Venepuncture
An Open
learning pack for registered nurses and
midwives
Start off
your study of this pack by reading this article
Venepuncture
This
procedure is perhaps the most common extended role activity carried out by
nurses. With some basic instruction most
qualified nurses should quickly become competent.
BACKGROUND
"The
Scope of Professional Practice ",(1) is the current UKCC
document covering what used to be called "extended role activities",
this term is no longer considered
suitable as it tends to limit the parameters of practice. The Code of
Professional Conduct,(2) places
emphasis on the principles of knowledge, skills, responsibility and personal
accountability. This means that the individual is fully accountable for all
aspects of their own practice. The best way to give evidence of professional
competence in any area not covered in basic training is to be able to
demonstrate attendance at a recognised course of training, and to retain
recorded evidence of supervised practice in the clinical area. Once any skill
or area of knowledge has been learned it is the responsibility of the
individual to maintain and improve professional knowledge and competence,(2).
Nurses
usually take blood as delegated by the doctor or when following local protocols.
The type of tests used are usually haematological, biochemical or
immunological. In common with all nursing procedures the patient will be
treated as a whole person and care individualised.
SAFE PRACTICE - RISK OF NEEDLE STICK INJURY
Needle
stick injuries do pose a hazard to health care workers,(3). The scale of this risk has been found to be
as high as one needle stick injury for every 3 175 to 4 006 needle-handling
procedures,(4). Another study
found that there were 6.9 needle stick injuries per hundred full time nursing
staff per year,(5). It should be remembered that Hepatitis B is much more
transmissible that HIV,(6) so any nurse working with body fluids
should be vaccinated for Hepatitis B and have their antibody levels checked.
If unfortunately
an inoculation injury does occur the wound should be encouraged to bleed. An
effective way to do this is to squeeze the area round the puncture site to
"milk" out as much blood as possible, it should also be held under
warm running water. After this it may be soaked in an iodine based solution. In
addition to these first aid measures the patients
details should be recorded on an accident form and a medical opinion taken,
usually through the occupational health department.
The idea of
a "high risk patient" is perhaps an unhelpful one, patients carrying
Hepatitis B or HIV may look perfectly healthy and "respectable" so
all body fluids must be treated with respect.
Seamless
rubber gloves should be word unless the individual feels that these will interfere
with manual dexterity. However many nurses feel they are more likely to stab
themselves with the needle if they wear gloves. Gloves should be worn when the
practitioner has any wounds on the hands or, arguably, if the patient is known
to be infected with HIV, Hepatitis B or C virus,(7).
However no blood at all should be spilled with good technique. Local infection
control protocols and policies should of course be obeyed.
Perhaps the
main risk to the nurse is posed by unpredictable patients who may move or
otherwise thrash around during the procedure. If the procedure is explained and
the psychological status of the patient assessed before the procedure this risk
may be minimised. If there is any perceived risk of being splashed with blood
goggles should be worn.
CORRECT USE OF TOURNIQUET
The
tourniquet should be applied at a pressure which is greater than venous blood
pressure and lower than arterial. This
will allow blood into the arm but restrict blood leaving thereby causing the
veins to engorge with blood. Care should
be taken not to nip the patients skin during
application. A good tourniquet will allow palpation of veins which feel
"bouncy". The tourniquet is removed before the needle is withdrawn.
SELECTION OF A VEIN
The primary
method of vein selection should be palpation, (fig.1) although it is more
straightforward if the vein can be visualised as well. The usual site used is
the antecubital fossa where there is a selection of superficial veins,(8), (Fig. A). The area should be
palpated from side to side
to assess all the possible veins.
When one is selected it should be palpated in an up and down direction
to allow the practitioner to learn the position of the vein. If time is taken at this stage to be sure of
the local anatomy there should be little question of missing the vein with the
needle.
Usually the
left arm would be used in a right handed person. However if a suitable vein is
not found in one arm the other should be examined. The opposite arm should also
be used if there is a haemodialysis arterio-venous fistula in place as
venepuncture can damage the vessels concerned.
