Phlebotomy and the Aging Patient
Special techniques and knowledge help ensure that the elderly are comfortable with the procedure
As a white candle In a holy place, So is the beauty Of an aged face.
--From The Old Woman,
by Joseph Campbell
By Virginia Faber, MLT(ASCP), CLS(HEW), CPT(ASPT)CDCS
There is relatively little written about dealing with the aging or elderly patient. Yet right now more than 13 percent of our population is over age 65. That number is expected to spiral to 32 million (about 21 percent) by the year 2030, and 60 million by 2050, according to U.S. Census Bureau predictions.
The fastest growing segment of the elderly population is age 85 years or older.1 With this fact comes the reality that our aging population--those over 65 years old--suffer from loss of hearing, organ failure, circulatory distress, arthritis, memory loss, Alzheimer's disease and loss of muscle tone, not to mention graying hair and wrinkled skin.
There are more than a million people in institutions or nursing homes--5 percent of those over 65. They suffer from stroke, paralysis or cancer--about half may exhibit some degree of senility.2
It seems as though aging predisposes one to a variety of diseases, but it has not been proven that disease is inherent with aging. Whatever research confirms, sooner or later the health care provider will encounter an aging patient while performing her daily work. This may include taking vital signs, doing an electrocardiogram or drawing a blood specimen.
The geriatric patient challenges the blood drawing skills of the best phlebotomist. Phlebotomists who have learned and practiced phlebotomy in a nursing home may well have been challenged beyond the levels normally obtained in a clinic or hospital setting. Geriatric and pediatric phlebotomy require a unique insight into phlebotomy skills.
It is important for the health care provider to gain the knowledge and necessary skills to make the aging patient comfortable in whatever procedure must be endured--thus ensuring that the patient feels somebody cares about what is happening to him. If this is not conveyed, any physical, mental or psychological problems experienced by the patient can impede his ability to cooperate with a health care provider.
There are special techniques that can be used for obtaining blood specimens from elderly patients, and other tips that may provide food for thought about their feelings and apprehensions.
Physiological Changes of Aging
Many times the elderly patient suffers from disease, malnutrition or dehydration. This accentuates changes that naturally occur in the skin and subcutaneous tissue.
The skin has two main parts--the outer layer (epidermis) and the inner layer (dermis). The epidermis, made up of non-living cells which need no blood supply, sheds its dead cells regularly. As it sheds, new cells from beneath replace the old skin.
As one ages there is a reduction in the ability to replace cells quickly, leading to slower healing time and more chance of infection. There is also a gradual loss in the ability of the immune system to fight off infection and invading microorganisms. Therefore, it is important to be conscientious in hand washing, so no agents are spread from patient to patient.
With these facts in mind, venipuncture site preparation becomes even more important in the elderly patient.
The dermis is made up of connective tissue that holds the blood vessels, nerve tissue, hair follicles and sweat glands. Underneath this layer is the fatty subcutaneous layer that insulates the body from heat and cold and serves as a "shock absorber."
Arteries and veins change drastically with age. There are three tunics in a vein or artery. The outer layer supports the blood vessel, the middle layer is the "elastic" layer for contraction and dilation, and the innermost layer is where the valves are located in a vein. Blood vessels become less elastic, straighten and fray with aging and can be easily injured during a venipuncture attempt.
Compensating for Changing Skin
There are some important steps to consider when preparing for a venipuncture on an elderly person. The phlebotomist's time to locate a suitable vein is limited; therefore the skill in locating the draw site should be honed to perfection.
Be sure to take your time in locating the "perfect" spot for the venipuncture. A light held over the access area can help illuminate the color and contour of the vein. Due to muscle loss in the elderly the antecubital fossa may not be the "perfect" area to consider a venipuncture. Look at the hands, digital veins, thumb veins or forearms.
In addition to veins being less stable, they lack muscle and collagen, they can be sclerotic and yield poor blood flow. They must be well anchored before the venipuncture attempt is made. Holding the skin alongside the vein instead of directly over the vein will help prevent obstructing it and causing it to collapse.
Never probe for a vein. If the area is bruised, or shows a hematoma, draw distal to that area. If you feel the need, ask someone to help you. That individual can even assist just by holding the arm still so you can get your specimen without multiple sticks.3
Aging skin is fragile and bruises easily, so never "slap" the arm to dilate the vein. This could cause the patient to bruise. Sometimes, using iodine--providing the patient is not allergic to it--can help locate the vein by discoloring the skin; this is especially true in a dark-skinned person. Make sure the iodine will not compromise the tests being drawn.
An aging or dying patient may be very emaciated and have bony prominences. Be very cautious when using tourniquets and bandages. He may also have prolonged bleeding times, so be sure that bleeding has stopped before leaving his side. Due to autoregulatory blood flow distress, circulation may slow dramatically and legs and hands may be cold and cyanotic. Careful positioning for a venipuncture is important. Skin punctures will not be advisable if hands and legs are cold and cyanotic.
