hematomas? drawing blood on elderly clients

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Specializes in geriatrics.

hi i was wondering what are ways to make it easier to draw blood on elderly clients? more likely than ever clients seem to keep getting hematomas. am i doing something wrong or is this just common for the elderly? what are your experiences and how do i fix this problem????? what am i doing wrong? help!

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Specializes in ER, ICU.

If the needle doesn't penetrate all the way into the vessel it draws blood into the tissue as well as the tube. If you look at the beveled part of the needle it is pretty large compared to the thickness of a blood vessel wall. So make sure you are sticking all the way into the vessell. Sometimes there is nothing you can do. Just be sure to hold pressure as long as necessary to prevent further bleeding.

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Specializes in geriatrics.

how do u know if u are in far enough in a vein with butterfly needle? and how can u stablize the needle well and change tubes at the same time?

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Specializes in Hospice.

Another option is to use an upside down manual BP cuff instead of a traditional tourniquet.

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Specializes in ICU.

Hi Pear8 :)

I have found that it is very difficult to hold the needle in place while useing one hand to attach the tube with the other. To fix this I now do ALL my blood draws with a 10cc syringe attached to the end of the butterfly needle. Very rarely do I have to use two syringes to get enough blood, usually this is because they are enrolled in a research project. You really only need 1 cc of blood for all tubes except for coags that have to be filled to the top, 4.5cc. After I am done drawing blood I then hold pressure for almost a min and not had problems. I think holding pressure is the KEY. :) Also, I have found that if the tourniquet is on to tight, the veins in the elderly tend to blow/leak easier.

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Specializes in LTC Family Practice.
how do u know if u are in far enough in a vein with butterfly needle? and how can u stablize the needle well and change tubes at the same time?

A butterfly will have a "flash back" so you can see if you are in the vein. Also you will 'feel' a pop when you are in the vein, you might want to reivew the A&P of the vein and recommended sites to draw blood from.

A butterfly used for blood draws is different than one used for IV purposes and will have a hub adapter specifically to attach to a tube holder/needle adapter with a retractable needle. Using a butterfly meant for IV's and a syringe can easily colapse a vein with the elderly, a secondary problem with using a syringe is you can cause hemolysis and damage the sample.

To stablize a butterfly I found using a "one side" approach by holding only one side of the wing (instead of pinching the wings together) to insert the needle you are better able to see the flashback and anchor the skin with your other hand. Once in the vein, I can use one hand to anchor the butterfly while I insert the tubes with the other. I found laying the attached tube holder/needle adapter on a flat surface with all the tubes needed the easiest way to change the tubes, you will need to practice doing it one handed. Also, check with your lab on the amount of blood needed for the lab work. Many labs need only a small amount and you can use smaller tubes and they will create less vacum.

Also review with your lab about the types of blood work needed and the requirements, often it can be done with a dermal puncture if you have the right equipment (micro-tubes and lancets).

Another thought to improve blood draws for the elderly is ask you lab to come do an inservice on equipment needed and techniques. When I took my phlebotomy course (I recently became a certified phlebotomy tech) I found practicing on a "dummy arm with color water" really improved my technique and how to manage the coordination of the stick, stablizing the needle and changing tubes one handed without the pressure of doing it "live". Input from a phlebotomist who does it day in and day out might help you.

Make sure your patient is well hydrated before you do your draws.

The most common causes of hematoma are:

-excessive probing to obtain blood

-failure to insert the needle far enough into the vein

-failure to remove the tourniquet BEFORE removing the needle

-inadequate pressure on the site after the removal of the needle

-bending the elbow while applying pressure

There are several really good phlebotomy books on the market and if you are drawing blood on a regular basis you might consider buying one (I found mine used on Amazon) or I have seen two day seminars on phlebotomy available to nurses.

Drawing blood is a skill and can be improved with practice practice practice.

Good Luck!!

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My old ones always get bruises if their skin is thin and fragile. Always.

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Specializes in critical care, home health.

You've received a lot of good advice here. One thing I do with the elderly and anyone else whose tissue looks friable is to NOT use a tourniquet. I'll use the tourniquet to help me locate the best vein, but take it off before I actually draw (or start an IV). This reduces the risk of blowing the vein.

I also agree that holding pressure is the key. If the pt is on coumadin, I'll hold pressure for a few minutes or as long as it takes to be sure.

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

I put the extremity in a dependent position to dilate the veins and do not use a tourniquet. And I agree, you have to hold pressure longer on the elderly than the young...generally speaking.

