venepuncture (phlebotomy) - delegate

VENEPUNCTURE

(PHLEBOTOMY) -

DELEGATE

NOTES

ECG © January 2018

© 2017 ECG - All rights reserved Course info/Lesson plan & course materials/Venepuncture/Workbook June 2017

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Contents Introduction ............................................................................................................ 3

Delegating and accepting the clinical task .................................................................. 3

Definition and indications ......................................................................................... 3

Consent................................................................................................................... 4

Mental capacity ........................................................................................................ 4

Chaperoning ............................................................................................................ 5

Confidentiality .......................................................................................................... 5

Infection control ...................................................................................................... 5

Anatomy and physiology .......................................................................................... 7

Vein structure .......................................................................................................... 8

Valves ..................................................................................................................... 9

Vein selection ........................................................................................................ 10

Site selection ......................................................................................................... 11

Veins to avoid ........................................................................................................ 12

Associated nerves .................................................................................................. 13

Preparation of the environment .............................................................................. 14

Equipment ............................................................................................................ 14

Devices ................................................................................................................. 15

Tourniquets ........................................................................................................... 15

Lab forms .............................................................................................................. 16

Preparing your patient ............................................................................................ 16

Procedure .............................................................................................................. 17

Improving venous access ....................................................................................... 19

Order of draw ........................................................................................................ 20

Labelling (3) ........................................................................................................... 22

Potential complications ........................................................................................... 22

Needlestick injuries (1, 3) ......................................................................................... 23

Storage and transport ............................................................................................ 24

Documentation ...................................................................................................... 24

Unsuccessful venepuncture ............................................................................... 24


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References ............................................................................................................ 25

Introduction These delegate notes are designed to supplement your face to face training, providing you with

the theoretical foundation to enable you to safely practice venepuncture.

Delegating and accepting the clinical task Blood tests used to be performed exclusively by medical staff, however with venepuncture becoming one of the most common procedures in healthcare, it is a role that can now be undertaken by all healthcare professionals, including unregistered practitioners. (1) Venepuncture must only be carried out on the direction of a member of clinical staff. The

clinician completes a request for a blood test and then delegates to a suitably trained

colleague. The clinician remains accountable for the appropriateness of this delegation, and for

ensuring the person who does the work is competent to do so. (2)

Once delegated to, those who perform venepuncture are responsible for ensuring they have received the correct training and have documented, supervised practice in which another competent practitioner has deemed them competent to perform the skill unsupervised. The onus is also on individuals to ensure that their knowledge and skills are maintained and updated, and to recognise and work within their limitations. (1)

Venepuncture is a skill regulated by the Care Quality Commission (CQC) - practitioners must be registered with CQC or work for an organisation registered by CQC. (13)

All staff must operate within the policies, protocols and guidelines of their particular organisation.

Definition and indications Venepuncture is the procedure of inserting a needle into a vein, usually to obtain blood.

Blood analysis is one of the most important and commonly used diagnostic tools available to clinicians. A sample of blood is sent to the laboratory for one of the following types of analysis; Haematology, Biochemistry, Immunology or microbiology. (9)

Blood test may be taken for • Diagnostic purposes

• Monitor levels of blood components • Assess organ function • Monitor levels of drugs • Monitor response to medical treatments (e.g. fluids, drugs) • Cross match for a blood transfusion • Screen for infection • Genetic screening


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Consent It is a general legal and ethical principle that valid consent must be obtained before starting any treatment, investigation, or providing personal care for a person. (6) This includes venepuncture. Consent must be:

a) Given by a competent person b) Voluntary c) Informed

Informed Consent This is when the healthcare professional has given the patient full information about the procedure and the risks so that they understand what they are consenting to. Practitioners need to ensure all aspects of “informed consent” are discussed with the patient. (2) Informed consent can be easily established in a friendly and informative manner. The following points must be discussed: (3)

• What is involved in the procedure

• Why the blood is being taken

• Potential risks and side effects of the procedure

• When the blood results will be available

• Consequences of the procedure e.g. commencement of treatment following the results

Implied consent We assume we have the patient’s consent when the patient sits down and rolls up their sleeve. Implied consent should be avoided as it has no standing in a court of law. (1)

Written consent This is not normally required for a blood test but would be required in specific circumstances, for example if the blood was being provided for research or genetic testing.