The patient should keep his arm below the heart to help increase blood flow. The use of smaller gauge needles also helps reduce trauma to the vein and the patient--this is a good time to use butterfly needles. If the vein is fragile and small, use smaller pediatric vacuum tubes, which cause less back draw and lessen the chance of "blowing" a vein.
You can try to place the tourniquet over clothing which will be more comfortable for the patient, or remove the tourniquet just before inserting the needle. This can reduce the risk of rupturing the vein, causing a hematoma. Use one quick motion when inserting the needle. It is less painful and more effective.
When your draw is complete, apply pressure and make sure bleeding has stopped. It is very important to pay special attention to the fragility of the patient's skin. It can be "tissue thin" and the use of a bandage or tape can cause him to suffer from raw and seeping areas when it is removed. Even paper tape can cause a problem. Elastic bandages will hold the gauze in place, while not adhering to the skin.
The Difficult Vein
There are general things the health care provider can do when trying to locate a difficult vein. These suggestions are not exclusive to the aging patient: It is important to:
* pay careful attention to identification; the elderly may be confused and unable to help.
* look at both arms--the back, wrists, hands and complete forearms.
* feel for a vein with your fingertip--which is the most sensitive. Consider bounce; size of vein, to determine needle gauge and tube size; depth, to determine angle of entry and direction the vein is "running."
* have the patient make a fist; not pump the fist.
* massage the arm from wrist to elbow.
* apply heat to the site to aid blood flow.
* anchor the vein firmly.
* be aware of excessive blood collection--elderly are prone to anemia.
Of course no specimen collection would be complete without meticulous attention to identification protocol. The patient must have an identification armband. Ask the patient his name--he must give the first and last name. If there is any doubt as to identification, have the nurse ID the patient and document, document, document!
If there is any question or any portion of this protocol is omitted, DO NOT proceed with specimen collection!
The Elderly Patient
It is well known that sometimes the aged are hearing-impaired, so speak clearly and slowly and allow time for the patient to ask questions. At times they are treated as though they are not there. People talk "around" them or talk down to them as if they are incapable of understanding, when their only problem is some degree of deafness. Senior citizens may lose their hearing, but it doesn't mean they have lost their mind.
As with any patients, the elderly have the right of informed consent. There is nothing more frustrating than feeling the loss of the ability to control your own destiny. Everyone needs to feel in "control." Too many times this fact is lost in dealing with any patient, but it seems more prevalent in dealing with the aging patient. If capable, the patient has the right to make his own decisions, and be actively involved in the determination of his own care.
The Mortal Element
As noted above, many of our elderly are in nursing homes and long-term care facilities, some are home-bound and others are in hospitals. The sad but true fact is that many are just waiting to die.
Dying is a lonely and impersonal experience. Death and dying is the last stage of the life process. Doctors, nurses and phlebotomists are all rushing in to do their daily chores, without ever "seeing" the patient. Without realizing it, we spend little time "with" the patient. He asks questions; we do not take the time to answer.
Working with the elderly is difficult at best. Perhaps we are reminded that we too are mortal and must face our own limitations. The responsibility of any health care professional is to remember that a patient, no matter if sick or dying, is still a living person.
It is especially important that they feel loved, secure, cared for and in control. The professional can achieve some of this by being a good listener. Most times we do not have answers to questions a patient asks or know how to respond to feelings they express. The key is to just listen while the patient "vents." An assuring response of "I understand" shows you care enough to listen.
Do not be afraid to touch. A soft touch on the patient's arm or hand says, "I'm here and I care that you are afraid." This is as important as a verbal communication. It shows interest and allows the patient to feel humanness.
Often patients die as they have lived. The fearful die in fear; the angry die in anger; the peaceful die in peace. Try to make that last connection in life one of caring, peace and love. Help your patient reach acceptance.
Talking to the patient, even if he is unconscious, is essential. Hearing is the last sense to be lost, and loving, kind words even in death can be most comforting even to a patient who seems to be unaware.
Patients can accept or fear death. For some, it can be a welcome relief from pain and suffering and the belief they are a burden on those they love. Death can be a way of entering into a new "life," free from pain and fear. Other dying patients may fear death because they believe they have not yet "finished" their earthly duties--too many things left unattended. They may also feel guilt over the fact they have not lived in a righteous way. Or they may just fear death itself.
Remember the lines of the opening poem. One can find beauty in persons of age--respect and admire them.
Virginia Faber is regional director of the American Society of Phlebotomy Technicians and a frequent contributor to ADVANCE.
Helen Maxwell, ASPT executive director, collaborated in writing this article.
1. Miller, S. Successful Aging in America. MLO. March, 1997: p. 23.
2. Compton's Interactive Encyclopedia, 1995. NewMedia Inc. "Aging."
3. Enich, M. and Hinderer, G. Performing venipuncture in elderly patients. Nursing Journal. February, 1991: Hospital Nursing Section; pp. 32C-32H
BLOOD COLLECTION: ROUTINE VENIPUNCTURE AND SPECIMEN HANDLING
NAACLS Phlebotomy Program Approval