From Vein Selection to Troubleshooting: A Nursing Student’s Ultimate Guide to Phlebotomy Best Practices

Phlebotomy, the practice of drawing blood from patients for testing, is an essential skill for nursing students to master.

Proper technique is critical to ensure patient comfort and safety, and obtain accurate lab results..

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Anatomy and Physiology of the Venous System

From Vein Selection to Troubleshooting: A Nursing Student’s Ultimate Guide to Phlebotomy Best Practices

To effectively draw blood, it’s important to understand the anatomy and physiology of the venous system. Veins are blood vessels that carry deoxygenated blood back to the heart. They have thinner walls and lower blood pressure compared to arteries. The most commonly used veins for phlebotomy are:

• Median cubital vein: Located in the antecubital fossa (elbow pit), this vein is often the first choice for blood draws due to its size and accessibility.
• Cephalic vein: Runs along the lateral aspect of the arm, from the wrist to the shoulder.
• Basilic vein: Found on the medial aspect of the arm, from the wrist to the axilla (armpit).

Smaller veins, such as those on the back of the hand, may be used for patients with difficult venous access or when larger veins are unavailable.

Vein Identification Techniques

Locating suitable veins is a crucial skill for successful phlebotomy. Here are some techniques to help identify veins:

1. Visual inspection: Look for visible veins that appear as blue or green lines under the skin. Veins may be more prominent in people with fair skin, low body fat, or after applying a tourniquet.
2. Palpation: Gently feel for veins using your fingertips. Veins should feel soft, bouncy, and refill quickly when depressed. Avoid arteries, which have a stronger pulse and do not refill when pressed.
3. Tourniquet application: Placing a tourniquet 3-4 inches above the intended puncture site can help distend veins, making them more visible and palpable. Be sure not to leave the tourniquet on for more than one minute to avoid discomfort and hemoconcentration.
4. Warming the site: Applying a warm compress or having the patient lower their arm below heart level can increase blood flow and make veins more prominent.

Remember to always choose the most distal site possible to preserve proximal veins for future access.

If a vein is not easily located, ask a more experienced colleague for assistance.

Blood Draw Procedure

Once a suitable vein has been identified, follow these steps to perform a successful blood draw:

1. Gather necessary supplies: Tourniquet, alcohol wipes, gauze, bandage, needle, vacuum tubes, sharps container, and gloves.
2. Identify the patient using two identifiers (e.g., name and date of birth) and explain the procedure to them.
3. Position the patient comfortably with their arm extended and supported. Apply the tourniquet 3-4 inches above the intended puncture site.
4. Clean the site with an alcohol wipe using a circular motion, starting at the center and moving outward. Allow the area to air dry completely.
5. Hold the patient’s arm firmly and anchor the vein below the intended puncture site with your non-dominant thumb. Inform the patient of the impending needle stick.
6. With the bevel up, insert the needle at a 15-30 degree angle into the vein. A slight pop or give may be felt as the needle enters the vein.
7. Stabilize the needle and attach the vacuum tube, allowing it to fill until blood flow stops. If using a syringe, gently pull back on the plunger to draw blood.
8. Release the tourniquet and place a gauze pad over the puncture site as you remove the needle. Immediately dispose of the needle in the sharps container.
9. Apply pressure to the site for 2-3 minutes, then apply a bandage. Invert the tubes gently to mix the blood with any additives.
10. Label the tubes with the patient’s information, date, and time of collection. Transport the samples to the lab promptly.

Remember to always prioritize patient safety and comfort. If a vein is missed or the patient experiences pain, apologize and reattempt the draw with a new needle at a different site.

Tube Order and Additives

When drawing multiple tubes, it’s important to fill them in the correct order to avoid cross-contamination of additives. The recommended order of draw is:

1. Blood culture bottles (if applicable)
2. Coagulation tubes (light blue top)
3. Serum tubes with or without clot activator (red or gold top)
4. Heparin tubes (green top)
5. EDTA tubes (lavender top)
6. Glucose tubes (gray top)

Each tube contains specific additives that either promote or inhibit clotting, depending on the desired test.

For example, EDTA tubes contain an anticoagulant to prevent clotting for hematology tests, while serum tubes have a clot activator to obtain serum for chemistry tests.

Always refer to your facility’s specific tube order and additives guidelines, as they may vary slightly. When in doubt, consult the lab or a phlebotomy reference guide.

Infection Control and Safety Precautions

Phlebotomy carries a risk of exposure to bloodborne pathogens, so strict adherence to infection control and safety protocols is essential. Here are some key precautions to follow:

• Wash your hands thoroughly with soap and water before and after each patient encounter.
• Wear gloves and change them between patients or if they become contaminated.
• Use a new, sterile needle and syringe for each patient.
• Dispose of sharps immediately in a designated sharps container. Never recap needles.
• Clean any blood spills promptly with a disinfectant solution.
• Follow standard precautions, treating all blood and body fluids as potentially infectious.

If you experience a needlestick injury or blood exposure, immediately wash the affected area with soap and water and report the incident to your supervisor. Follow your facility’s post-exposure protocols, which may include testing and prophylactic treatment.

Troubleshooting Difficult Draws

Even with proper technique, some patients may present challenges for blood draws. Here are some tips for troubleshooting difficult situations:

• Rolling veins: Use a smaller gauge needle, anchor the vein more firmly, or try a different site.
• Fragile veins: Use a smaller gauge needle, apply less tourniquet pressure, and release the tourniquet as soon as blood flow is established.
• Dehydrated patients: Encourage fluid intake if possible, apply a warm compress to the site, or try a larger vein.
• Needle phobia: Explain the procedure calmly, use distraction techniques, or consider using a topical anesthetic.
• Mastectomy patients: Avoid the arm on the side of the mastectomy due to the risk of lymphedema. Use the other arm or an alternate site.

Remember, it’s always better to ask for help or reschedule the draw than to cause undue pain or distress to the patient. Communicate openly with the patient and prioritize their comfort and safety.

Conclusion

Phlebotomy is a valuable skill for nursing students to develop, as it directly impacts patient care and diagnostic accuracy.

By understanding vein anatomy, mastering identification techniques, following proper procedures, and prioritizing safety, you can become proficient in this essential nursing task.Remember, practice and experience are key to building confidence and competence in phlebotomy.

Take advantage of opportunities to observe and perform blood draws under supervision during your clinical rotations.

Don’t hesitate to ask questions or seek guidance from experienced nurses or phlebotomists.

With dedication and a commitment to learning, you’ll soon be able to perform phlebotomy with skill and confidence, contributing to the health and well-being of your patients.

To further develop your phlebotomy skills, consider enrolling in a specialized training program, such as those offered by PhlebotomyU.

Their nationally accredited courses provide hands-on experience and prepare students for certification and career success. Click here to learn more about becoming a certified phlebotomist.