Mental capacity (4) The conversation around consent is a good opportunity to assess whether a patient has mental capacity – i.e. is able to understand the conversation and make their own informed decisions. A person’s Mental Capacity may be impaired either temporarily or permanently. Temporary impairment may be due to sedative medications or acute confusion. Longer term impairment may be as a result of dementia, brain injury or a learning disability. Occasionally you may be referred a patient who has dementia who will be accompanied by their relative or carer who may have a power of attorney to make decisions on their behalf. A healthcare professional has the ability to make some decisions in the patient’s best interest. When assessing capacity, the first decision is whether there is impairment of the mind or brain (either temporary or permanent). If so, does this make them unable to make a particular decision? The person will be unable to make the particular decision if they cannot do the following things:

1. Understand the information relevant to that decision, including understanding the likely consequences of making, or not making the decision


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2. Retain that information

3. Use or weigh that information as part of the decision-making process

4. Communicate their decision

If you have concerns regarding a person’s capacity to make a decision, discuss with a clinician to get further advice

Chaperoning Patients may find any examination distressing, in particular if it involves the need to undress or

be touched. It is good practice to offer all patients a chaperone for any examination or procedure.

The chaperone serves several functions:

1) It acknowledges the patient’s vulnerability, and provides support to the patient 2) Provides protection for healthcare professionals against unfounded allegations of

improper behavior 3) The chaperone can identify unusual or unacceptable behaviour on the part of the

healthcare professional thus protecting the patient from abuse (5)

It is important to document that a chaperone was present and either name/or initials of the chaperone. If the patient is offered a chaperone and declines it is important to record that the offer was made and declined.

- For more information, ECG offer chaperoning courses both onsite and online

Confidentiality As with any aspect of care, confidentiality must be maintained. (2)

Infection control Venepunture provides a direct portal of entry for infectious pathogens into the circulation system plus puts the practitioner at risk of exposure the patients blood. The following standard infection control precautions help reduce the risk of healthcare acquired infections (HCAI’s)

• Hand hygiene

Good hand hygiene is the single most important way of preventing the spread of infection. (7) Hand hygiene describes processes that reduce the number of micro-organisms and

includes hand washing and use of alcohol gel. Effective hand hygiene involves making sure

all aspects of the hands have been cleaned.

If hands are visibly soiled or potentially contaminated wash hands with antibacterial soap

and water and dry with single use towels.

If hands are not visibly contaminated, clean with alcohol rub (use 3ml of alcohol rub on the

palm of the hand, and rub it into fingertips, back of hands and all over the hands until dry).


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The National Patient Safety Agency (NPSA) have produced guidelines on how to

clean hands effectively with either soap and water or alcohol based gel. These

pictorial guidelines can be found on www.npsa.nhs.uk

• Personal Protective Equipment (PPE)

Standard infection control precautions advise that staff should wear protective clothing

appropriate to the clinical activity. In venepuncture, it is appropriate for clinicians to wear

gloves and a disposable apron. (9)

NICE (2012) states that “Disposable plastic aprons should be worn when there

is a risk that clothing may become exposed to blood, body fluids, secretions or

excretions, with the exception of sweat” (8)

• Gloves

The National Institute for Clinical Excellence (2012) states that: “Gloves must be worn for

invasive procedures, contact with sterile sites and non-intact skin or mucous membranes,

and all activities that have been assessed as carrying a risk of exposure to blood, body fluids,

secretions or excretions or sharp or contaminated instruments”. (8)

The World Health Organisation advise that health workers should wear well fitting, non-sterile gloves when taking blood; they should also carry out hand hygiene before and after each patient procedure, before putting on and after removing

gloves.

Natural latex rubber (NLR) proteins found in latex gloves can cause severe allergic reactions – following a risk assessment, if latex gloves are selected they must be low protein. Neoprene or nitrile are good alternatives to NLR showing comparable barrier performance. (15)

Vinyl gloves can be used to perform many tasks in the health care environment. However, depending on the quality of the glove, vinyl may not be appropriate when handling blood, blood-stained fluids, cytotoxic drugs or other high risk substances. (15)

Please check the local policy for your workplace for further guidance

Put on close fitting, non-sterile gloves. Gloves should be close fitting otherwise dexterity will

be impaired. Use one pair of gloves per procedure or patient.

To support compliance with hand hygiene in the workplace, health care workers should meet the following standards while working: (15) • keep nails short, clean and polish free. Artificial nails or nail extensions must not be worn • avoid wearing wrist watches and jewellery • avoid wearing rings with ridges or stones (a plain wedding band is usually acceptable, but refer to local policies) • cover any cuts and abrasions with a waterproof dressing • wear short sleeves or roll up sleeves prior to hand hygiene (refer to local dress code or uniform policies)

http://www.npsa.nhs.uk/


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• Aseptic Non-Touch Technique (ANTT)

ANTT is a process that seeks to prevent or reduce micro-organisms from entering a vulnerable body site or during the insertion of invasive devices.

