IV's/Blood draws on Small Veins

[FaithLove&Nursing]

Hello everyone! In my previous positions I rarely did blood draws except off PICCs or central lines. I've recently started a new position where I am responsible for doing both. I was hoping to get some advice on sticking veins (especially in women) that are extremely tiny and hard to stick. Yesterday, I had a patient that was extremely dehydrated and had very small veins to begin with. She hadn't been at a clinic in nearly ten years due to a fear of needle sticks.

At several of her previous visits ten years prior she had to be stuck numerous times in order to get blood. She finally came into the clinic, but has been sick for going on a year getting progressively worse and is now in poor shape. I laid her down (because of her hesitance in case she fainted), situated her arm straight on a pillow, and used a blood pressure cuff pumped up to 60 after applying a heat pack. I made sure the alcohol dried completely to avoid pain, kept the needle out of sight of the patient, and found one spot that I was able to palpate that felt nice and bouncy (because she was unsure of any previously successful locations). I assured her I was using a small needle and I was able to get her on the first stick with a 23g butterfly into her AC.

I inserted at a 15 degree angle had a great flash back and immediately stopped when I saw the flash and held the butterfly still with the wings. I was just drawing for a CBC and my lavender top was filling great, but then slowed drastically by the time the tube was 1/3 full. I gently pulled back and repositioned the needle just a tad in case it was up against the vein wall and tried slightly tilting the needle up. No luck! I tried using gravity to my advantage and by pulling the skin more taunt where I was anchoring the vein a few inches below the insertion site. I was able to get enough for the test, but am wondering what I did wrong or should have done differently? I hate sticking patients more than I have to and I'm very obsessive about doing things well. I removed the BP cuff, and held pressure on the site for 2 minutes or so and there was no additional bleeding.

The patient said that the stick "really hurt" and made her feel "hot all over," but then said that it wasn't anything even close to what she went through in the past and that if she had to she would get another stick again when she has her follow-up appointment in a few weeks. I checked the site after putting compression on it, and there was only a tiny drop of blood and only a small purple circle at the insertion site. I put gauze on it to tape it down, but she insisted she didn't want that and that a bandaid was fine and that she felt better. I was supposed to check her vitals before she was released, but she refused all vitals.

What should I have been doing differently? Initially I wasn't worried, but driving home from work my brain kicked into overdrive thinking over the day like it always does and I became worried about her stating she felt hot. Do you think I could have hit a nerve and that's why she was in pain or is it more likely it was the typical discomfort associated with venipuncture? Is it likely that the hot feeling was from anxiety or more likely hitting a nerve? She denied any shooting pain/numbness/tingling and said that it was better when it was over. Is it likely I blew the vein and that's why my tube stopped filling even after attempting to slightly adjust the needle? I hope I didn't make my poor patient have a black and blue arm today... Sorry for the obsessiveness. Just worried and hoping I didn't hit a nerve....

[kiszi, RN]

I didn't see if you mentioned where the site was, but hands are notoriously more painful. I wouldn't worry about keeping the needle out of sight; how is that even possible? If they want to look away, they will. You want to get the best possible angle.

Some people have success in approaching the vein from the side, but I've never been able to do that with any consistency. I prefer the "over the top" approach myself.

Don't know if there's a scientific basis for this, but I find veins to blow more often when the touniquet is on too tight.

Above all, practice all you can and know that sometimes, despite your best efforts, you'll just have to stick em again!

oh, oops. I see now where you stuck the ac. I don't see any problems with your technique. I'm sure the patient will be fine..

[xoemmylouox, ASN, RN]

She was just obviously very anxious. Don't stress. Sounds like you did just fine..

[NursinginProgress]

Sounds to me, her vascular system started shutting down out of anxiety. Not the first time to hear or see that. If you notice someone is dehydrated or nervous or anxious, talk to the patient and have them relax. Works every time. I do blood draws for research patients in an IVIG setting. No hemolyzing on my watch! Calm and relaxed environments help veins smoothly. That or the patient went on E for blood. Teehee!