Nuffield Health Venepuncture Training Virtual E - Learn 2021

Nuffield Health

Venepuncture Training

Virtual E - Learn 2021

Session NotesVersion - January 2021

Copyright The Training & Development Consultancy Ltd.

THE TRAINING & DEVELOPMENTCONSULTANCY LTD.

NUFFIELD HEALTH VIRTUAL E-LEARN 2021VENEPUNCTURE PROGRAMME

SESSION NOTES

Learning Outcomes

To describe the anatomy and physiology of veins and associated structures.

To recognise the infection prevention and control aspects.

To discuss the professional and legal aspects.

To describe blood vacuumed systems.

To demonstrate the procedure of venepuncture.

To recognise potential complications.

Copyright The Training & Development Consultancy Ltd. rev January 2021

Page 1


Tunica Adventitia

Tunica Media

Tunica Intima


SESSION NOTES

Anatomy and Physiology

The wall of a vein has three layers.

1. The tunica intima. The innermost layer made up of endothelium, which is in contact with venous blood. The lining is smooth with the exception of one - way valves which prevent backflow of blood and pooling of blood in vessels affected by gravity. Valves can sometimes be detected as small bulges in veins and can often be felt on palpation. The negative pressure associated with venepuncture can cause the valve to close the lumen of the vein, where a valve is detected the venepuncture site should be above the valve. Damage to this lining can result is platelet adherence and thrombus formation.

2. The tunica media. The middle layer in a vein wall, made up of elastic tissue, nerve and muscle fibres. There is less elastic tissue and fewer muscle fibres than seen in arterial walls, making veins more prone to collapse. The nerves in this layer are sensitive to temperature changes and chemical or mechanical irritation which can cause spasm of the vein.

3. The tunica adventitia. The outer layer of a vein wall, made up of collagen, nerves and connective tissue. (cont.)


Page 2


Cephalic vein

Basilic vein

Median cubital vein

Brachial artery

Radial artery

Ulnar artery


SESSION NOTES


Patients taking steroids may have more delicate skin which is prone to damage and those taking anti - coagulants or have a coagulopathy may be more prone to bruising and haematoma.

With age, there is a reduction in subcutaneous fat and collagen, with the epidermis becoming thinner and less elastic. Consequently, the veins may be easier to visualise but can be more mobile (therefore can ‘roll’ more easily), be more fragile and thrombosed. The skin is more fragile making it more prone to tearing and bruising, which needs to be considered when applying counter - traction. The increased mobility of the veins coupled with a less elastic skin may require a greater degree of counter - traction and vein anchoring.

Older veins have an increased peripheral resistance due to calcium deposits and a reduction in elastin. Therefore the lumen of the veins may be reduced possibly requiring a smaller gauge of needle and it may be necessary to reduce the insertion angle.

Thinning of the subcutaneous fat layer increases the risk of hypothermia, and the cold can affect the tunica media (muscle) layer of the vein causing venous spasm.

Key Veins and Arteries of the Arm


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Radial nerve

Median nerve

Ulnar nerve


SESSION NOTES


Key Nerves of the Arm

Commonly the veins in the antecubital fossa (ACF) are used for venepuncture.

1. The basilic vein. Is often the more prominent vein but as it is not well supported by subcutaneous tissue can ‘roll’ more easily. This vein can run in close proximity to the median nerve and the brachial artery.

2. The cephalic vein. Travels along the radial aspect of the forearm into the ACF where is crosses to become the median cubital vein. As it crosses the ACF it also crosses the brachial artery and it is in close proximity to the radial nerve.

3. The median cubital vein is another vein of choice in the ACF.

Veins in the feet are not recommended for venepuncture particularly in diabetic Patients as there may be an increased risk of tissue necrosis. The metacarpal veins on the dorsum of the hand are also not recommended as a first option.

The main arteries that travel the arm are the brachial, ulnar and radial.The main nerves that travel the arm are the median, ulnar and radial.