ANTT reduces the risk of an infection developing as a result of the procedure.

Adhering to an ANTT means that once the skin has been cleaned, only the sterile needle then comes into contact with that area.

• Skin cleansing

The use of an appropriate skin disinfectant will reduce the number of micro-organisms at the site of insertion.

Skin cleansing with 2% chlorhexidine in 70% isopropyl alcohol is recommended. Chlorhexidine is an anti-microbial agent that has been shown to reduce the risk of infection. Clean the site for 30 seconds and allow to dry completely (30 seconds). Apply firm but gentle pressure. DO NOT touch the cleaned site or you will need to clean the site again. (3)

• Sharps disposal

There are a number of laws that require employers to protect health care workers from sharps injuries. The overarching law is the Health and Safety at Work etc. Act 1974. The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013, enforce this act. Health and Safety regulations (2013) now state that where a sharp is required the use of safer sharps (incorporating protection mechanisms) should be used where reasonably practical. The term ‘safer sharp’ means medical sharps that incorporate features or mechanisms to prevent or minimise the risk of accidental injury. For example, a range of syringes and needles are now available with a shield or cover that slides or pivots to cover the needle after use. (14) The correct sharps disposal procedure should be adhered to in accordance with policies and procedures within the workplace. To minimise the risk of injury, sharps should never be re-sheathed and should be discarded into an appropriate sharps bin immediately after removal from the patient. Place the sharps bin within easy reach, no more than one arms distance away from the client. They should not be filled above two-thirds full (there is a mark on the side indicating the fill line).

• Blood spills

Use of the vacutainer system reduces the risk of blood spillage by drawing the blood directly into the tube however, there is still a risk of blood spills with this procedure. Blood spills must be dealt with quickly and safely to minimise the infection risk, follow your workplace’s written policy for blood spills.

Anatomy and physiology The Heart The Heart is a four-chambered pump split into - the top two chambers (atrium), bottom two (ventricles) and into the left and right side.


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Designua/Shutterstock.com

The role of the right side is to pump deoxygenated blood to the lungs. Blood returns to the right atrium from the inferior and superior vena cava where it flows down into the right ventricle and then is pumped to the lungs via the pulmonary artery. The reoxygenated blood is returned to the left side of the heart via the Pulmonary Vein to the left atrium, it flows into the left ventricle which then pumps the reoxygenated blood around the rest of the body. (1) Blood is carried to the body’s tissues via blood vessels. Arteries carry oxygenated blood away from the heart and veins carry deoxygenated

blood back to the heart.

Vein structure


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NelaR/Shutterstock.com

Veins consist of three layers:

The tunica externa is the protective outer layer of the vein and consists of connective tissue which surrounds and supports the vessel.

The tunica media is the middle layer of the vein and is composed of muscular tissue and nerve fibres that can stimulate the veins to contract or relax. Stimulation of this layer by changes in temperature, mechanical stimulation (e.g. introducing the needle into the vein) can produce spasms which can make venepuncture more difficult.

The tunica interna is the inner lining of the vein and is constructed of smooth endothelial cells which facilitates the passage of blood cells etc. In veins this inner lining has valves which prevent the backflow of blood and aid the blood return back to the heart. They are present in larger blood vessels and at points of branching (bifurcation).

Arteries have the same three layers, however because arteries transport blood away from the heart under pressure, they have a thicker tunica media to withstand this pressure. (9)

It is very important not to inadvertently puncture an artery during venepuncture.

To do so would cause significant discomfort and complications. (1)

Valves Valves can be seen as noticeable bulges in the veins and are usually found at bifurcation points

(junctions). The practitioner needs to learn to palpate the vein to check for the presence of

valves and ensure that venepuncture occurs away from the valve in order to facilitate collection

of the blood sample.


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Avoid valves! They will be more painful and will prevent the withdrawal of blood.

Vein selection (10) The veins normally used for venepuncture are those found in the inner elbow, known as the antecubital fossa (ACF). They are usually of a good size and are capable of providing copious and repeated blood specimens. They are also easily accessible, thus ensuring that the procedure can be performed safely and with the minimum of discomfort for the patient. The main veins of choice are:

• Median cubital vein

• Cephalic vein • Basilic vein

The median cubital vein may not always be visible, but its size and location make it easy to palpate. It is also well supported by surrounding tissue, which prevents it from rolling under the needle.

