What if you can't hit a vein to draw blood?

[Jo Dirt]

At my HH job I was sent out to draw a lab on this woman who has a portacath. I told the boss I've never drawn blood from a portacath and she gives me this instruction sheet and tells me it's easier than drawing from a PICC line.

So today I go out to this lady's house. She is really heavy and when I feel for her portacath it feels like it is about two inches below the skin. She says it is sore and I back off from this option because I am not comfortable with it.

So I drive to the hospital lab and come back with some butterfly needles and a tourniquet. She has no veins to speak of, but I make a sad attempt to hit what I hoped was a vein (the only place on her arm that felt elastic at all).

She winces in pain even though I am as gentle as I can be (she has metastatic bone cancer so no doubt she is in tremendous pain), so after one stick I tell her I won't subject her to any more and I will get a more experienced nurse to come out and see what they can do (there was an LPN staying with her but I couldn't get her off the couch to help me).

I call one of the nurses who told me he would help with anything I needed. He made some kind of excuse but said he would get it done in the morning and that was the last time I could get ahold of him (I know he won't do it, he can't do it because I never go the chance to tell him this woman's name ) So, I talked to the boss, basically she said to have her drink plenty of fluids and use warm compresses to get the veins to come to the surface and I had better get the blood tomorrow, or else.:gandalf:

Now I have been stressed out and worried because I am not the best at drawing blood and it is lucky for me to get it with good veins. I feel like I want to go sit in the corner and count my own fingers or suck my thumb. The stress with this job lately has been about to run me around the bend.

Does anyone have any other advice they can offer about how to get this done? I know I should have more experience/better orientation and it would be noble for me to refuse to take the case and find another job but this is not what is going to happen. For one thing, I had a hard enough time finding a job and I have too many bills to just up and quit.

[TazziRN, RN]

{{{MM}}}

drawing from a portacath is scary if no one is showing you how to do it the first time. i wish i had some tips for you. did you look at her feet?

[LanaBanana]

Any chance your just drawing something simple like a CBC or H&H and maybe you could get it from a finger stick? Also, how are the hand veins? If you don't think you can get it and have already tried once, I would say someone else needs to (but then again I'm not a nurse yet, just a phlebotomist!) Also, sometimes syringes are easier for the delicate veins.

[glb1960]

I have a few tips to try, but overweight pt's are tough draws. Keep your tourniquet close to where you intend to draw, either at the wrist, mid-forearm or just above the elbow to draw from the antecubital area. Have the pt. lie down and hold the arm below the heart, towards the floor. Gravity and the tourniquet will help fill the veins. Commonly, your best shot is the vein in the bend of the elbow, the antecubital area. If you can palpate this vein, be patient to allow the vein to fill. Get her talking about a subject her likes while you set up and allow the vein to fill. This is true wherever you choose to draw from. Some will actually use a sharpie/pen to mark their spot and then alcohol the area. Hold the skin taught over the vein you have choosen by grasping below the arm/wrist/hand to pin the vein and keep it from moving. Always be palpating the vein for your location and reswabbing the area. You will need to take a little steeper angle than you would on a normal weight pt. and go for it. Know that you made need to try more than once. This poor woman has been stuck like a pin cushion, judging by your reported diease status, so ask her for the best draw site. She will proably be very helpful. And keep her talking. Pain levels are greatly reduced in pts. talking about a favorite subject. The brain is too busy on the subject to concentrate on the stick. Good luck and just do good nursing, which is soooo much more than the task at hand. Assessing, teaching, empathy, distraction, nursing the family members and caring still have to happen before and after this task.

Post tomorrow how it turned out, Gary

[sharann, BSN, RN]

Does anyone else think that since mortorcycle momma told her boss that she has NEVER done this procedure that the boss was wrong in just blowing her off with an instruction sheet? This is a skilled procedure that needs special training(not complex, just special). I think that the boss is a jerk and setiing herself and her nurses up for failure and lawsuits. If this woman has a port we know her veins are crapped out.

This steams me. I don't know what advice to give except that I would insist on not ever being hung out to dry if I was up front and said I was not comfortable with a procedure.