Page 4



SESSION NOTES

Choosing a Vein

A suitable vein should;- Be soft, bouncy (not thrombosed) and straight- Refill quickly after pressure has been applied and then released- Be well supported (can apply pressure on the vein without it rolling away)- Be palpable

(Not all veins will be visible and the practitioner may have to be guided by palpation)

Veins to be avoided;- If the surrounding area is affected by cellulitis, dermatitis, lymphoedema, bruising, fracture or a cerebrovascular accident- If the Patient has had a mastectomy on that side- If it is thrombosed- If there is an AV fistula or vascular graft

Palpation of a vein - key points;- Palpation should distinguish between veins and arteries / tendons, identify any local valves and assess the condition and location of veins.- Two fingers should be used.- Fingers on the non - dominant side may be more sensitive.- Thumbs should not be used as they have a pulse and could lead to confusion in deciding whether a vessel is a vein or an artery.- Ensure good lighting and a position that does not cast shadows across the ACF.(cont.)


Page 5



SESSION NOTES

Choosing a Vein

Where it is difficult to visualise and / or palpate a vein the following techniques can be used;- Gravity- Gentle tapping- Application of warmth- Application of a tourniquet (which should be removed after a vein has been identified)- It is preferable not to ask the Patient to ‘make a fist’ as this can potentially release intracellular potassium which could lead to a false - high potassium blood result.

In dehydrated Patients it may be easier to locate and access a vein after rehydration.

Note: when taking blood the tourniquet should be tight enough to prevent venous blood leaving the arm and so distending the veins, but not so tight that arterial blood is prevented from entering the arm. If this happens and several bottles of blood are being taken, the vein can collapse. The tourniquet should be disposable, placed approximately 6 to 7cm above the proposed venepuncture site and not be left in place for more than one or two minutes to avoid haemolysis or pooling of blood. Local policy may recommend not using a tourniquet when taking blood tests for calcium.


Page 6



SESSION NOTES

Infection Control

Venepuncture breaches the intact barrier of the skin and involves direct access into the blood stream with a risk of blood - borne infection. Sources of infection can be extrinsic (contamination of sterile items) or intrinsic (poor technique, poor skin disinfection or ineffective operator hand washing).

There are some Patients who may be at a greater risk of infection;- Immunocompromised or immunosuppressed- Older Patients (the rate of epidermal cell replacement in the older Patient can be reduced by more than 50%, resulting in a decreased rate of healing and a compromised skin barrier. The immune system also becomes less responsive with age)- Presence of chronic diseases such as diabetes, vascular insufficiency or cancer- Malnourishment- Presence of invasive devices- Length of stay in hospital

An aseptic non - touch technique (ANTT) must be used where key parts and non - key parts are identified. Key parts should only be in contact with sterile surfaces, Non - key parts can be touched by non - sterile surfaces.

Additional infection prevention and control aspects;- Non - sterile gloves- Plastic apron- Hand hygiene prior to palpation and again before putting on gloves for the procedure- Environment - clean, free from sources of contamination. If possible should not be undertaken during periods of domestic cleaning or high activity (mealtimes)- Sterile equipment should be checked for tamper / integrity prior to use- Patient skin disinfection - if the Patient’s skin is visibly dirty it should be first washed with soap and water. The skin should then be cleaned with 2% chlorhexidine / 70% alcohol using a ‘cross-hatch’ method for a minimum of 30 seconds and allowed to air dry for at least the same amount of time(cont.)


Page 7



SESSION NOTES

Infection Control

Common faults in ANTT during venepuncture can include;- Poor hand hygiene- Ineffective skin disinfection- Using re - usable tourniquets- Blowing or fanning the skin to help evaporation after skin disinfection- Touching the insertion site after skin disinfection- Inadvertently touching a ‘key part’

Disposal of Sharps

The sharps container should be kept in close proximity to where the procedure is being undertaken and the operator should dispose of their own sharps as soon as possible after the procedure. Needles should not be re - sheathed, bent or broken prior to disposal. Safety engineered devices should be used.

