If you have drawn blood or started IV's for any length of time; one knows that you cannot be vain when it comes to your patients veins
Veins will collapse or shrink or blow; due to many reasons within our control and some beyond our control. If the provider does not prepare the patient and keep the patient calm the patient may panic. If the provider does not use the right equipment samples will hemolyze. Parents who may be scared will not hold their children and the kids will kick.
Difficult venipunctures are simply a part of the everyday task that every nurse working may face. If you think that your day will be perfect every day you come to work and draw blood or start an IV then you are vain.
There are so many different patients, illnesses, and other factors that will play into your success at drawing blood or starting your infusion therapy. Drawing blood from drug addicts, obese people, critically ill patients, geriatric patients, and pediatric patients will definitely take a toll on you if you are not aware of the potential pit-falls with each patient you attempt to perform venipuncture on. Nurses are so focused on the task at hand that we forget the most important part of our job; and that is our Patients.
Patients who are critically ill are often the most difficult draws because they are subject to more blood withdrawal than most other patients and they are typically suffering from fluid overload or severe dehydration. So why not just use their IV lines to draw their blood?
The problem is when you draw blood from a line, you save the patient from the pain of a stick, or even yourself from the challenge of a difficult draw; however, the test results can be erroneous due the nurse not flushing the lines before drawing a sample, medications, hemolysis, and many other factors that we often do not think about at the time of the process.
Another big problem with blood draws and intravenous starts may be that the patient has fragile veins that blow more easily than normal. What about small children; their veins have not yet quite developed and if one attempts to use a large catheter in a small vein; guess what? POP, goes the vein. Or how about a geriatric patient that has high blood pressure and their veins have weakened over time and again the provider attempts to use a larger catheter in these types of veins. You got it; POP. When a provider fails to realize this, they are merely setting themselves up for failure as well as potentially causing the patient get a hematoma. What if you miss or cause injury; wheat do you do?
The standard is to try again at another site, which may produce the same result if you did not learn from the first mistake. However, if you are unsuccessful two times you should move along and let another provider attempt the stick. Also, think about how you may get a geriatric patient to clench their fist to help the draw may be pointless because they may be weak or have little muscle mass to do so.
Should I Use a Tourniquet?
The use of a tourniquet is up to the nurse attempting the venipuncture. The sole purpose of the tourniquet is to make the veins more visible and easier to palpate. On the other hand, using a tourniquet with weak or underdeveloped veins can cause the veins to blow when the needle is inserted. Leaving the tourniquet on longer than one minute prior to venous access can also cause hemolysis which may result in erroneous lab samples as well. Whenever finding and accessing a vein takes longer than one minute, it should be released and two minutes should be allowed to pass before reapplying it so that the blood can return to its normal state.
Initiating IV Therapy or venipuncture on patients with a history of drug abuse can be quite difficult as scarification of both skin and veins are a common problem. When the drug addict has repeatedly punctured their skin with a needle, it will build up scar tissue over time leaving limited use of their veins for blood withdrawal and IV Therapy.
Children are often scared of the doctor’s office and/or needles and by nature this makes it very difficult for the nurse as well as the patient/parents. Kids seem to want to watch the needle going into their skin and thus this can make them even more nervous. So we don’t want to give them the chance to watch. Avoid this by concealing the needle as well as reducing their fear by talking, coaxing, and comforting them throughout the procedure.
Distraction can be a highly effective tool when drawing blood or starting an IV in any patient. Sit down, look at the patient eye-to-eye, talk with them, hold their hand, and understand their culture and how they may tolerate pain. Explain the procedure to them in understandable terms.
There are several types of assistive instruments on the market today that can help detect veins, such as Accuvein AV300, Veinlite, and the vein Viewer. The technical term for these devices are call "Tissue illuminators" and some have been around for a while. The handheld Accuvein AV300 came out in 2009 and costs about $4,000. The Veinlite is likely to be the least expensive one but also it is not as effective, and last the Vein Viewer is the most effective on the market today as well as the most expensive one too.
What Can One Do
If the venipuncture proves extremely difficult because you cannot find a vein, think about warming up the patients arms with a warm blanket or towel. This will cause their vessels to vasodilate and move close to the top of the skin and make it easier to find. If you suspect the patient is suffering from dehydration ask the patient to drink water if they are not on fluid restrictions and return later to do the venipuncture. If the patient is suffering from fluid overload and shows severe signs of edema; you may have to push down the surrounding tissue to see the vein that you may want to access. This will be a difficult but not impossible task and you may need help in accomplishing this task. Help your patient to relax, keep them calm because once they get nervous their "Fight or Flight” response will kick in and their veins may disappear for quite some time.