The cephalic vein is located on the lateral aspect of the wrist, and rises from the dorsal veins and flows upwards along the radial border of the forearm, crossing the antecubital fossa as the median cephalic vein. Care must be taken to avoid accidental arterial puncture, as this vein crosses the brachial artery. It is also in close proximity to the radial nerve.

The basilic vein, originating in the ulnar border of the hand and forearm, is often avoided as a site for venepuncture: this is for good reason. Although the basilic vein may be prominent (particularly in men), it is awkward to access and it is not well supported by subcutaneous tissue and tends to roll easily. These features make venepuncture of the basilic vein difficult. Care must also be taken to avoid accidental puncture of the median nerve. (10)

Of the three veins the median cubital is the ideal choice for venepuncture. It is easily visualized, located and palpated and is known as the “Phlebotomist’s friend”.


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Blamb/Shutterstock.com

Site selection The choice of vein is an important step. The best choice is a vein which appears healthy, is easily detected, accessible and unused. The most visible vein is not always the best option. (10) As arteries and nerves can be in similar locations care must be taken during assessment to avoid them. (9)

Choosing the vein is a 2-stage approach which includes:

1. Visual inspection

To identify factors that could cause problems such as:

• Areas of infection • Thin and fragile veins

2. Palpation

In order to

• Determine the location and condition of the vein • Distinguish from arteries, tendons and nerves so reduces the risk of damage to

one of these structures • Identify the presence of valves

To palpate - place two fingertips over the vein and press lightly. Release pressure to assess for elasticity and rebound filling. When you depress and release an engorged vein, it should spring


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back to a rounded full state. (10) Try and use the same fingers for palpation as, over time, this will increase sensitivity. The thumb should not be used – it is not as sensitive and has a pulse which may lead to confusion in distinguishing arteries from veins. (10)

Choose veins which are:

Soft, bouncy, refill when depressed, well supported by subcutaneous tissue, easily detected.

Also, listen to the patient – they will be able to advise you which veins may have been successful or unsuccessful in the past.

Arteries have much thicker walls so will feel more elastic on palpation. You will also feel a pulse which is caused by the artery expanding in response to the blood being pumped from the left ventricle. (1)

Tendons feel very rigid, do not have a pulse and move when the patient moves their fingers.

Veins to avoid

When making a choice, avoid veins that are: (9)

Arterial puncture Arterial puncture is caused by inadequate assessment and poor technique. It will lead to bright red blood pulsating into the tube. If an artery is punctured the needle should be removed immediately and digital pressure applied for 5 minutes followed by a pressure bandage for a further 5 minutes. The tourniquet must not be re-applied to the arm for at least 24 hours. The patient will need to be observed, assessed and receive medical supervision, and the incident recorded in the patient’s notes. (10)


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Associated nerves Care must be taken during the assessment and procedure to avoid nerves. (9)

The median nerve

This nerve passes down the inside of the arm and crosses the front of the elbow. The median

nerve supplies muscles that help bend the wrist and fingers. It is a main nerve for the muscles

that bend the thumb. The median nerve also gives feeling to the skin on much of the hand

around the palm, the thumb, and the index and middle fingers.

Blamb/Shutterstock.com

The ulnar nerve

This nerve passes down the inside of the arm. It then passes behind the elbow, where it lies in

a groove between two bony points on the back and inner side of the elbow. The ulnar nerve

supplies muscles that help bend the wrist and fingers, and that help move the fingers from side

to side. It also gives feeling to the skin of the outer part of the hand, including the little finger


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and the outer half of the back of the hand, palm, and ring finger. When the elbow is bumped

over the ulnar nerve, it's often called hitting the ‘funny bone’.

The radial nerve – This nerve passes down the back and outside of the upper arm. The radial nerve supplies muscles that straighten the elbow, and lift and straighten the wrist, thumb, and fingers. It gives feeling to the skin on the outside of the thumb and on the back of the hand and the index finger, middle finger, and half of the ring finger. Careful site selection and insertion of the needle will minimise the risk of nerve injury. The needle

should be inserted at less that 40° and blind probing avoided. (10)

In the event of damage to the nerve, the patient will experience sharp pain or burning sensation

down their arm and potentially numbness and tingling to fingers. The needles should be removed

immediately and guidance given if pain/numbness for more than a few hours. The event should

be documented in the patient’s notes.

