This article will take you through the basics of how to draw blood so you can understand the steps and current guidelines for best practice. Remember to check with your healthcare institution about specific policies and procedures regarding blood draws as well as any state regulations before performing any procedure.
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 veins are also used.
Clean your hands via hand washing or hand sanitizer.
Don gloves.
Place a tourniquet and clean the area for 30 seconds with an alcohol wipe using a back-and-forth technique.
Allow the area to dry for approximately one minute following cleansing the area.
Pull the skin taut to anchor the vein.
Insert the beveled needle at a 15 to 30-degree angle into the vessel.
Once blood is seen in the tubing, connect the vacutainers or use a syringe to draw the needed amount.
Properly label the tubes (at the bedside) and send them 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 healthcare 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 AC has already been accessed, there are other great options for venipuncture.
Other commonly used veins include:
Basilic vein
Cephalic vein
At the end of the day, you will be most successful at a blood draw if you access the best vein. This will be the vein that you can feel or see most prominently. This will vary depending on your skill level and comfort level with blood draws.
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 the 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 or Chlorhexidine wipes (CHG) 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 it is not applied too tight or for more than 1 minute. Reasons for concern would include numbness, tingling, change of color to blue or white, and/or 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 60 seconds. Do not wave, fan, or blow on the area as this contaminates the area and leads to an increased risk for infection.
Grab the patient’s lower arm (below the site of the puncture, never above) 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.
If you do not get a flash of blood into the catheter, you can manipulate the catheter; however, do not entirely remove the catheter and re-stick using the same needle.
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 them into transport bags.
Invert the tubes properly (depending on the type of tube).
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.
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 contributes to needle sticks
For 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
The 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
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