Phlebotomy , the practice of drawing blood from a vein, is a proficiency that all nurses should learn in their career. While not commonly taught in nursing school programs, many recommend that nursing students take extra courses in how to take blood to hone this skill.

    Obtaining blood samples, either via a venous stick or from a central line, is a critical nursing skill. Phlebotomy is essential for a variety of medical diagnoses, procedures, and tests. Without proper specimens, unhelpful or even harmful medical treatment could happen. Nursing schools do not teach this skill due to legality issues. Students should study venipuncture in books and watch licensed nurses in clinical settings perform this task. In doing so, this will enable students to learn basics prior to graduation. 

    Even though most hospitals do have phlebotomy teams, it is still critical for nurses to learn these skills in order to provide the best patient care. In fact, the majority of intensive care units require their nurses to possess these skills. Phlebotomy teams generally only make rounds at specific times in hospital settings, therefore, if a lab test is ordered immediately it could be the responsibility of the nursing staff to draw the specimen. 

    How to Learn How to Draw Blood

    The practice of phlebotomy is not something that can strictly be learned from watching videos or reading a how-to guide but something that must be practiced repeatedly in a controlled environment with other trained professionals. It’s important to speak to your supervisor to learn the steps in order to become certified in your hospital. Each healthcare system has its own requirements prior to nurses performing blood draws

    The World Health Organization's Blood Draw Guidelines

    The World Health Organization’s (WHO) best practice guidelines for blood draws include the following:

    • Planning ahead
    • Using an appropriate location
    • Quality control

    The overall purpose of establishing the guidelines is to

    • Improve knowledge and awareness of the risks associated with phlebotomy among all health workers involved in the practice
    • Increase safe practices and reduce blood borne virus exposure and transmission
    • Improve patient confidence and comfort
    • Improve the quality of laboratory tests

    The WHO has set forth the following standards of patient care for hospitals to adhere by: 

    • Availability of appropriate supplies and protective equipment
    • Availability of post-exposure prophylaxis (PEP)
    • Avoidance of contaminated phlebotomy equipment
    • Appropriate training in phlebotomy
    • Cooperation on the part of patients
    • Quality of laboratory sampling

    They also identify dangerous and unsafe practices for blood draws including,

    • Recapping used needles using two hands
    • Recapping and disassembling vacuum-containing tubes and holders
    • Reusing tourniquets and vacuum-tube holders that may be contaminated with bacteria and sometimes blood
    • Working alone with confused or disoriented patients who may move unexpectedly, contributing to needle-sticks

    How to Draw Blood

    Drawing blood from a patient can be a daunting task but it also is a necessity for nurses. Here are the basic steps to drawing blood:

    • The first step is to discuss with the patient what you will be doing and why as well as gather all the needed supplies.
    • Next, identify the vein that you will be using. The most common vein is the antecubital fossa; however, the median cephalic and median basilic vein are also used.
    • Place a tourniquet and clean the area for 30 seconds with an alcohol wipe.
    • Insert the beveled needle at a 30-degree angle into the vessel.
    • Once blood is seen in the tubing, connect the vacutainers or use a syringe to drawback.
    • Properly label the tubes and send to the laboratory for analysis

    Step 1: Identify The Vein

    The first step in drawing blood correctly is to identify the appropriate veins to puncture. For adult patients, the most common and first choice is the median cubital vein in the antecubital fossa. Commonly referred to as the antecubital or the AC it can be found in the crevice of the elbow between the median cephalic and the median basilic vein

    This is an extremely large vessel and if stuck properly can yield excellent blood results. Some health care settings may insert blood drawing peripheral intravenous catheters into this vessel for frequent blood draws.  

    For novice phlebotomists, this vein is the first choice because it is close to the skin’s surface and tends not to roll when punctured. Furthermore, it has a low risk of damaging surrounding nerves, arteries, and tendons versus other veins in the hands. 

    Learning the anatomy of the main veins and arteries in the body is essential to becoming competent in phlebotomy. If the antecub has already been accessed there are great options for venipuncture.

    Other commonly used veins include:

    • basilic vein
    • cephalic vein

    Avoid Puncturing These Areas

    While it is important to know the best veins to access it’s also important to know which areas to avoid.

    These areas include:

    • Edematous sites (swollen sites filled with serous fluid)
    • Scarred or burned areas
    • Fistulas and grafts
    • Hematomas
    • From an IV cannula (unless permitted by your institution)
    • Sites above an IV cannula in the same vessel
    • Arm with PICC line 
    • Arm with a preexisting or current blood clot
    • Arm on side of a mastectomy
    • Via an open wound or area of infection
    • Arm in which blood is being transfused
    • Arm on the side of a surgical procedure

    Step 2: Gather Supplies

    After identifying the site for the blood draw, gather the appropriate supplies needed. Some institutions have kits with all of the needed supplies while others will require the nurses to gather them individually. An important tip - take extra supplies into the patient’s room in case you need to attempt a second venipuncture.

    These supplies include:

    • Evacuated Collection Tubes (tubes specific to labs ordered)
    • Personal Protective Equipment (ie gloves)
    • Appropriate blood-drawing needles
    • Tourniquet
    • Hand Sanitizer
    • Alcohol swabs for skin disinfection
    • Laboratory specimen labels
    • Gauze
    • Blood transfer device
    • Adhesive bandage/tape
    • Laboratory forms
    • Bio-hazard leak-proof transportation bags
    • Puncture resistant sharps container

    Step 3: Venipuncture

    After assembling the appropriate equipment, follow the next steps to perform a proper venipuncture. Once again, please be aware that these are only guidelines for blood draws and nurses should consult with the appropriate hospital personnel regarding performing this procedure on patients.

    Additionally, these steps only apply to the adult and pediatric population and not neonates. 

