture bottle.

Some people hold the butterfly needle by the wings , others prefer holding it back behind the wings. This is personal preference, but I find holding the wings leads to the fingers obscuring your view of blood flashback in the tubing).

Sharps management:

Always have a sharps bin within easy reach during this procedure. The needle must go directly from the patient into the sharps bin.
NEVER place a needle down on to any other surface. Even if you think you will pick it up again in just a second. Never.

Also remember that the vacuette collection tube also contains a needle (although this one is often hidden under a rubber coating) that can easily lead to an exposure injury if you inadvertently place your finger over the lip. Again, directly into the sharps bin.

Puncture site care.

Apply direct sustained pressure to the site once you have removed the needle. If the patient is able, they can assist with this once you have demonstrated how to do it.

Don’t let the patient ‘bend their arm’ to apply pressure as this usually leads to a bigger haematoma at the puncture site.
Obviously if the patient is on anticoagulant therapy they may need pressure to be applied for a longer time.

Care of blood tubes:

After collecting blood most tubes should be inverted gently 6-8 times to mix with any anticoagulant, antiglycolytic or clot activators present in the tube. An inversion is one complete turn of the wrist, 180 degrees, and back.  

Only after the specimen has been collected should any patient identification information be attached. Re-confirm this information before doing so.

Documentation:

Remember to correctly complete all documentation relevant to this blood draw including pathology forms, labelling and signing of tubes and completing an entry in the patients notes confirming the venipuncture was attended.


References:

  1. Venipuncture Procedure At a Glance – LabCE.com, Laboratory Continuing Education [Internet]. Available from: https://www.labce.com/spg263754_venipuncture_procedure_at_a_glance.aspx

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