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Specializes in ER, progressive care.
how do u know if u are in far enough in a vein with butterfly needle? and how can u stablize the needle well and change tubes at the same time?

You will see a flash of blood at the base of the butterfly needle. To stabilize the needle, I designate my dominate hand (right) to stick the patient and to stabilize the needle and my other hand to manipulate the different tubes. Prior to sticking the patient, I make sure the vaccutainer/tubes I need to draw are by my left hand. I take the first tube that I am going to draw and place it in the vaccutainer, WITHOUT pushing the tube into it (that creates a vacuum and can ruin it if you do it before you draw....at least from my experience). If I do it this way when I go to draw, as soon as I see that flash of blood I just push on the tube and can quickly get blood. I find if I don't do this I get clumsy and I tend to blow the veins.

Use a smaller gauge needle...22-23g, or smaller if you have them (we recently got 25g butterfly needles).

If you have problems trying to get the vein to show, flick the skin a couple of times (sometimes that will cause them to pop up), lower the extremity (to promote filling) or place a warm washcloth over the area for a few minutes. And be sure to turn some bright lights on! Remember, feeling a vein is more important than seeing.

Also make sure the bevel is up!!!

Drawing blood takes a lot of practice.

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Specializes in Cardiology.

Just wanted to add that butterflies are designed to be let go without coming out. I'm not saying this will be the case 100% of the time- if it isn't all the way in or there is too much downward pull, it is going to come out, but you should be able to let go of it and have it stay if need be. I've been drawing blood for 11 years (as a phleb) and I still don't like to do this, but I certainly will if the situation warrants it; this obviously makes it easier to change a tube. With a straight needle, you just need to be able to rest your hand lightly on something to stabilize it before you pop the tubes- usually this is the patient's arm.

I would not recommend drawing blood into a syringe and then putting it into a tube. This can be done, but it is definitely a distant second to the preferred method of direct drawing. We don't even allow our phlebs to use syringes (though I personally think they are easier to guarantee 100% no misses with, at least for me- I can get blood from a stone with a syringe.) If you end up doing this, be aware that you need to work quickly, still be aware of order of draw, and be extra careful to avoid sticking yourself. We have so many preanalytical errors in our lab because of syringe draws.

With elderly, just pretend that every last one of them is on warfarin. Chances are pretty good you'll be right. With that in mind, unless you've gone in one side of the vein and out the other or some similar mishap that will cause bleeding under the skin before you're even done, pressure will be your best preventative measure. You want the pressure to be steady and firm, without being too hard. Current recommendations run from 2 to 3 MINUTES. Most of my staff, sadly, don't hold pressure for this long. Finally, when you release the pressure, you want to leave the gauze in place so the clot isn't ripped off if you try to remove it, and pull your bandage just slightly so that it creates a small amount of pressure over the venipuncture site.

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Specializes in ER, progressive care.
just wanted to add that butterflies are designed to be let go without coming out. i'm not saying this will be the case 100% of the time- if it isn't all the way in or there is too much downward pull, it is going to come out, but you should be able to let go of it and have it stay if need be. i've been drawing blood for 11 years (as a phleb) and i still don't like to do this, but i certainly will if the situation warrants it; this obviously makes it easier to change a tube. with a straight needle, you just need to be able to rest your hand lightly on something to stabilize it before you pop the tubes- usually this is the patient's arm.

the one time i failed to stabilize the butterfly with one hand, the butterfly went all over the place and ended up going to close to a 90-degree angle in the patient's arm and caused a hematoma (this was after i accessed the vein) :uhoh3: because of that, i always make sure to stabilize.

i would not recommend drawing blood into a syringe and then putting it into a tube. this can be done, but it is definitely a distant second to the preferred method of direct drawing. we don't even allow our phlebs to use syringes (though i personally think they are easier to guarantee 100% no misses with, at least for me- i can get blood from a stone with a syringe.) if you end up doing this, be aware that you need to work quickly, still be aware of order of draw, and be extra careful to avoid sticking yourself. we have so many preanalytical errors in our lab because of syringe draws.

unfortunately for blood cultures, that is the only way to draw at my hospital. other hospitals can have the tops of the bc bottles go into the vacutainer thing which is really nice...but sadly at my hospital they don't fit on the tops of our bc bottles. we have to draw with a syringe and then inject the blood into the bottles. sometimes it's unavoidable!

and i definitely agree with working quickly. one nurse got cultures from a patient and the blood coagulated in the syringe - she couldn't inject the blood into the bottles. this method is also a huuuuge safety issue for nurses, too!

good advice :)

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