Preparation of the environment (3, 10) Ensure the environment has been prepared taking into the consideration the following points-

• Quiet • Comfortable • Appropriate temperature - a cold environment will cause vasoconstriction and will be difficult

to palpate the vein • Clean and tidy • Well lit • Private • 2 chairs • Sink

Equipment (3) Place equipment safely and within easy reach on a trolley or tray and have spare equipment to hand. You will need:

• Specimen request form • Disposable tray • Alcohol hand gel • Alcohol swabs (refer to local policy) • Non-sterile gloves • Apron • Tourniquet • Gauze swabs • Sterile needle or winged device • Single use vacutainer needle holder • Vacuumed specimen tubes • Sterile plaster • Sharps box • Leak proof specimen bags

Check expiry dates and packaging to ensure sterility has been maintained. All sterile equipment must be single use. (3)


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Devices There are a number of vacuum systems that can be used for taking blood samples. This is the safest method for taking blood – offering a completely closed system for the process so reducing the risk of contamination. They are simple and cost effective. (10) Blood collection systems with safety devices are now readily available and should be used for all procedures. (12) The standard needle gauge to use is 21 gauge which enables blood to be withdrawn at a reasonable speed without undue discomfort to the patient or damage to the blood cells. (10) For smaller veins, if the needle is too large it can damage the vein so a smaller gauge (23 gauge) may be needed.

Remember - The smaller the gauge of the needle the larger the gauge number Safety needle (21 gauge) and vacutainer holder

• Easy to use with larger veins • Cheaper than butterfly devices

Winged infusion device (butterfly) – 21-23-gauge needle

• Good for blood drawing from patients with small or fragile veins • Allows better precision than needle

Care must be taken to choose the right gauge needle. If the needle is too large for the vein for which it is intended, it will tear the vein and cause bleeding (haematoma); if the needle is too small, it will damage the blood cells during sampling. (3)

Tourniquets


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There are several types of tourniquet available. The tourniquet material should be cleanable and latex free. Single use tourniquets should be used where possible. (12) Fabric tourniquets that cannot be cleaned should not be used. (3) The tourniquet should be applied 7-8cm above the antecubital fossa with enough pressure to impede venous flow – if the radial pulse cannot be felt, the tourniquet is too tight. Careful attention needs to be paid to the length of time the tourniquet remains in place. The tourniquet should not be left on for longer than 90 seconds - leaving a tourniquet on for longer may cause damage to blood cells that can cause potassium to be released thus leading to inaccurate blood

results. (1)

Lab forms (11) Traditionally paper “blood forms” were used to request blood tests. Many clinical settings now use computer based systems - with the clinician completing an electronic request form that the practitioner then prints off when the patient attends for the blood test appointment. Blood request forms must contain the following information:

• Surname and forename • NHS number (depending on local policy) • Date of birth • Gender • Sample date and time • Name of clinician requesting blood • Specimen type • Tests required • Relevant clinical details

These blood forms will often advise the practitioner what colour bottle they will need for the test. In your preparation for venepuncture, check the request for the specific test(s) required. Be certain that you understand what type of blood specimen is required, what tube is needed and the amount of specimen required (if in doubt, call the appropriate lab).

Preparing your patient (3) Ensure the following steps are followed:

• Introduce yourself and ask patient to confirm their name and date of birth

• Check the lab form matches the patient identity

• Check for allergies, phobias, previous problems, preferred arm/contraindications

• If the patient is anxious or afraid, reassure the person and ask what would make them more comfortable

• Make the patient as comfortable as possible

• Discuss procedure and gain informed consent


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Also:

• Offer chaperone

• Check whether they have fasted or altered their medication regime if necessary

Procedure (3, 10)

Action Rationale

Pre-procedure Wash hands To ensure hands are not contaminated to

prevent cross infection. Approach patient in a confident manner and explain and discuss the procedure with the patient.

To ensure that the patient understands the procedure and gives his/ her valid consent.

Allow the patient to ask questions and discuss any problems which have arisen previously.

Anxiety results in vasoconstriction; therefore, a patient who is relaxed will have dilated veins, making access easier.

Consult with patient regarding arm preference. Check for allergies.

To involve the patient in the treatment. To acquaint the nurse fully with the patient’s previous venous history and identify any changes in clinical status e.g. Mastectomy.

Check the identity of the patient matches the details on the request form by asking their full name and date of birth (and if available check their identity bracelet).

To ensure sample taken from the correct patient.

Assemble the equipment necessary for venepuncture.