SKIN PREPARATION
For some
time it was commonly believed that skin cleaning with alcohol was only ritual
based practice. Research had shown that although skin cleaning did reduce the
number of bacteria on the skin surface(9)
it was not necessary to prevent infection prior to parental procedures,(10). However current bacteriological opinion is
firmly in favour of cleaning the site of insertion. The skin should be cleaned
to remove blood, mucus and other organic debris with a preparation such as
isopropyl alcohol or 1% iodine in ethanol 70%. In practice alcohol swabs are
usually used. The area should be swabbed in one direction. This will help to
move material and bacteria away from the entry site. If the
area is swabbed back and forward the bacteria will also be moved back and
forward. The site should then be allowed to dry, usually for about 30
seconds, before insertion of the needle, this is to prevent stinging(11).
Once the site has been swabbed it should not be touched again.
TEMPORARY CANNULATION
In a right
handed practitioner the vein should be "anchored" with the left thumb
about two inches down the arm from the entry site, (see fig. 2). This is especially important in older
patients who often have more "mobile" veins. The needle should be inserted along the line of the vein, the
position of which has previously been learned at the palpation stage. Table 1
give some guide-lines for "difficult patients".
The pointed
tip of the needle should be inserted through the skin into the vein first. The movement should be a continuous one. If there is delay in cannulating the vein,
blood will leak out round the bevelled tip of the needle, However, once the round part of the
needle is in contact with the vein the walls will form a seal around the shaft
of the needle. The vein should be
cannulated for about one centimetre, (half an inch) before the specimen is
withdrawn. The angle of entry into the
vein should be about thirty degrees,(12). Once the vein is cannulated the left thumb
can move to secure the needle position, (see fig 3).
As a
general rule in adults a green needle, (21 G) should be used as smaller bore
needle may cause increased haemolysis of the blood as it is drawn through the
narrow lumen. Slower drawing up of blood would also give it more time for the
blood to clot in the syringe.
ALTERNATIVE SYSTEMS
Several
"vacutainer" type systems are now
available. These leave the needle in situ while the different specimen
containers are attached. The specimen containers are pre-evacuated to draw up
the precise volume of blood required for the test. The advantage to these
closed systems is that there is no "aerosol" effect when transferring
the specimen from the syringe to the container, and
the volume should be automatically correct. However the various systems are
incompatible and it takes some practice to hold the needle in place while
changing the bottles. However the main problem is that there is no `flashback`
when the needle enters the vein. To get around this problem while learning, a
conventional green needle may be used on the end of a blue cannular connector.
As well as this there can be cost implications.
WITHDRAWAL OF THE NEEDLE AND FURTHER MANAGEMENT
Once the
required amount of blood has been drawn into the syringe or specimen container
the needle should be left in place and a folded gauze swab or cotton wool ball
placed over the entry site, (see fig 4).
Next the tourniquet is released, (see
fig 5). If this is not done
venous blood will still be at high pressure when the needle is withdrawn
causing significant bleeding and bruising. No pressure is applied on the swab
until the needle has been withdrawn as this may cause pain and damage to the
lower wall of the vein. The instant the
needle is withdrawn "white finger nail pressure" should be applied
for two to three minutes to arrest haemorrhage, (see
fig 6). The arm should not be folded as this will
cause sheering forces to be applied to the hole in the vein, thereby enlarging
it and causing more bleeding and bruising.
In addition if the arm is folded no white finger nail pressure can be
applied over the entry site. A small sticking plaster may be applied to the
site once the wound is sealed.
MANAGEMENT OF THE SPECIMEN
Blood
should be transferred to the specimen bottles without forcing it quickly from
the syringe as this may cause haemolysis and give altered results. This would
especially cause raised potassium readings. If citrate bottles are used these
may be rolled in the hands to ensure mixing. When using the vacutainer system
no further transfer of blood is required. If a needle and syringe has been used
and blood needs to be transferred to a vacutainer the needle should be inserted
into the vacutainer and the appropriate volume of blood gently transferred.
