Patient Reactions During a Blood Draw

Most blood draws end with a bandage and a thank you. A few do not. A patient goes pale and slides toward the floor. A lump rises under your needle. Someone cries out that their arm has gone electric. These events are rare for any one patient, but if you draw all day you will see them often. Each one has a right first move, and doing it fast limits the harm. This guide covers what to watch for, what to do in what order, and when to get help. You are not expected to treat a patient. Your job is to stop, keep them safe, get the right person and record what happened. Your employer's procedure comes first.

What You Will Be Able to Do

• Screen for reaction risk before you draw.
• Recognize fainting early and respond before the patient falls.
• Tell hematoma, arterial puncture and nerve injury apart, and respond to each.
• Respond to an allergic reaction or seizure.
• Know when to call the nurse or emergency help.
• Write an incident note that is useful.

The Same First Moves

For almost every reaction, your first moves are the same. Practice them until you do not have to think.

1. Tourniquet off.
2. Needle out, and activate the safety device.
3. Pressure on the site with gauze.
4. Protect the patient from falling.
5. Call for help if you need it. Do not leave them to go and find it.

The tube you were filling can wait. A sample is never worth a longer needle stick in a patient who is reacting.

Ask Before You Draw

Thirty seconds of questions can head off most trouble.

• "Have you ever felt faint or passed out with a blood draw?"
• "Are you allergic to latex, tape, iodine or chlorhexidine?"
• "Do you take any blood thinners?"
• "Have you eaten or had anything to drink today?"

Anyone with a history of fainting should lie down or use a reclined chair for the draw. Never draw from a standing patient, or from one sitting on a stool with no support. Keep your own body in a position to steady them.

Fainting

Fainting during a draw is usually a vasovagal reaction. Fear, pain or the sight of blood makes the heart slow down and the blood vessels widen. Blood pressure drops, less blood reaches the brain and the patient passes out. It can happen before the needle goes in, during the draw or several minutes after. A patient who says "I'm fine" and stands up quickly may faint at the door.

Warning Signs

• Skin turns pale or gray.
• Sweating, and clammy skin.
• Yawning, sighing or going quiet.
• Saying they feel hot, dizzy, sick to the stomach or "far away."
• Blurred or tunnel vision.

Keep talking during every draw. A patient who stops answering may be starting to faint.

What to Do

1. Do the first moves: tourniquet off, needle out, pressure on.
2. Tell them calmly what you are doing. "You're okay. I've stopped. I'm going to lean you back."
3. Lay them flat and raise the legs if you can. Recline the chair if it reclines. If they are in a chair that does not recline and start to slump, support them and lower them to the floor. Keep the head from hitting anything.
4. Call for help without leaving.
5. Loosen tight clothing, and put a cold cloth on the forehead or neck if your procedure uses one.
6. Stay until they are fully alert and their color has returned.
7. Sit them up slowly in stages, and keep them there until they feel well.
8. Check the puncture site, which may have bled while your attention was elsewhere.

A vasovagal faint usually clears within a minute or two once the patient is flat.

Warning: Call for emergency help if the patient does not wake up within a minute or two, is not breathing normally, has chest pain, has a seizure that goes on, or hit their head in a fall. Start CPR if they do not respond, are not breathing normally and you are trained.

Do not let a patient who fainted drive or walk off alone until your procedure's conditions are met. Tell the nurse if the patient is an inpatient. In an outpatient lab, follow your rule for how long they stay and who they leave with. Note the reaction in their record, so the next phlebotomist has them lie down.

For patients who faint often, ask them to breathe slowly and look away. In blood donation, tensing the leg muscles during the draw has been shown to help some people. Do not make promises, and always keep them reclined.

Hematoma

A hematoma is blood leaking from a vein into the tissue around it. You will see a swelling or a bruise spreading under the skin, often during the draw.

Common causes: the needle went through the vein, the bevel is only partly in the vein, the tourniquet stayed on when the needle came out, the patient bent the arm, or pressure afterward was too light.

1. Do the first moves. Do not wait to finish the tube.
2. Hold firm pressure for 5 minutes, and longer if the patient is on a blood thinner.
3. Keep the arm straight. Raise it if your procedure says to.
4. Use a cold pack if your procedure allows.
5. Choose another site if you still need the sample. Do not draw from the same swollen area, because that blood may be damaged.
6. Tell the patient to expect a bruise, and to get care if the arm gets more swollen or numb.

Call the nurse if the swelling keeps growing under pressure, or if the patient has numbness, tingling, severe pain or a cool, pale hand. A large hematoma can press on nerves and blood vessels.

Arterial Puncture

An artery carries blood under much higher pressure than a vein, so an accidental stick can bleed hard into the tissue. Arteries are deep, so this is rare, but the risk is highest near the basilic vein at the elbow.

Signs of arterial puncture:

• Blood is bright red.
• The tube fills unusually fast.
• Blood pulses into the tube in time with the heartbeat.
• The patient may report sharp pain.