To ensure time is not wasted and that the procedure goes smoothly without unnecessary interruptions.

Carefully wash hands using soap and water or bactericidal hand rub and dry before commencement.

To minimize the risk of infection.

Check hands for visibly broken skin and cover with a waterproof dressing.

To minimise the risk of contamination to the practitioner.

Check all packaging before opening and prepare equipment on the chosen clean receptacle/ area.

To maintain asepsis throughout and check that no equipment is damaged.

Procedure Take all the equipment to the patient exhibiting a competent manner

To make the patient at ease with the procedure.

Support the chosen limb on a pillow To ensure patient’s comfort and facilitate venous access.

Apply the tourniquet to the upper arm on the chosen side, making sure it does not obstruct arterial flow. (If the radial pulse cannot be palpated then the tourniquet is too tight).

To dilate the veins by obstructing venous return.

Select the vein by careful palpation to To prevent inadvertent insertion of the


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determine size, depth and condition. needle into other anatomical structures. Release the tourniquet. To ensure patient comfort. Select the device, based on vein size, site and volume of blood to be taken. Use a 23g winged infusion device for small veins.

To reduce damage or trauma to the vein and prevent haemolysis.

Wash hands with bacterial soap and water or use bactericidal alcohol hand rub.

To maintain asepsis and minimize the risk of infection.

Put on gloves. To prevent possible contamination of the practitioner.

Clean the patients skin using appropriate skin preparation (70% alcohol, 2% chlorhexidine impregnated swab for 30 seconds) and allow to dry for further 30 seconds.

To maintain asepsis and minimise risk of infection.

Re-apply the tourniquet. To dilate the veins by obstructing venous return.

Anchor the vein by applying manual traction on the skin 2-5cm below the proposed insertion site.

To immobilise the vein. To prevent counter tension to the vein which will facilitate a smoother entry.

Insert needle smoothly at angle of 30 degrees or less– the angle will depend on size and depth of vein.

To facilitate a successful, pain-free venepuncture.

Reduce the angle of descent of the needle as soon as a flashback of blood is seen in the vacutainer device or when entry to the vein wall is felt.

To prevent advancing too far through vein wall and causing damage to the vessel.

Slightly advance the needle into the vein if possible.

To stabilise the device in the vein and prevent it from becoming dislodged during withdrawal of blood.

Do not exert any pressure on the needle. To prevent a puncture occurring through a vein wall.

Withdraw the required amount of blood using vacuumed blood collection system in correct order (see ‘order of draw’ section for more info).

To minimize the risk of transferring additives from one tube to another and bacterial contamination of blood cultures.

Release the tourniquet. To decrease pressure on the vein. Place swab over the puncture point. To apply pressure.

Remove the needle but do not apply pressure until the needle has been fully removed.

To prevent pain on removal and damage to the interna of the vein.

Apply digital pressure directly over the puncture site. Pressure should be applied until bleeding has ceased; approximately 1 minute or longer may be required if current disease or treatment interferes with clotting mechanisms. The patient may apply pressure with the finger but should be discouraged from bending the arm.

To prevent leakage and haematoma formation.

Activate safety device and then discard the needle immediately in the sharps bin.

To reduce the risk of accidental needlestick injury.

Gently invert the blood tubes as per To prevent damage to blood cells and to mix


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manufacturer’s instructions. with additives. Label the bottles with the relevant details at the patient’s side.

To ensure that the specimens from the right patient are delivered to the laboratory, the requested tests are performed and returned to the patient’s records.

Post procedure Inspect the puncture point before applying a dressing.

To check the puncture point has sealed.

Confirm whether the patient is allergic to adhesive plaster.

To prevent an allergic reaction.

Apply an adhesive plaster or alternative dressing.

To cover the puncture point and prevent leakage or contamination.

Ensure that the patient is comfortable. To ascertain whether patient wishes to rest before leaving or whether any other measures need to be taken.

Discard waste – making sure it is placed in the correct containers. Remove gloves and clean hands.

To ensure safe disposal. To prevent re-use of equipment.

Follow local procedure for collection and transportation of specimens to the laboratory.

To make sure specimens reach their intended destination.

Document the procedure in the patient’s records.

To ensure timely and accurate record keeping.

Improving venous access Several techniques can be used to improved venous access

Try Reason

Lowering the arm below the heart Increases blood flow to the vein

Clenching the fist To encourage venous distention – avoid pumping which can damage cells and

release potassium which would affect blood results

Warming arm gently Encourages veins to dilate and fill.

