VENEPUNCTURE (PHLEBOTOMY) - DELEGATE NOTES

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Definition and indications ......................................................................................... 3
Equipment ............................................................................................................ 14
Devices ................................................................................................................. 15
Tourniquets ........................................................................................................... 15
Storage and transport ............................................................................................ 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
© 2017 ECG - All rights reserved Course info/Lesson plan & course materials/Venepuncture/Workbook June 2017
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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)
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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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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
• 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…

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