Do you have any tips for drawing blood? At my new job, we have to draw our own labs, and I keep getting a sluggish blood flow... or not hitting obvious veins... and giving the patient big bruises. I've been on a streak where i can't get blood or start IVs and I'm not exactly a new nurse so I'm pretty embarrassed. :(
I've told my new nurses this many times, so I will pass on the same advice here. Try not to let skills define you. We are living in a world where more and more professions are being outsourced, and sometimes replaced altogether by a cheaper alternative. We don't want that to happen in nursing, so we need to consider our most valuable asset our brain, and the ability to critical think and problem solve in stressful situations. But, since you asked, and I do pride myself on being one of the best "sticks" in the hospital, I'll tell you a little about my technique.
First, your number of attempt should always be relative to the situation. Blood drawn for non-urgent reason, then I say 2 sticks and your done. If we're in a trauma or code, we have 30-60 seconds to get a line, or else we're placing an IO (instraosseous line). So what I'm saying is, there are only a few extenuating circumstances where you should ever be sticking more than twice yourself before you find someone more qualified. Now, if you come find me to stick someone that absolutely needs a line for an urgent medication, procedure, or IV fluids, I'm probably going to stick 2-3 times if I need that many attempts. The reasoning behind this is that you should be saving sites for more experienced personnel to attempt. I am that experienced personnel, and if I can't get it, we're going for a central line, or going to IR to have a line placed.
When I do stick, I look everywhere. In pediatrics, that means hands, AC's, saphenous, feet, and head. In adults, hands, forearms, AC's, and upper arms. I will only place a line in a lower extremity in an adult in an emergent situation, or if for some reason the upper extremities have some type of severe trauma. Remember, you can still place an IV through burns, it's just more difficult to tape and requires gauze dressings instead of adhesive. Adults have a high instance of complications from a line placed in lower extremities, so I avoid them unless absolutely necessary. I always explain to the patient or family, if present, that the reason I am looking all over is to find the best vein, for the best chance of success. I will not stick someone just to say I did. If I don't see something I like, I won't stick. End of story. You shouldn't either, however, in the beginning, you will question yourself constantly, so I urge you to try at least once.
I see this happen with coworkers, in other hospitals, even when I have blood drawn myself. Nurses touching a site after they have prepped it. DO NOT TOUCH THE SITE. My only caveat to this is if you are in a critical situation and the chance of the patient dying without IV access is greater than the chance of infection. Why are you touching the site?? You already found it and cleaned it, now stick it. Quit questioning yourself. It's not necessary, it's a nervous habit people develop when they don't believe in themselves.
Next, when you go to enter the skin with the IV catheter, do not go flush with the skin. You also don't want to enter the skin at too much of an angle. This takes time and experience to gauge just how much of an angle you need to compensate for subcutaneous fat, the age of the patient and the site you're accessing. Toddlers tend to have lots of subcutaneous fat, or "baby fat", so you do need a bit more of an angle. Infants have very little subcutaneous skin, as do the elderly. With infants, toddlers, children and young adults, the veins still have significant resistance to them, you'll feel a "pop" when you enter the vein. As we age, the veins tend to relax somewhat, and have more of a stretched out pantyhose type feel to them, so unless they're engorged with blood, you may not feel anything. The elderly have veins like tissue paper, you won't feel anything, you'll be in one side and out the other, and you're site will be blown before you know it, so you have to be extremely careful and trust your instinct of when you're actually in the vein.
You also can't always rely on blood return in the IV catheter. Especially in emergency medicine, my patients can be severely dehydrated, multisystem trauma, comorbidities, etc., and I won't see anything in the catheter, but I know I'm in the vein. It's a combination of instinct, visual confirmation, and the feel of the catheter sliding forward when you're actually inside the vein. I tell new nurses that if they do see blood return in the catheter, to continue to advance the needle another millimeter or two and then slide the catheter off the needle, otherwise the catheter will bunch at the entry site and blow the vein. Next, you want to occlude the vein when you remove the needle, or else it's going to look like a homicide scene. I have a little ongoing challenge to myself not to spill a drop of blood. Depending on my patient, some days I win every attempt, other days, my patient does the alligator death roll and everyone winds up with blood on them.
Once you've removed the needle, at least at my institution, I obtain blood from the catheter, then attach the T-connector. There are several different ways to do this, but if you're obtaining blood culture, it should always be the first blood obtained, and the syringe should be securely attached to the catheter, so as not to introduce contaminates into the sample. Sometimes you need to release the tourniquet to allow the vein to fill again in order to get the appropriate amount of blood. Sometimes it's impossible to get anything, depending on how sick your patient is, and it's best to just save the IV site and worrying about labs later. Don't assume your IV is bad if you don't get blood return.
Here's another little bit of advice... It doesn't matter what size catheter you put in. That's right... You can still save a life with a 24g catheter. Now, if you put a 24g catheter in a healthy adult, I'm likely going to call you a pussy and make fun of you. However, if that's the best you can get, and that 24g catheter is in their index finger, well, I can still work with that. You can push blood (albeit not as quickly) through a 24g, you can bolus fluids through a 24g, and you can push drugs through that same 24g. Use it until you can get something bigger. In adult hospitals, they often won't even attempt with anything smaller than a 20g. I've got news for you, that's not always going to work. Tough shit, swallow your pride, and grab a smaller catheter. The goal is to help the patient, not sooth your battered ego when someone cracks a joke about what size needle you used. We still use a push/pull method with the rapid infuser and 24g IVs. It works, trust me.
Some other helpful hints for placing IV's... in infants, hands and feet are usually the best points of access, if you can't get those, go for a scalp vein. When accessing anything above the heart, you need to point the catheter towards the heart. So if you're accessing a scalp vein, you point the tip of the needle towards the heart. Otherwise you're going the wrong way in the vein and it's going to cause problems. I love a good saphenous vein in a toddler. It's about the only place they don't have that padding of baby fat, and you can sneak right in there without much difficulty. In older kids and adults, the forearm is a great site for access, they don't kink off the catheter with movement and it's a nice, stable vein that will maintain access for days. In people with serious, chronic medical problems, the typical veins you would access are going to be overused and abused. So look for something in a atypical place, the upper arms, fingers, hell, I've put IV's in breast tissue. Go for whatever you think you can hit, and will maintain patency long enough to get another point of access in.
In the end, practice makes perfect. And, prepare for the worst, hope for the best!