DISPOSAL OF MATERIALS
The needle
should be removed from the syringe as soon as it is withdrawn from the vein,
(fig. 7). With vacutainers, as long as
the sharps container is big enough the needle and hub may be thrown away
without unscrewing the needle. Again acquisition of such safe habits reduces
the risk of inoculation injuries.
In terms of
practitioner safety this is perhaps the most important stage of the
procedure. One study reported that 58%
of needle stick injuries occurred when needles were cut, broken or recapped,(6).
The needle should be removed from the syringe using the graduated slot
in the top of the sharps box. The habit
many nurses have of recapping needles can be overcome by disposal of the cap as
soon as it is removed from the needle the first time.
The use of
puncture resistant containers should now be universal, (see fig 8). However they are often over filled, with
sharps sticking out from the top of the container, so this should be
avoided. The use of these specific
containers has been demonstrated to reduce related injuries three fold,(13).
DEALING WITH BLOOD SPILLAGE SHOULD IT OCCUR
Seamless
gloves and a protective apron should be worn. The blood should be removed by
sprinkling on enough hypochlorite granules to soak it up(7).
The granules should be left on the spillage for at least two minutes before
removal into a clinical waste bag with a with a scoop
and scraper. The area may then be cleaned using a general purpose detergent.
An obvious
additional danger is broken glass, if present this
should be picked up using forceps. All contaminated materials should be
collected in a puncture resistant container. A "spillage kit" could
be available locally, (see Table 2)
CONCLUSION
If these
guide-lines are followed venepuncture should indeed be a straightforward
procedure, safe for nurse and patient, yielding accurate diagnostic results.
-
Disposable towels
-
Spillage absorption hypochlorite granules
-
Waste bucket and lid
-
Safety glasses
-
Seamless gloves
-
Plastic aprons
-
Disposable scoop and scraper
-
Clinical waste bag
-
Chlorine releasing tablets, (a useful disinfectant)
-
Forceps
Table. 2
Suggested contents of a "Spillage Kit"
Venepuncture
– potential problems
Anxiety
Explanation
of the procedure in broad terms before starting
Importance
of a professional, "competent" approach
Recognise
the problem as real and treat as such
Needle Phobia
Use of
desensitisation techniques
Allow
selected patients to familiarise themselves with the equipment to remove fears
based on misconceptions
Use of
local analgesic cream, (especially for children)
History of fainting
Take the
specimen with the patient lying down
Use
diversionary techniques to distract the patients
attention, eg. asking questions
Elderly people with collagen loss
"Anchor"
the vein with the left thumb
Make sure
the needle is precisely in line with the vein
Obesity and/or hidden veins
Take time
to learn the position of the vein by palpation
Ask the
patient to squeeze on something in their hand
Gently tap
or rub the area - do not slap
Use a
sphygmomanometer cuff instead of a tourniquet inflated to diastolic pressure,
Immerse the
arm in warm water
Consider
use of an alternative site, eg. back of the hand or
ankle
Stages in the procedure using needle and syringe
Appropriate explanation to
the patient
Assess degree of expected
patient compliance
Application of tourniquet
Palpation of candidate veins
Learn the position of chosen
vein
Clean the skin with
unidirectional swabbing
Allow time for antiseptic to
dry
"Anchor" the vein
Line the needle up with the
vein, go in at about 25 - 30`
Insert the needle about 1-2 cm into the vein
Observe the flashback for
conformation of entry
Stabilise syringe and needle
Withdraw required volume of
blood
Release tourniquet
Apply dry
swab over the entry site
Withdraw
needle
Immediately
apply white finger nail pressure
Ensure
haemostasis
Asepsis is maintained at all times
Use of vacutainers
This has
the advantage of protecting the practitioner from the blood as it is
transferred from the vein directly into the specimen container.