[kat911]

First of all relax. You won't be able to find blood if you are uptight and shaking to boot. Second no one should loose a job over drawing blood from someone who is a hard stick. You did all the right things. Take a 23 ga. butterfly with you, several actually. Several small syringes in case you can only get a ml or two at a time. Find out if you can use bullets, small blood tubes used for kids and babies, lab should be able to provide you with these if possible and give you guidance on how much blood is needed for each. If you can get someone to help it would be better to have a second set of hands to put the blood into tubes as you get it from the veins. Don't leave in the syringe too long or it will clot. Don't use too much force to draw back the blood or it will hemolyze. Put about a half ml of air in syringe and pull back slightly and allow blood to drip into the syringe, this may get you small increments but it will get the job done. sit with the patient while you work and don't get in a hurry. Use the warm compresses and gravity to try to plump up the veins. Look at the hands or wrist (palm side) for a hint of a vein. You only need the tip in the vein to get what you need. If she blows when the needle touches the vein try without the tourniquet. You can use those little veins in the thumb or fingers if needed. Good luck

[Jo Dirt]

Any chance your just drawing something simple like a CBC or H&H and maybe you could get it from a finger stick? Also, how are the hand veins? If you don't think you can get it and have already tried once, I would say someone else needs to (but then again I'm not a nurse yet, just a phlebotomist!) Also, sometimes syringes are easier for the delicate veins.

I have to get a CBC and BMP.

Thank you for the replies. I will definitely try them. I already made the mistake of being too honest with this woman. I told her I am clumsy and even though I know exactly what should be done in my mind it doesn't always flow through my hands to what I am doing. She said please don't tell me that....I feel really bad for her now. The poor woman is dying of cancer and instead of making her more comfortable I guess I did the opposite and I'm sure she is wondering why they sent such an idiot out to take care of her.

[medsurgnurse, RN]

Does anyone else think that since mortorcycle momma told her boss that she has NEVER done this procedure that the boss was wrong in just blowing her off with an instruction sheet? This is a skilled procedure that needs special training(not complex, just special). I think that the boss is a jerk and setiing herself and her nurses up for failure and lawsuits. If this woman has a port we know her veins are crapped out.

This steams me. I don't know what advice to give except that I would insist on not ever being hung out to dry if I was up front and said I was not comfortable with a procedure.

Exactly. To be expected to perform a procedure which you have never been trained to do is unacceptable. It puts you and the company at liability if something goes wrong. The best thing to do would be have the most experienced nurse go out to the home with you and have them show you how to do the procedure. That way next time you'll know how to do it. Run that by your boss. It is not acceptable patient care try if you don't know how. And guess what when soemthing goes wrong and you loss your license try explaining to The BON "my boss made me do it". Good Luck.

[jenny031]

Ports are scary the first time, but they are easy to access. If you feel comfortable using the directions you were given, and the hesitation is because it's sore, then numb the port site with a little lidocaine first. Take your time and feel the port site. Don't rush. You'll feel the rubber stopper in the center of the port. Go straight in till you hit bottom. Then pull your needle back just a tad. Be sure to flush it first, if your not in, you'll feel it swell just like a PIV. If you have trouble getting it to give blood, have her lie down flat or raise her arm above her head. I do agree totally that you should have been given the opportunity to have at least see one accessed first. But if you have good written instructions to follow and observe asepsis you'll be fine. Good luck.

[NRSKarenRN, BSN, RN]

motorcycle mama:

may i respectfully submit that you are in over your head and your agency is setting you up for failure, especially as you are a new rn.

this is due to the agency being the new one in town, having minimal staffing and accepting any referral that comes their way. thy have already gone through 2 dons, one a third. no established polices/ solid orientation for you to fall back on....your learning by the ropes. never should you be just "talked through" a procedure without someone right next to you to eval performance, give feedback and take over if trouble occurs.

i am very concenred re the high acuity infusion patients your agency is accepting without adequate staffing and the inability of administrative backup to call on especially on weekends.

my first two agencies were start-ups, so i've been in your shoes. my first agency however, gave solid orientation and had owner/administrator come out to show procedure if i'd never done it ---lots of inservices in iv infustion prior to first time too. however, had been lpn for 5 years, rn for three with high tech vent/infusion/chemo/ resp icu/telemetry experience before i accepted this position. we both learned a lot on the job. my second position was fly by the seat of your pants---staff talked thru procedures over phone, any referral taken despite poor staffing. i helped them grow but quit over don allowing lpn to do admit visits for subcontracting agency with expectation rn supervisor will cosign!

i am very concerned that your newly minted license is on the line. please look in your community for an established agency. check out the vnaa (visiting nurse assoc of america) to see if established agency in your community: http://www.vnaa.org/vnaa/gen/html~home.aspx

or look up agency that's member of national association for home care and hospice ::

[Jo Dirt]

I finally got the other nurse to come help me draw the blood. Of course, he went into this woman's house and put on his southern charm, said "this must be the young lady we are getting the blood from today," giving her a wink.

So he starts feeling around and says "you're right, she shore don't have any veins." But then he starts feeling around and says, gimme that needle. Takes it at an angle and slides it right into a vein and the woman doesn't give so much as a whimper...this woman and her family are just laughing and giddy over the gentleman who came in and knew what he was doing. That woman was flirting up a storm with this nurse and I may as well have been invisible.

Well, at least it got done, I guess.

[NewLynney]

5 years later, I bet you're feeling much more confident, thanks for sharing!