Phlebotomy & Venepuncture

Taking blood is one of those skills that separates “I’ve read about it” from “I can actually do it.” It looks simple until you’re standing at the bedside with a needle in your hand and a patient watching you. This guide covers everything your training should have taught you — and the things it probably didn’t.

If you’ve ever stood at a bedside holding a venepuncture kit and thought “please let this be a good vein” — you’re not alone. Every nurse, no matter how experienced, has had a difficult take. The difference between a competent phlebotomist and a great one isn’t a magic touch — it’s preparation, technique, and knowing when to stop and ask for help.

First: Are You Actually Allowed To Do This?

Let’s start with the most important point. Venepuncture is not an automatic part of being a student nurse. It is a delegated, competency-assessed skill. You must have completed your trust’s venepuncture training, been assessed as competent, and be working within your trust’s policy before you take blood from any patient [1].

If you haven’t been trained, or your competency has lapsed, you cannot perform venepuncture — even if a staff nurse says “you’ll be fine” or “just have a go.” This is exactly the kind of situation where learning to say no protects both you and the patient. Saying “I haven’t been signed off for this yet” is not weakness — it’s professional accountability, and it’s exactly what the NMC expects of you [2].

Consent, Identification & Preparation

Consent

Consent for venepuncture must be informed and voluntary. Explain what you’re doing, why you’re doing it, how many bottles you need, and that it will feel like a sharp scratch. The patient can refuse at any time — even mid-procedure. Document consent in the notes [3].

Patient Identification

Wrong blood in tube (WiT) is a serious patient safety incident — a transfusion reaction from incorrectly labelled blood can kill. You must identify the patient using three identifiers: full name, date of birth, and hospital number. Check against the wristband AND the request form. Never pre-label bottles. Label them at the bedside, in front of the patient [4].

Infection Control

Venepuncture is an aseptic procedure. Perform hand hygiene, use an aseptic non-touch technique (ANTT), and wear gloves. For full details on ANTT — including the difference between standard and surgical ANTT — read my complete guide to aseptic non-touch technique. Clean the site with 2% chlorhexidine in 70% isopropyl alcohol and allow it to dry completely (usually 30 seconds) — do not fan, blow on, or touch the site after cleaning [5].

Choosing Your Site — Anatomy Matters

The antecubital fossa (the bend of the elbow) is the standard site because the veins are large, superficial, and well-supported. But not all veins here are equal:

Sites To Avoid

• Arms with IV cannulas or infusions — blood will be diluted/contaminated. If unavoidable, use the other arm or take below the cannula after stopping the infusion.
• Arms with lymphoedema or after mastectomy/axillary node clearance — risk of infection and impaired lymphatic drainage. Avoid entirely; use the other arm.
• Arteriovenous fistulas or grafts (dialysis patients) — never use these for venepuncture. Ever.
• Bruised, scarred, or infected areas — unreliable and painful.
• Lower limbs (legs/feet) — higher risk of thrombosis and infection. Only with medical authorisation in exceptional circumstances.
• Arteries — never attempt to take blood from an artery. If you see bright red, pulsatile blood, withdraw immediately and apply firm pressure.

The Procedure — Step by Step

1. Prepare everything at the bedside — bottles, needle/holder, gauze, tape, sharps bin within reach. You do not want to be reaching across the patient with a needle in your hand.
2. Apply the tourniquet — tight enough to occlude venous return but not arterial flow. The patient should still have a radial pulse.
3. Select and palpate the vein — feel for bounce and direction. Note the angle and depth.
4. Clean the site — chlorhexidine/alcohol wipe, allow to dry. Do not touch the site after cleaning.
5. Anchor the vein — pull the skin taut below the site with your non-dominant hand. This stops the vein rolling away.
6. Insert the needle — bevel up, at 15–30° to the skin, aligned with the direction of the vein. A shallow angle for superficial veins, steeper for deeper ones. Advance slowly — you will feel a “give” as you enter the vein (flashback).
7. Collect the bottles — in the correct order of draw (see below). Fill until the vacuum stops. Gently invert each bottle 5–8 times to mix — do not shake (causes haemolysis).
8. Release the tourniquet — before withdrawing the needle. Some guidelines say release as soon as the last bottle starts filling [7].
9. Withdraw the needle — apply gauze and firm pressure. Do not bend the arm up — keep it straight and elevated. Activate the needle safety device immediately and discard into the sharps bin.
10. Label the bottles at the bedside — in front of the patient. Check against the wristband and request form again.
11. Thank the patient, check the site, and document — what was taken, by whom, any difficulties, and that consent was obtained.