Stages in the procedure
A needle is
screwed into the hub, the sheath is left in position
at this stage. The required specimen containers are arranged in the correct
order.
The
tourniquet is applied and the vein selected by palpation. The `line` and
position of the vein is accurately assessed.
The site is
cleaned using an alcohol based swab using unidirectional swabbing
The vein is
`anchored` using the left, (on non - dominant thumb)
The sheath
is removed from the needle and discarded
The hub and
needle are lined up with the vein.
The needle
is advanced into the vein penetrating the skin at an angle of about 25
-30`degrees.
The vein is
`cannulated` by about 1 cm. Once the needle is in the
vein the needle may need to be levelled off slightly to prevent the needle
penetrating the other wall of the vein.
Once the
needle is in the vein the first specimen container is pushed forward onto the
sealed needle inside the hub. It is essential that the specimen container is
not penetrated before the needle is in the vein, if this is done air would be
drawn into the specimen container. When this is done the position of the hub
must be secured with reference to the vein to prevent the needle being pushed
through the vein.
One
difficulty in learning the vacutainer system is the
lack of a flash back when the vein is first entered. When learning to use the
system a cannular connector may be screwed into the
hub and a green needle fitted to the cannular
connector, this combination should provide a flashback.
When the
specimen bottles are changed it is essential to have a technique for securing
the position of the hub to keep the needle in the same position in the vein.
The
specimens must be collected in the correct order, plain tube for clotted
specimen first, then biochemistry, then haematology. (Additives in the
haematology tube can contaminate the blood in the biochemistry tube,
potentially altering some results.)
Once the
last specimen is collected the tourniquet is released. A dry swab is placed
over the entry site of the needle, no pressure is
applied until the needle is out of the arm. The instant the needle is out of
the arm `white finger nail pressure` is applied to the site for three minutes
to ensure haemostasis.
Throughout
the procedure the systemic condition of the patient is monitored.
Asepsis is maintained at all times
References
1. The
Scope of Professional Practice, (1992),
2. Code of Professional Conduct, (1992),
UKCC.
3. Krasinski K. LaCouture R. Holzman RS
(1987). Effects of changing
needle disposal systems on needle injuries.
Infection Control, 8 (2):59-62, 1987 Feb.
4. Goldwater PN. Law R. Nixon AD. Officer JA. Cleland JF (1989). Impact of recapping device on venepuncture
related needle stick injury. Infection
Control and Hospital Epidemiology, 10 (1): 21-5 Jan.
5.
6. De Laune S. (1990). Risk reduction through
testing, screening and infection control precautions. Infection control and hospital epidemiology,
11 (10): 563-5, Oct.
7. HMSO,
(1990), Guidance for Clinical Health Care Workers: Protection Against Infection with HIV and Hepatitis Virus.
8. Pollard
C. (1990), How to take blood, Practice Nurse, September.
9. Veikko AK. Philip F.
(1978). Is skin preparation necessary
before insulin injection? The Lancet,
1072-1073, 20th May.
10. Dann TC. (1969) Routine skin preparation before injection, An
Unnecessary Procedure. The
Lancet, 96-98. July 12th.
11. Elliott TS. Faroqui MH. Infections and intravascular
devices. British Journal of Hospital Medicine. 48(8):496-7, 500-3, 1992 Oct 21-Nov 3.
12. Lippincott Nursing Series, Manual of
Clinical Nursing Procedures, (1986).
Page 466, Harper and Row Ltd.
13. Ribner BS,
Answer all of the following questions,
it is best if this is done after discussion with colleagues on your ward or
unit.
List the
blood tests commonly carried out from your ward or unit. For each test you list
give one example of diagnostic information that the test may yield.
For each of
the tests listed state the type of container used and the volume of blood
required for the test.
List the
order in which vacutainer specimens should be taken,
(using colour codes and the names of the specimen containers).
