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(Editor's note: This article originally appeared in Phlebotomy Today-STAT!, a free e-newsletter from the Center for Phlebotomy Education Inc. Reprinted with permission. For more information, visit www.phlebotomy.com.)
You've selected and cleansed the site for your venipuncture. You're engaging in a pleasant conversation with the patient about the weather. You anchor the vein, remove the needle's sheath, warn the patient of the imminent puncture, and insert the needle. Suddenly, he becomes nauseous, or passes out, or faints, or has a seizure, or screams in pain, or demands you stop. What do you do?
Doing the right thing might make the difference between a mere incident or much worse. Are you prepared to handle any patient reaction appropriately? Do you know what your facility's policy says about reacting to these reactions? If not, now's a good time to brush up. Here's what you need to know about reacting to five not-so-uncommon patient reactions.
 Nausea: If your patient becomes pale, begins to sweat, or states he's feeling sick or nauseous, you have been given a warning. The patient may be on the verge of passing out or vomiting. Although you'd like to be able to fill the tubes or syringe, now is not the time. Instead, use the warning as an opportunity to safely remove and dispose of the needle, and provide your patient with an emesis basin. Then call for assistance to get the patient on a cot or gurney until his symptoms subside. Never leave nauseous patients unattended.
Perhaps the patient has a needle phobia; perhaps he is diabetic or has been fasting too long; perhaps he can't stand the sight of blood. Regardless, an uneventful outcome demands your immediate termination of the procedure before things get worse. Be thankful you have time to remove the needle before he passes out or vomits on your shoes. Not everyone is so lucky.
- Fainting: If you're a believer in statistics, you'll appreciate knowing that studies show as many as five percent of patients pass out during or immediately following a blood collection procedure. The problem is they don't come with a label on their forehead that reads, "I will pass out today." Therefore, be prepared for all patients to faint without warning. That means drawing outpatients in a chair with side armrests (minimum) and never drawing any patient who is sitting upright on exam table or bed. If a chair with armrests isn't available, have the patient lie down on a cot, bed or gurney.
That's being proactive. Now for being reactive. Should your patient lose consciousness, keep your wits about you and protect her from falling. Call for help. Trying to lower the patient to the floor yourself, or reclining the patient onto a cot or gurney without assistance can injure both you and the patient. Stabilize the patient's position until assistance arrives. If possible, lower the patient's head below the plane of her heart. Avoid using ammonia inhalants as the patient may be asthmatic or have some other respiratory disorder the ammonia could worsen. When assistance arrives, the patient should be placed horizontally and medical evaluation sought.
Above all, follow your facility's policy. If your facility doesn't have a well-defined protocol, assist in developing one. Protecting the patient from injury is critical, but protecting yourself is just as important. Should your patient pass out while the needle is in her arm, have the presence of mind to remove it, activate its safety feature immediately, and release the tourniquet, if still applied. You can discard it later, but at the very least, conceal the sharp. Don't forget the contaminated sharp not only poses a risk to your patient should it slice a vein, artery, nerve or tendon, but to you as well. Not only can it impale you or lacerate your skin, it can deliver bloodborne pathogens deep into your tissue.
- Seizures:Seizures are not caused by venipunctures, but can occur during them for reasons unrelated to the draw. There's no way to predict or prevent them in the patients you draw, so be mindful that this reaction can occur randomly and without warning. Should your patient go into a seizure, give the same high priority to removing the needle and activating its safety feature as described under "fainting." Immediately call for help. Attempts to restrain the patient may not be advisable, but keep the patient from potential injury by preventing falls and limiting movement of the limbs. Medical evaluation should be immediate.
- Shooting pain:When properly performed, venipunctures can be mildly uncomfortable. But when the patient expresses excruciating, unusual or shooting pain, discontinue the draw immediately. Extreme pain can indicate needle contact with nerves or other structures, which, if damaged, can lead to disabling injuries. Any expression of pain distant to the insertion point indicates nerve involvement.
The proper reaction to shooting, electric-like pain is to terminate the attempt. Even indications that the patient feels tingling in the fingers indicates the needle could be coming in contact with the nerves. Immediate needle removal is the best way to prevent permanent injuries.
- Demands to remove the needle: Sometimes, patients demand the needle be removed. Such requests constitute a withdrawal of consent, and must be honored. To fully protect your employer from legal claims of battery or operating beneath the standard of care, commands such as "Stop!," "Quit!," "Take it out!" must be obeyed.
Knowing how to react to reactions is important for every healthcare professional with blood collection responsibilities. Being prepared for the reactions discussed in this article will help you keep calm and have the presence of mind to do the right thing if and when one of your draws goes in a direction you didn't anticipate. Just remember, when you expect the unexpected, the unexpected never happens.
Dennis J. Ernst is the executive director of the Center for Phlebotomy Education Inc., Corydon, IN.
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