Order of Draw — Get This Wrong And The Results Are Meaningless

The order of draw exists to prevent cross-contamination between additives in different bottles. Drawing them in the wrong order can cause falsely elevated potassium, abnormal clotting results, or contaminated blood cultures. The UK standard order is [8]:

Complications — And What To Do About Them

Haematoma (Bruising)

The most common complication. Caused by: insufficient pressure after withdrawal, needle going through the back wall of the vein, releasing the tourniquet after removing the needle, or bending the arm up. Prevention: firm, straight-arm pressure for 2–3 minutes (longer if the patient is on anticoagulants — see my guide to high-alert medications and anticoagulants). Treatment: apply pressure, reassure, document. If large or expanding, escalate [9].

Syncope (Fainting)

Some patients faint during or after venepuncture. If a patient says they feel dizzy, hot, or sick — stop immediately. Remove the tourniquet and needle, lie them flat, raise their legs, monitor observations. Never leave a patient who feels faint sitting upright. If they lose consciousness, follow your trust’s emergency protocol — airway, breathing, circulation, call for help [10].

Nerve Injury

If the patient reports shooting pain, tingling, or numbness radiating down the arm during insertion — withdraw the needle immediately. This suggests nerve contact. Do not re-attempt at the same site. Document and inform the medical team. Nerve injury from venepuncture is rare but can result in permanent damage — early recognition is everything [11].

Arterial Puncture

Bright red, pulsatile blood = you’re in an artery. Withdraw immediately and apply firm, sustained pressure for at least 5–10 minutes (longer if anticoagulated). Check distal perfusion and escalate. Do not apply a dressing and walk away — an expanding haematoma in the antecubital fossa can cause compartment syndrome [12].

Needlestick Injury

If you sustain a sharps injury: encourage the wound to bleed under running water, wash with soap and water (do not suck), report immediately to occupational health or A&E (depending on time of day), and follow your trust’s sharps injury protocol. Timing matters — HIV post-exposure prophylaxis is most effective within 1 hour [13].

Difficult Venepuncture — When To Stop

Every nurse has patients they can’t get blood from. The skill is not persisting until you get it — it’s knowing when to stop. General guidance: maximum two attempts per person, then ask someone more experienced. Multiple failed attempts cause pain, bruising, anxiety, and damage to veins. If two experienced staff have failed, consider alternative routes: a doctor may need to take from a femoral or neck vein, or the sample may need to be taken under ultrasound guidance [14].

Patients on anticoagulants, with fragile veins (older adults, long-term steroid use, chemotherapy), or with difficult anatomy (obesity, oedema) require extra care. For anticoagulated patients, apply pressure for longer and check the site before leaving. For older adults, use a smaller needle (23G butterfly), avoid the tourniquet if possible or apply it loosely, and be gentler — their veins tear easily [15].

Documentation — If It’s Not Written Down, It Didn’t Happen

Record in the patient’s notes: date, time, your name and designation, number and type of bottles taken, any patient-reported difficulties, the site used, and that consent was obtained. If there were complications — fainting, haematoma, failed attempts — document them clearly and inform the nurse in charge. Good documentation protects the patient, the next member of staff, and you.

And once the blood is taken, the real value is in understanding what the results mean. For a complete guide to interpreting blood results — reference ranges, what abnormal values mean, and when to escalate — read my Understanding Blood Results guide.

Final Thought

Phlebotomy is a skill that looks simple and is anything but. The best phlebotomists I’ve worked with are not the ones who always get it first time — they’re the ones who prepare properly, respect the patient, know their limits, and aren’t afraid to say “I can’t get this, let me find someone who can.” That humility is what keeps patients safe. And it’s exactly the same skill you’ll use with every other clinical procedure you learn.