What steps
would you take if a patient was particularly anxious prior to the procedure?
How would
you modify the way you carry out the procedure if an individual has a history
of syncope?
How would
you select the vein to be used for withdrawal of the specimen?
How will
you prepare the skin prior to needle insertion?
Why is it
important to allow the alcohol on the skin to dry before inserting the needle?
List the
reasons for bruising and/or haematoma formation after the procedure
For each of
the possible caused of bleeding listed state how you will prevent its occurrence
How far
into the lumen of the vein will you insert the needle?
How may
pain be minimised during the procedure?
How may
tissue damage be minimised during the procedure?
What
additional measures will be taken if blood is being taken for blood culturing?
How will
you remove the risk of nosocomial or other infectious complications from the patient?
How will
you minimise the risk to yourself and colleagues during and after the
procedure?
What
measures would you take if you unfortunately sustained a needle stick injury
What
measures would you take if some blood was splashed into your eye?
Other
points and comments
Finally
read through these objectives and satisfy yourself that you can meet them all.
Space is left under each objective for your self-evaluation or evaluation by
someone else
The student will be able to;
Discuss the types of
hypodermic needles, their sizes and individual indications.
Give reasons for the strict
maintenance of asepsis.
Discuss how asepsis will be maintained
in practice.
Describe possible veins which
may be used for venepuncture.
Demonstrate the selection of
an appropriate vein.
Describe the use of the
tourniquet
Discuss the appropriate skin
preparation for the procedure
Demonstrate the correct
method of insertion of the needle.
Discuss the removal of the
needle.
Discuss the correct methods
for transferring blood specimens from
the syringe to the specimen
bottles.
Discuss the protection of the
practitioner and others from the possibility of nosocomial infection.
State
current policy from "Guidance on the management of infections" re. wearing
of gloves.
Describe how any haemorrhage
or haematoma will be managed.
Discuss first aid and
administrative procedures in the event of needle stick injury.
Discuss possible
complications of cannulation, eg. air embolism,
haematoma, infection.
Demonstrate awareness of the
role of the Nurse in relation to the scope of professional practice document
and the code of ethics.
Give the indications for venepuncture
as agreed with local nurse managers
Once you have completed this pack you should keen it
safe as part of your PREP portfolio
Please give John Campbell a
call at St. Martins,
* You
have any suggestions for improving this pack
* There
are any omissions of information or concepts
* You
have found any mistakes or points of disagreement
Fig. 1 Some possible
sites for venepuncture. Underlying arteries and nerves are protected by muscle
facia.
1. The tourniquet
is applied. Time is taken to palpate and learn the position of the vein to be cannulated.
2. The needle is inserted into the lumen, in
line with the vein. Note the left thumb anchoring the vein in position.
3. Once the vein is cannulated
the left thumb is moved to secure the position of the needle. The specimen is
drawn up.
4. When the
specimen has been drawn up a cotton wool ball is placed over the entry site.
5. Prior to
withdrawal of the needle the tourniquet is loosened. No pressure is applied to
the cotton wool ball until after the needle has been withdrawn.
6. Bleeding
is prevented by application of "white finger nail pressure" for at
least two minutes.
7. The
needle is removed from the syringe, using the slot on the sharps container, prior
to transferring the specimen to the containers.
8. All
equipment is safely disposed of.
Venepuncture
Background
Venous blood samples are often required for diagnostic
tests in areas such as biochemistry, haematology, endocrinology or virology, (Black and Hughes 1997). The blood sample is removed from the venous
circulation, usually from a vein in the arm.
Practical aspects
The procedure must be explained to the patient to reduce
their anxiety and secure co-operation. Gloves should be worn to protect the
nurse against accidental spillage of blood, however with good technique there
should be no haemorrhage at all.
The equipment is assembled and a tourniquet is applied
above the elbow. This will cause the veins to fill up with blood as their
drainage is restricted, allowing improved palpation and needle insertion.
