› Venipuncture Skills

Venipuncture Tips and Techniques

Phlebotomy or venipuncture as it is also called, is the act of using a needle and collection container (either syringe or directly into a lab tube) to collect blood from a vein for testing. There are a variety of methods used.

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Arterial blood gases, on the other hand are drawn from an artery and is not something you will have to deal with. 

This nursing skill in particular requires practice and a good sense of touch. It takes some finesse to perform. I’m sure you will hear stories from patients about the phlebotomist who is amazingly good at getting a vein on patients with little to find. 

I have often said, there are some lab techs that could throw a needle from across the room and land in a vein. They just have the magic touch. 

Of course there is also the other end of the spectrum and you will hear the horror stories.

Venipuncture is a procedure where a lot of patients know which needle works best for them and which vein is easiest to access. Even If I feel there’s a better option, if the patient feels strongly about what they want, I’ll give it a try. That’s because I am only fair to middlin’ when it comes to getting a vein. If I miss after insisting on doing it my way…. Well, you get the picture. 

Hell hath no fury like a patient scorned!

I will try no more than 3 times to get a vein. At that point I am calling my office and telling them to send someone else to do the job.

Venipuncture Using A Straight Needle

This is a pretty good phlebotomy video except for a few minor details.

  • First, she mentions placement of the arm on a sterile field. I hate to be picky, but you do need to know the difference between clean and sterile. This area is clean. 
  • Second, notice the awkward position of her hand. She should have repositioned the patient’s arm to make the entry of the needle straight forward into the vein. Kudos for her on getting in the vein in spite of her positioning. 

Pros of using a straight needle for venipuncture are:

  • It fills the tubes faster. I usually use the green top (21 gauge) or black top (22 gauge) needle. 

Cons of using a straight needle for venipuncture:

  • You can only go by feel that you are in the vein. There is no flashback to see. When you perform venipuncture regardless of the needle, you usually feel some resistance and then a very small "pop" sensation as you enter the vein. At that point you stop and get your blood. 

Other tips:

  • Wear as small a glove as comfortable because that makes it easier to manipulate your supplies and also to feel the vein.
  • Some phlebotomists cut a finger off the gloveso they can palpate the vein better but that defeats the purpose of wearing gloves and also of cleaning the area with alcohol.
  • Please, please, PLEASE! Get all your supplies out, opened up from the package and put togetherbefore you apply the tourniquet.Don't leave your patient sitting there with the tourniquet on for any more than a minute. 
  • When getting tubes in and out of the vacutainer, try very hard to be aware of how much you are moving that needle around in the arm. That can be very uncomfortable for a patient. Hold it steady by resting your hand on their arm until you are done with the venipuncture.
  • If the patient's veins roll, sometimes placing the needle to one side of the vein and entering from the side and pushing forward is easier than from the top and forward.
  • If the doctor wants the test results to be fasting(nothing to eat or drink after midnight) s/he will specify that on the order. Or s/he will give a time when to draw the blood. Other than that, it is up to you when to get the phlebotomy done. PT / INR (anticoagulant) test is usually done in the morning because (at least at home) Coumadin is taken in the evening. So a morning lab has time to run and get the results to the doc so s/he can decide if there are any changes to the Coumadin dose for that coming week. 

Another Good Video Using A Straight Needle

Notice the better position of the patient's arm and the tech's hand with the needle.

Phlebotomy Video Using A Butterfly Needle

You can also use what is known as a Butterfly needle. Use a 21 to a 23 gauge needle. If you try to use a much smaller, the diameter of the needle will be too tiny for the red blood cells to flow through without rupturing (hemolyzing). That makes the specimen unacceptable for lab testing. 

Pros using a Butterfly needle:

  • You can get into smaller veins easier
  • You get a blood flash back so you know you are in the vein and can draw blood
  • It's easier to change tubes without jarring the patient's arm

Cons using a Butterfly needle:

  • It takes longer to get blood into the tubes. Smaller diameter needle means slower blood flow. 
  • You have to remember that with a blue top tube, you need to put another tube on first to get the blood all the way down the tubing. Then waste that first tube and attach the blue top tube. Just that little bit less of blood will throw the test off. The lab will be calling you saying the tube wasn’t filled and you will wonder why.

Butterfly needles for blood collection are different from Butterfly needles for IVs in that they have a sheath covered needle on the end so you can attach to a vacutainer holder and puncture the tubes. IV butterfly needles do not.

For Infusions

butterfly needle for IVs

For Vacutainer Blood Collection

Butterfly needle for vacutainer blood draw

Phlebotomy Using A Syringe

You can use a syringe with either a straight needle or a Butterfly for Infusion (not for blood collection). 

The tubes fill only so much based on the amount of vacuum in them that sucks the blood inside.

Different tubes have different additves in them, hence the different colored tops. Most lab slips have the color tube you need to use right next to each test requested.

If they don’t and you are unfamiliar with the test, do what I do. Call the lab and ask what color tube and if any special precautions need to be made (ie, keep out of the light, pack in ice, etc.) 

Order Of Tubes To Be Drawn

  1. Blood culture
  2. Blue top
  3. SST (Serum Separator Tube / Tiger Top) or Gold
  4. Red
  5. Green (light or dark)
  6. Lavender, Pink or White
  7. Gray top
  8. Yellow top

Types of Vacutainer Holders

depending what you are going to attach to the vacutainer determines which one you use.

Use with straight needle or butterfly for blood draws

vacutainer holder

Notice, no needles attached

Use for transferring blood from a syringe to a Lab Tube. Called a "transfer device"

vacutainer female connection

Notice, sheath covered needle and a connection to screw into a luer lock syringe. (female connection)

Use for direct connection from an IV to a Lab Tube

vacutainer male connector

Notice, sheath covered needle and a connection to screw into an IV. (male connection)

Handy Reference Tool

I found this handy 3x5” card set that has a bunch of helpful information for you. If you want a set just click and order below. 

Each CHAINED SET includes one each of the following two-sided pocket cards: 

  • Best Sites for Venipuncture / Inappropriate Sites for Venipuncture
  • Troubleshooting Hints for Blood Collection (Proper insertion of evacuated tube) / Troubleshooting Hints for Blood 
  • Collection (Needle positioning and failure to draw blood)
  • Special Handling of Specimens Intended for Light-Sensitive Analyte Testing / Special Handling of Chilled Specimens
  • Tube Additive Guide
  • Order of Draw for Multiple Tube Collections / Mix Tubes by Inverting the Recommended Number of Times
  • Processing of Tubes / Processing (Mixing) of Tubes

Terminology

Luer Lock: a connection on IV and phlebotomy supplies where needles and other connections can be screwed on.

Luer lock syringe and needle

A Luer Lock on syringe to allow the needle to be screwed on

Hemolyze or hemolysis: (how to pronounce hemolyze and hemolysis) the breakdown of red blood cells

SST (Serum Separator Tube): a tiger top tube with gel or wax in the bottom is put in the centrifuge after the blood is drawn and the spinning makes the red blood cells sink to the bottom, the gel then moves to sit on top and then the clear serum is the uppermost layer. The tube separates the serum from the cells. 

Tiger top: red top with gray swirls in it.

Blue top: Light blue is for coagulant tests, have no clue what navy blue is for. 

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WHEW! Who woulda thought there was that much to talk about venipuncture?

Related Pages

Cardiovascular Nursing Skills