What to do:

1. Do the first moves.
2. Hold firm, direct pressure for at least 5 minutes yourself. Do not hand this over to the patient.
3. Check that the bleeding has stopped completely before you bandage. Do not use a pressure wrap to replace your own hands.
4. Check the hand for color, warmth and feeling.
5. Tell the nurse or your supervisor right away, and report it as your procedure directs.
6. If you collected any sample, ask the lab how to handle it, and make sure they know it may be arterial.

Patients on blood thinners need longer pressure and closer watching.

Nerve Injury

A nerve hit by a needle gives a sharp, shooting or electric pain, and it may run down to the fingers or up the arm. Tingling or numbness can follow. Some patients do not call it pain, and say "something weird just happened" or pull the arm away.

1. Remove the needle at once. Do not ask them to hold still so you can finish.
2. Apply gentle pressure. Do not move the needle around.
3. Ask what they feel and where.
4. Do not redraw from that site. Use another site or arm if the patient agrees.
5. Report it and record their words exactly: "Electric pain from the elbow to the thumb."
6. Tell the patient to seek care if the pain, numbness or weakness lasts, and follow your procedure for referring them.

Most of these injuries settle, but pushing on after the first sign is what turns a short pain into a lasting problem. Deep angles, probing and the inner side of the elbow raise the risk.

Allergic Reactions

Patients can react to latex, adhesive, chlorhexidine, iodine and other products.

Warning: Anaphylaxis can kill within minutes. Do not wait to see if it gets better. Call your emergency response, keep the patient lying down unless breathing is easier sitting up, and stay with them. Medication is given by a licensed provider or by trained staff under your site's rules.

After any reaction, the patient's allergy list should be updated. Tell the nurse, and use alternatives next time.

Seizures

Seizures can happen on their own, and sometimes a person who faints will jerk briefly. Either way:

1. Tourniquet off and needle out, if you can do it safely.
2. Do not hold the person down, and do not put anything in the mouth.
3. Ease them to the floor if they are in a chair, and move hard objects away.
4. Protect the head with something soft.
5. Call for help, and time the seizure.
6. When the shaking stops, turn them on their side and stay with them.
7. Apply pressure to the puncture site when it is safe to do so.

Call 911 or your emergency response if a seizure lasts more than 5 minutes, happens again, or the person does not wake afterward.

Bleeding That Will Not Stop

Firm pressure normally stops a puncture site within a few minutes. Blood thinners, liver disease and low platelets make it slower. If the site still bleeds after 5 minutes of firm pressure, keep pressing and get the nurse. Do not bandage over active bleeding, because it keeps going under the gauze.

Fear, Refusal and Confusion

Some reactions are not medical. A frightened patient may pull back, cry or get angry. Slow down, say what will happen and let them set a small part of the pace, such as choosing the arm.

If a patient says no, stop. If they cannot understand what you are doing, or they fight the draw, do not restrain them to get the sample. Tell the nurse, and follow your procedure. Children may need a parent or trained helper to hold them comfortably. The rule is the same: no one is held down just because it is faster.

Writing It Down

Report every reaction as your procedure directs. A useful note is short and factual.

• What you saw and heard, with the time.
• The site, the needle and how many attempts.
• What you did, in order.
• Who you told, and when.
• How the patient was when they left.

Example note. "10:42. During right antecubital draw, 21 gauge, first attempt, patient reported dizziness and turned pale. Tourniquet released, needle removed, pressure held. Chair reclined, legs raised. Patient remained awake. RN notified 10:44. Color normal and patient alert 10:50. Site clean, no hematoma. Patient left with spouse at 11:05. Draw not completed. RN to reschedule."

Common Mistakes

Check Your Understanding

1. Halfway through a draw, a talkative patient goes quiet and starts to sweat. What do you do?

Treat this as the start of a faint. Take off the tourniquet, take out the needle, apply pressure, recline him or lay him flat, raise his legs and stay with him. Call for help without leaving.

2. The tube fills very fast with bright red blood that pulses. What do you do, and for how long?

This may be an artery. Take out the needle and hold firm pressure yourself for at least 5 minutes, and until the bleeding has stopped. Check the hand, and report it right away.

3. A patient reports that her thumb went numb as the needle went in. She says you can keep going. Do you?

No. Remove the needle at once, apply gentle pressure and do not redraw from that site. Record her exact words and report it.

4. Ten minutes after you use a chlorhexidine prep, a patient's lips begin to swell and he says his throat feels tight. What do you do?

Treat this as a possible severe allergic reaction. Call emergency help immediately and stay with him. Do not wait to see what happens.

Key Takeaways

• The first moves are the same for nearly every reaction: tourniquet off, needle out, pressure on, patient safe.
• Keep talking during a draw, because a patient who goes quiet may be about to faint.
• Lay a faint patient flat with the legs raised, and stay until they fully recover.
• Bright red, pulsing or fast blood means firm pressure from you for at least 5 minutes.
• Electric pain means the needle comes out at once and stays out of that site.
• Trouble breathing or swelling of the face is an emergency. Report every reaction in writing.