Possible veins which may be used are palpated,
a suitable vein will feel full and bouncy. It is essential time is taken to
learn the position of the vein to be used so venepuncture may be achieved at
the first attempt, (Anonymous 1999). The direction and `line` of
the vein must be assessed so the needle can be aligned along the vein later in
the procedure. The vein chosen will often be in the upper forearm in the
antecubital fossa.
The skin over the vein should be cleaned, in one
direction, using an alcohol impregnated swab. Unidirectional swabbing will
remove bacteria from the area of overlying skin. The alcohol must be allowed
time to dry, if the needle is inserted when the alcohol is still wet this will
cause stinging.
The sheath is removed from the needle and discarded to
remove the temptation of later re-sheathing. Most needle stick injuries occur
when needles are re-sheathed unnecessarily after use, (De Laune 1990).
With vacutainers the needle is
screwed into the needle holder, with a needle and syringe the needle is fitted
firmly onto the syringe hub to produce an airtight seal.
The vein will tend to move when the needle is inserted,
to prevent this it should be `anchored` with the left thumb. The needle is
lined up along the line of the vein and should be inserted into the lumen at an
angle of about 15 - 20 degrees.
It is ensured that the pointed tip of the needle
penetrates the skin first. A green (21 G) needle is normally used for
venepuncture.
Once the needle is in the vein the angle may need to be
reduced to prevent the penetration of the other wall of the vein, (Stevenson 1997). When using a needle and syringe a `flash back` of
blood is usually seen in the hub of the needle. One of the disadvantages of the
vacutainer system is that there is no flashback when
the vein is first penetrated. When learning to use these systems a cannula
connector may be screwed into the hub and a green needle fitted to the cannula
connector, this combination should provide a flashback.
The needle should cannulate
the vein by about 1 - 2 cm to give stability and prevent blood leaking out
around the needle. The left thumb may now be moved to hold the needle holder or
syringe in position.
With a needle and syringe the desired volume of blood is
drawn up into the syringe using gentle suction. At this stage care should be
taken not to pull the needle out of the vein prematurely.
With a vacutainer system the
needle holder is held firmly and the first specimen container pressed onto the
internal needle. When this is done the position of the needle holder must be
secured to prevent the needle being pushed through the vein. It is essential
that the specimen container is not penetrated before the needle is in the vein,
if this occurred air would be drawn into the specimen container filling the
vacuum.
With vacutainers the correct
volume of blood should be drawn into the container automatically. If subsequent
specimens are required the needle holder is secured with the left finger and
thumb, the full specimen bottle removed and the next one pushed onto the
internal needle. It is important to follow the manufacturers
recommendations on the order in which the specimen bottles are filled. If this
is not done fluids from one container may adversely effect
the quality of a later blood sample.
Once the last specimen is collected the tourniquet is
released. A dry swab is placed over the entry site of the needle; no pressure
is applied until the needle is out of the vein. The instant the needle is out
of the arm `white finger nail pressure` is applied to the site for three
minutes to ensure haemostasis. Throughout the procedure the systemic condition
of the patient is monitored.
If a needle and syringe system has been used the blood
specimen will be transferred into the appropriate containers up to the marked
volume lines. Specimen containers should be gently inverted 8 to 10 times to
mix additives with blood.
A small sterile elastoplast
may be applied over the puncture site, finally all used equipment must be
safely disposed of.
Safe practice
The principle risks to the nurse are needle stick injury or being splashed with blood in the eye. Hepatitis B is more transmissible than HIV, so any nurse working with body fluids should be vaccinated against Hepatitis B and have their antibody levels checked. Hepatitis C is also a growing threat with no vaccination currently available.
Perhaps the main risk to the nurse is posed by
unpredictable patients who may move or otherwise thrash around during the
procedure, (
If an inoculation injury does occur the wound should be
encouraged to bleed. This can be helped by squeezing around the puncture site
to "milk" out as much blood as possible, it should also be held under
warm running water. Both of these measures are designed to wash out as many
possible infective agents as possible. Patient details should be recorded on an
accident form and a medical opinion taken, usually through the occupational
health department.