If someone is dehydrated, their veins may be sunken/flat and hard to palpate.


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Troubleshooting (10)

Order of draw

There are different types of tubes used in blood drawing. Each tube is identified by the colour

stopper and additive within the tube, each additive has a particular function.

When taking blood samples, it is essential to take them in the correct order to avoid cross-contamination of additives between the tubes. As colour coding and tube additives may vary, verify recommendations with your local laboratories. (3) Most manufacturers will have a coloured chart available that will show which blood bottle is required for the test and the correct order of draw. It is recommended that this chart is displayed in your clinical area to prevents mistakes being made. (1)


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Example of order of draw chart

Take in order starting at top of chart first and working down.

Each bottle must be gently inverted several times to mix the blood with the additives thoroughly. Do not shake the tubes as this will damage the blood cells and invalidate test results.

= One inversion


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Labelling (3) • Do immediately after you’ve taken the sample, never before • Label bottles with information required by the lab – typically patient’s surname, forename,

date of birth plus date and time of when blood collected • Complete request form including time sample taken • Finally sign/initial the form in bottom right corner. • Do all this before leaving the patient

Potential complications (3, 9, 10) There are a number of potential problems associated with the practice of venepuncture:

Phlebitis Infection at the venepuncture site is rare. Following good infection control practice will reduce the risk of phlebitis. The site should be covered for 15-20 minutes after the procedure. Accidental damage To the nerve, tendon or artery if these have not been identified during visual inspection/palpation. This can result in pain and damage/complications for the patient as well as loss of confidence for the practitioner. This is rare (1:10,000 venepunctures). To minimise damage to the other structures the angle of the needle insertion should be less than 40° and blind probing should be avoided. Haematoma This is caused by the infiltration of blood into the tissues and this is the most common complication arising from venepuncture. This may occur as a result of poor technique on the part of the practitioner including

• Overshooting the vein • Failure to release the tourniquet before removing needle • Inadequate pressure on the venepuncture site once the needle has been removed • Bending the arm on completion of the procedure

Selecting a needle gauge smaller than the vein will reduce the risk of puncturing the vein. If a haematoma occurs during the procedure remove the blood bottle, release the tourniquet, remove the needle and apply pressure for 2-3 minutes. Prolonged bleeding time This may be due to a medical condition (clotting disorder such as haemophilia) or drug therapy (e.g. anticoagulation medication). Practitioners should ensure they are aware of the


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patient/client’s relevant drug and medical history prior to performing venepuncture. Incorrect or lack of details on the request card and/or sample This increases the likelihood of errors occurring; any discrepancies will cause the sample to be rejected by the laboratory, necessitating repetition of the procedure.

WARNING: the wrong patient details on the card can result in a patient receiving unnecessary or dangerous treatment. All samples must be correctly labelled and the details must correspond with those on the request card. The patient’s details, both on the request form and the specimen bottle should be ascertained using the Trust’s policy for the positive identification of patients. Insufficient sample/wrong specimen bottle The laboratory will not be able to process the sample necessitating repetition of the procedure. However, if it was difficult to obtain the blood sample from the patient, check with the laboratory staff whether they might be able to process the smaller sample without it compromising the results. Needlestick (sharps) injury Use of vacutainer systems helps to reduce the incidence of this occurring. Needles must not be re-sheathed, and practitioners must adhere to the Trust sharps policy. In the event of a needlestick injury, please refer to the section of needlestick injuries. Blood spillage Use of the vacutainer system reduces the risk of blood spillage since the blood is drawn directly into the evacuated sample tube. However, there is a risk of blood spurting from the vein when venepuncture commences. Please refer to section in ‘Infection Control’ for the procedure of cleaning blood spills. Needle or blood phobia If the patient has a needle or blood phobia it might make it harder to take blood from them. They might also faint at some point during the procedure. It is important to establish whether the patient has had previous problems with venepuncture. Approaching the patient in a confident manner and giving clear and comprehensive information may help to reduce the patient’s level of anxiety. (1) Distraction is a useful technique for the mildly anxious. Fainting In the event of a faint, if possible lie the patient down with their legs raised. This will ensure the blood is returned to the brain where it is needed. Slowly sit the patient back up after several minutes to ensure they have recovered.

