Question on blood draws and BP with bilateral mastectomies and single.

cafecreme · Sep 18, 2006

Any oncology nurses got ideas here? I am a nurse also but will be having bilateral mastectomy done soon and there are others out there wondering if any tips for us as patients. I also want to know to deal with in my own practice. Please respond.

barbshortt · Sep 18, 2006

On a double mastectomy pt, we always do blood pressures on the calf of the leg.

In our institution, almost all breast cancer chemo pts have a port, so we are able to do blood draws through the port. In the case of a double mastectomy, I can't imagine the pt not having a port or some other central venous line to administer chemo, since the drug regimen is likely to include a vesicant (Adriamycin). Even Taxol can be nasty (was considered a vesicant when it first came out).

In the case of a single mastectomy pt, whose "good" arm has lousy veins and there is no central line.....we do see pts like this and it is not an optimal situation. Hydration does help, as does using some form of heat (heating pad, warm water, etc) to dialte the veins prior to cannulation. We do not use lidocaine routinely for IV starts - we use 24g needles for chemo, so their size is not so large that the pain is overwhelming. Certainly use a butterfly for the blood draw, but not for the chemo as again, it will probably be a vesicant drug and using a butterfly is not recommended for vesicant administration.

Also, I would always try to draw the blood while starting the IV - not only to minimize sticks for the pt, but to be certain the vein you are using is fresh, without other sticks possibly superior to the one being used for chemo.

FYI - I have seen a breast cancer pt get lymphedema 12 years out from mastectomy, so I never assume there is a safe time to use the affected arm. All the best - Barb

NcCareN4kids · Jul 2, 2007

What I've found that works the best when dealing with most difficult sticks is to apply heat (such as with an infant heel warmer/heat pad) to the site for at least 5 mins before the venipuncture. This allows me time to gather a 23 gauge butterfly and (usually) 10 ml syringe and transfer device. I have found that with these difficult sticks I do not want to take the chance of using up the only possible good vein I might have left by using a straight vacutainer needle on that patient. The vacuum in the tube can often cause the vein (espeically small ones) to collapse from the pressure of the vacuum needed to pull the blood into the tube. Using the syringe allows me to manually draw back the amount of blood needed without losing the vein. Yes it take more time but I've never had a patient of mine complain because I took the time. Be sure to remind your patient not to pump their hand (as we were taught old school) once the tourniquet is applied because this pumping action can incorrectly yield a dramically high potassium level.

Make sure you run the syringe plunger up and down the barrow of the syringe to loosen it up inside before use. Push the plunger all the way back (eliminating any air into the syringe). Failure to do so will result in little to no blood being able to be brought into the syringe. Nurses often mistake this lack of blood return to a bad needle position and try to make unnecessary needle adjustments. Doing this can often cause the specimen to be very hemolyzed (not to mention the extra pain to the patient) and time needed for a recollect.

In a perfect world we'd always be able to draw the blood from the a/c site but depending on the patient's medical condition I would check your unit's policy as to what sites are allowed and not allowed.

Remember... syringes are our friends