Anonymous.
Venepuncture. Nursing
Standard. 13(36):supplement 1-2, 1999 May 26
Black F. Hughes
J. Venepuncture. Nursing Standard. 11(41):49-53, 1997 Jul 2.
De Laune S. Risk reduction through
testing, screening and infection control precautions. Infection control and
hospital epidemiology. 11 (10): 563-5, 1990 Oct.
Stevenson B. Venepuncture. Community Nurse. 3(9):21-2, 1997 Oct.
Venepuncture. (Notes)
Read
through these notes after you have attended a classroom session or watched the
video and read through the above article. Make additional comments on the right
hand side of the page of any
points that come to mind as you read.
Tests
* haematological
* biochemical
* immunological
Treat
person as an
individual
SAFE PRACTICE
Needle
stick injury
* Hepatitis B and C
* HIV
First aid
* encourage bleeding
* squeeze the area
* hold under warm
running water
* soak in iodine
Universal
precautions
Seamless
latex gloves
Unpredictable
patients
Goggles
USE OF TOURNIQUET
* greater than venous
pressure
* lower than
arterial
* veins should
feel "bouncy"
SELECTION OF A VEIN
Palpation
Visualisation
Antecubital fossa
* palpate from side
to side
* palpate up and
down
* learn the
position of the vein
* check both arms
Never
puncture an arterio-venous fistula
Skin
cleaning with alcohol - allow time to dry
TEMPORARY VENOUS ACCESS
Anchor the
vein
Insert
along the line of vein
Pointed tip
of needle first
Angle of
entry into the vein - about thirty degrees
Continuous
movement
Cannulate for about one to two
centimetres
Secure the
needle position
Adults -
green needle, (21 G)
ALTERNATIVE SYSTEMS
Vacutainer type systems
WITHDRAWAL OF THE NEEDLE AND FURTHER MANAGEMENT
Tourniquet
is released
Folded
gauze swab or cotton wool ball
No pressure
until needle is out
"White
finger nail pressure"
- two minutes
Do not bend
arm
A small
sticking plaster
MANAGEMENT OF THE SPECIMEN
Remove
needle
Transferred
to the specimen bottles - no forcing
Citrate
bottles - roll
DISPOSAL OF MATERIALS
58% of needle stick injuries - needles were cut, broken or recapped
Dispose of
the cap beforehand
Puncture
resistant containers
Do not
overfill
Puncture
proof containers -
reduce related injuries three fold
DEALING WITH BLOOD SPILLAGE SHOULD IT OCCUR
Seamless
gloves, apron
Sprinkle on
enough hypochlorite granules to soak it up
Granules
should be left on the spillage for at least two minutes
Remove into
a clinical waste bag
Scoop and
scraper
Clean area
with a general purpose detergent
Broken
glass - forceps
CONCLUSION
Safe for
nurse and patient
Accurate
diagnostic results
COMMENTS
Venepuncture
Anxiety
Explanation
of the procedure in broad terms before starting
Importance
of a professional, "competent" approach
Recognise
the problem as real and treat as such
Needle Phobia
Use of
desensitisation techniques
Allow
selected patients to familiarise themselves with the equipment to remove fears
based on misconceptions
Use of
local analgesic cream, (especially for children)
History of fainting
Take the
specimen with the patient lying down
Use
diversionary techniques to distract the patients
attention, eg. asking
questions
Elderly people with collagen loss
"Anchor"
the vein with the left thumb
Make sure
the needle is precisely in line with the vein
Obesity and/or hidden veins
Take time
to learn the position of the vein by palpation
Ask the
patient to squeeze on something in their hand
Gently tap
or rub the area - do not slap
Use a
sphygmomanometer cuff instead of a tourniquet inflated to diastolic pressure,
Immerse the
arm in warm water
Consider
use of an alternative site, eg. back
of the hand or ankle
Stages in the procedure using needle and syringe
Appropriate explanation to
the patient
Assess degree of expected
patient compliance
Application of tourniquet
Palpation of candidate veins
Learn the position of chosen
vein
Clean the skin with
unidirectional swabbing
Allow time for antiseptic to
dry
"Anchor" the vein
Line the needle up with the
vein, go in at about 25 - 30`
Insert the needle about 1-2 cm into the vein
Observe the flashback for
conformation of entry
Stabilise syringe and needle
Withdraw required volume of
blood
Release tourniquet
Apply dry
swab over the entry site
Withdraw
needle
Immediately
apply white finger nail pressure
Ensure
haemostasis
Asepsis is maintained at all times
Use of vacutainers
This has
the advantage of protecting the practitioner from the blood as it is
transferred from the vein directly into the specimen container.