Needlestick injuries (1, 3) Injuries from needles used in medical procedures are sometimes called needlestick injuries or sharps injuries. Sharps can include other medical supplies such as scalpels. A sharps injury is an incident in which the sharp penetrates the skin. Sharps contaminated with infected patient’s blood can transmit up to 20 types of diseases including hepatitis B, hepatitis C and HIV

If you sustain a needlestick injury follow this process immediately:

• Encourage the wound to bleed • Wash the wound using running water and plenty of soap • Don’t scrub the wound while you are washing it • Don’t suck the wound


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• Dry the wound and cover it with a waterproof plaster or dressing

You should then attend the nearest A&E department or contact your employer’s Occupational Health service.

The healthcare professional treating you will assess the risks to your health and ask you about your injury. Samples of your blood may be tested for Hepatitis B, Hepatitis C or HIV. Your healthcare professional may also arrange to test samples of the other person’s blood if they give their consent.

If you are deemed to be at low risk, you may not need any treatment. If there’s a higher risk, you may need:

• Antibiotic treatment • Further vaccination against Hepatitis B

Avoid a needle stick injury at all cost by good practice when dealing with sharps and remaining vigilant throughout all procedures

Practitioners undertaking venepuncture must be vaccinated against hepatitis B

Storage and transport Samples should be securely stored in a designated sample collection area, away from direct light

and heat sources (e.g. window sill) and out of reach of patients. The local laboratory guidance

indicates which sample types should be refrigerated and which should be stored at room

temperature.

Documentation Professional and succinct records must be maintained; not only for clinical reasons, but also documentation acts as a safeguard against formal complaints or, in extreme cases, legal action.

Document:

• Chaperone offered/present - with name/initials • Consent gained • Blood sample taken • Which arm and site – e.g. left ACF • Note any issues

Unsuccessful venepuncture There should be no more than 2 unsuccessful attempts by the same practitioner on one patient at any given time. If the attempts are unsuccessful, the patient must be reassured and referred to another more experienced practitioner.

The healthcare professional requesting the sample must be informed if the sample was not taken and it might delay or affect treatment.


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References

1 Brooks, N. (2014) Venepuncture and Cannulation. MK: Cumbria 2 Nursing and Midwifery Council (NMC) (2015) The Code- Professional standards of practice and behaviour for nurses and midwives (online) Available at –https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf 3 World Health Organisation (2010) WHO Guidelines on drawing blood: best practices in

phlebotomy. [online] Available at

http://www.who.int/injection_safety/phleb_final_screen_ready.pdf

4 Mental Capacity Act (2005) (online). Available at -

http://www.legislation.gov.uk/ukpga/2005/9/section/3

NOTES -

http://www.legislation.gov.uk/ukpga/2005/9/section/3


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5 Medical protection Society (2016) (online). Available at -https://www.medicalprotection.org/uk/resources/factsheets/england/england-factsheets/uk-chaperones 6 Department of Health (2010) Reference Guide to consent for examination and treatment (online). Available at -https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf 7 World Health Organisation (2009) WHO guidelines on Hand Hygiene in Healthcare; a summary (online). Available at http://apps.who.int/iris/bitstream/10665/70126/1/WHO_IER_PSP_2009.07_eng.pdf 8 National Institute for Clinical Excellence (2012) Infection: Prevention and control of healthcare-associated infections in primary and community care. (online) Available at http://www.nice.org.uk 9 Lavery, I. Igram. P. (2005) Venepuncture: best practice. Nursing Standard. 19,49. 55-65. 10 Dougherty L. Lister S. (2015) Royal Marsden Clinical Procedures (6th Ed). Blackwell Publishing: London. 11 Hospitals and Science, NHS England (2016) (online) Available at

http://hospital.blood.co.uk/media/27451/mpd1108.pdf

12 Royal College of Nursing (RCN) (2016) Standards for infusion therapy (4th Ed.) (online).

Available at - https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/

13 Care Quality Commission (2018) Guidance for providers http://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-4-requirements-where-service-provider#full-regulation

14 Health and safety Executive (2013) Health and Safety (Sharp instruments in Healthcare) regulations 2013 (online). Available at – http://www.hse.gov.uk/pubns/hsis7.pdf

15 Royal College of Nursing (RCN) (2017) Essential practice for Infection Prevention and Control. Guidance for nursing staff (online). Available at - https://www.rcn.org.uk/professional-development/publications/pub-005940

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf

http://apps.who.int/iris/bitstream/10665/70126/1/WHO_IER_PSP_2009.07_eng.pdf

http://www.nice.org.uk/

http://hospital.blood.co.uk/media/27451/mpd1108.pdf

http://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-4-requirements-where-service-provider



http://www.hse.gov.uk/pubns/hsis7.pdf


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