    • Explain the procedure and reason for the blood draw to the patient.
    • Identify the patient using two patient identifiers as mandated by JCAHO.
    • Confirm the ordered tests and fill out the appropriate forms and labels.
    • Check for any allergies or sensitivities with the patient regarding antiseptics, adhesives, or latex. True allergies should be identified on an allergy ID band but sensitivities may not be reported at the time of patient admission. 
    • Position the patient and hyperextend the patient’s arm.
    • Perform good hand hygiene and don appropriate PPE. 
    • Apply a tourniquet approximately 3-4 inches above the selected site. Closely monitor the arm to ensure that is is not applied to tight or for more than 2 minutes. Reasons for concern would include numbness, tingling, change of color to blue or white, and extreme pain. 
    • Ask the patient to make a fist and not pump the hand. This is a common misconception - pumping the hand does not increase venous circulation. 
    • Prep the venipuncture site by cleansing the area with an alcohol prep pad for 30 seconds and allow to air dry for 30 seconds. Do not wave, fan, or blow on the area as this contaminates the area and leads to increased risk for infection. 
    • Grab the patient’s lower arm (below site of puncture) firmly to draw the skin taut and anchor the vein from rolling. Insert the needle at a 15 to 30-degree angle into the vessel.

     

    • If properly inserted blood should flash into the catheter. If this does not happen then the needle has either not punctured the vein or the needle went through the vessel.
    • Attach the needed tubes or syringes to remove the proper volume of blood. Remove the tourniquet as the last amount of blood is drawn.
    • Remove the needle from the patient’s arm and press down on the vessel with gauze. 
    • Dispose of contaminated materials and needles in the designated hospital approved containers.
    • Label appropriate tubes at the bedside and place into transport bags.
    • Deliver blood specimens to the laboratory promptly. If the blood is not delivered in a timely manner it can cause hemolysis and skew the lab results. 

    Don’t be discouraged if at first, you don’t access the vein. Venipuncture is a skill that takes time and practice to master. Always remember to ask for help from seasoned nurses and seize opportunities to practice your skills. 

    Things Nurses Should Know About Drawing Blood

    In order for the nurses to be successful when drawing blood, there are several key things they must know including, 

    • Proper technique
    • Proper safety standards to avoid a needle stick
    • Vein placement in the arms
    • Troubleshooting blood draws
    • Rationale for blood draws

    Blood Draw Best Practices

    The WHO has best practices that are key to preventing infection and being successful during blood draws. Furthermore, they protect the nurse or healthcare professional from a potential needle stick. 

    Best practices in phlebotomy involve the following factors:

    • planning ahead
    • using an appropriate location
    • quality control
    • standards for quality care for patients and health workers, including
      • availability of appropriate supplies and protective equipment
      • availability of post-exposure prophylaxis (PEP)
      • avoidance of contaminated phlebotomy equipment
      • appropriate training in phlebotomy
      • cooperation on the part of patients
    • quality of laboratory sampling

    Drawing Blood FAQs: 

    What is the best vein to draw blood from?
    For adult patients, the most common and first choice is the median cubital vein in the antecubital fossa. Commonly referred to as the antecubital or the AC it can be found in the crevice of the elbow between the median cephalic and the median basilic vein. more
    How long should you wait to draw blood from the same vein?
    Its best to alternate veins. A vein takes at least a couple days to heal. 0ore time is better. If you use the same vein, shoot DO:N STREA0 from your last shot (that means closer to your heart. more
    What vein is blood drawn from?
    Most of the time, blood is drawn from a vein located on the inside of the elbow or the back of the hand. The site is cleaned with germ-killing medicine (antiseptic). An elastic band is put around the upper arm to apply pressure to the area. This makes the vein below it swell with blood. more
    Why can't they draw blood from my veins?
    If you have been to a clinic or lab before and had the phlebotomist stick you more than once for a blood draw, you may have been told that you are a "difficult stick." This can happen to people for quite a few different reasons, including small or deep veins, rolling veins, dehydration, collapsing veins, constricted more
    What vein is best to draw blood from?
    For adult patients, the most common and first choice is the median cubital vein in the antecubital fossa. Commonly referred to as the antecubital or the AC it can be found in the crevice of the elbow between the median cephalic and the median basilic vein. more
    Which vein do you draw blood from?
    For adult patients, the most common and first choice is the median cubital vein in the antecubital fossa. Commonly referred to as the antecubital or the AC it can be found in the crevice of the elbow between the median cephalic and the median basilic vein. more
    What are the 3 main veins to draw blood?
    The most site for venipuncture is the antecubital fossa located in the anterior elbow at the fold. This area houses three veins: the cephalic, median cubital, and basilic veins (Figure 1). more
    What vein do you draw blood from?
    For adult patients, the most common and first choice is the median cubital vein in the antecubital fossa. Commonly referred to as the antecubital or the AC it can be found in the crevice of the elbow between the median cephalic and the median basilic vein. more
    What happens if you draw blood from an artery instead of a vein?
    The primary reason for taking blood from an artery rather than a vein is to measure blood gases. Because arterial blood is oxygenated blood flowing directly from the heart, analysis of arterial blood can determine the chemistry of the blood before it is used by the tissues. more
    Which vein is best for drawing blood?
    For adult patients, the most common and first choice is the median cubital vein in the antecubital fossa. Commonly referred to as the antecubital or the AC it can be found in the crevice of the elbow between the median cephalic and the median basilic vein. more
    What to do if you can't find a vein to draw blood?
    If the medical staff does not see a vein that will work for a blood draw, they may take blood from another location. Depending on the protocols of the lab, clinic, or doctor's office, they may be able to do a blood draw from the top of the hands, wrists, and other areas on the arms. more

    Source: nurse.org

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