Stages in the procedure
A needle is
screwed into the hub, the sheath is left in position
at this stage. The required specimen containers are arranged in the correct
order.
The
tourniquet is applied and the vein selected by palpation. The `line` and
position of the vein is accurately assessed.
The site is
cleaned using an alcohol based swab using unidirectional swabbing
The vein is
`anchored` using the left, (on non - dominant thumb)
The sheath
is removed from the needle and discarded
The hub and
needle are lined up with the vein.
The needle
is advanced into the vein penetrating the skin at an angle of about 25
-30`degrees.
The vein is
`cannulated` by about 1 cm. Once the needle is in the
vein the needle may need to be levelled off slightly to prevent the needle
penetrating the other wall of the vein.
Once the
needle is in the vein the first specimen container is pushed forward onto the
sealed needle inside the hub. It is essential that the specimen container is
not penetrated before the needle is in the vein, if this is done air would be
drawn into the specimen container. When this is done the position of the hub
must be secured with reference to the vein to prevent the needle being pushed
through the vein.
One
difficulty in learning the vacutainer system is the
lack of a flash back when the vein is first entered. When learning to use the
system a cannular connector may be screwed into the
hub and a green needle fitted to the cannular
connector, this combination should provide a flashback.
When the
specimen bottles are changed it is essential to have a technique for securing
the position of the hub to keep the needle in the same position in the vein.
The
specimens must be collected in the correct order, plain tube for clotted
specimen first, then biochemistry, then haematology. (Additives in the
haematology tube can contaminate the blood in the biochemistry tube,
potentially altering some results.)
Once the
last specimen is collected the tourniquet is released. A dry swab is placed
over the entry site of the needle, no pressure is
applied until the needle is out of the arm. The instant the needle is out of
the arm `white finger nail pressure` is applied to the site for three minutes
to ensure haemostasis.
Throughout
the procedure the systemic condition of the patient is monitored.
Asepsis is maintained at all times
The student will be able to;
Discuss the types of
hypodermic needles, their sizes and individual indications.
Give reasons for the strict
maintenance of asepsis.
Discuss how asepsis will be
maintained in practice.
Describe possible veins which
may be used for venepuncture.
Demonstrate the selection of
an appropriate vein.
Describe the use of the
tourniquet
Discuss the appropriate skin
preparation for the procedure
Demonstrate the correct
method of insertion of the needle.
Discuss the removal of the
needle.
Discuss the correct methods
for transferring blood specimens from
the syringe to the specimen
bottles.
Discuss the protection of the
practitioner and others from the possibility of nosocomial infection.
State
current policy from "Guidance on the management of infections" re. wearing
of gloves.
Describe how any haemorrhage
or haematoma will be managed.
Discuss first aid and
administrative procedures in the event of needle stick injury.
Discuss possible
complications of cannulation, eg. air
embolism, haematoma, infection.
Demonstrate awareness of the
role of the Nurse in relation to the scope of professional practice document
and the code of ethics.
Give the indications for
venepuncture as agreed with local nurse managers