Professional and Legal Considerations

Before undertaking venepuncture, practitioners must have received training and have subsequently been assessed a competent, and that competency is maintained.

Practitioners should ensure that the procedure is in the best interests of the Patient and practice within the boundaries of accountability and duty of care.

Informed consent must be gained before undertaking venepuncture. This means providing the Patient with sufficient information to enable them to make a decision to have the procedure or not. Therefore, the practitioner must have a knowledge of the blood tests that have been requested and their significance. In the older Patient, deficits in hearing or sight can affect how that Patient understands procedures and information may need to repeated or reinforced. Practitioners also need to ensure that the Patient has capacity to give informed consent.

The Patient must be correctly identified prior to the procedure and the Patient details checked against the request form.


Page 8



SESSION NOTES

Vacuumed Collection Systems

A vacuumed collection system includes a vacutainer holder (or barrel) onto which is attached a vacutainer needle or butterfly. Both will have a self sealing needle which will puncture and allow blood into the blood bottle. The system avoids decanting or transferring blood from a syringe to a blood bottle. The syringe and needle technique should only be used in exceptional circumstances in adult Patients.

Blood bottles are pre - vacuumed to take up the correct volume of blood and will have a different colour top to identify which blood tests can be taken. There can be some variation between manufacturers so check with your local pathology department.

Some blood bottles contain additives and some do not. It is important when taking more than one bottle of blood to fill them in the order advised by the manufacturer, this is known as the ‘order of draw’ and avoids contamination between bottles. Once the bottles have been filled with blood it is important to check that the correct volume has been taken and to invert (not shake) the bottles the number of times recommended by the manufacturer. Commonly the order of draw would be:

Blood cultures - Aerobic before anaerobic. If there is insufficient blood fill both bottles, the aerobic bottle should be filled in preference to the anaerobic one.

Pale blue - Clotting studies, invert 3 - 4 timesGold - U&E, LFTs, Calcium, TFTs, CRP, invert 5 - 6 timesPurple - FBC, invert 8 - 10 timesLilac - Transfusion tests, invert 8 - 10 timesGrey - ethanol, glucose, lactate, invert 8 - 10 times


Page 9



SESSION NOTES

Steps in A Venepuncture Procedure

Deep breathing, relaxation and distraction can be useful strategies for many anxious Patients. The environment is which the procedure is to be undertaken should afford the Patient privacy, dignity and comfort.

Identify the Patient against the request form.Ensure the Patient has complied with any pre - test requirements such as a fasting blood glucose.Gain informed consent.Assemble equipment (arrange blood bottles in a tray in the order to be filled)Ensure the Patient is comfortable and place the arm on a pillow.Wash hands and identify and palpate a suitable vein.Wash hands and put on gloves.Clean the skin and allow to dry.Apply the tourniquet.Remove the vacutainer needle / butterfly from its packaging and inspect for integrity.Apply traction to the skin below the proposed venepuncture site, do not touch the area that has been cleaned or have your fingers above the proposed venepuncture site.Ensure the bevel of the needle is upwards and insert into the skin at an angle of approximately 300 (or less in older Patient).Once in the vein, reduce the angle slightly and advance the needle a further 1 - 2 mm.If using a butterfly secure with tape.Release traction on the skin.Connect blood bottles as per order of draw with the label facing away from you.During or at the end of the last bottle, release the tourniquet.Place a swab over the puncture site but do not apply pressure until the needle has been removed.Activate the safety device and discard in the sharps container.Ask the Patient (where possible) to keep their arm straight and apply pressure until bleeding ceases. Do not let the Patient bend their arm at the elbow as this can cause bruising.During this time the blood bottles can be inverted and labelled - they must never be pre - labelled. Always label whilst still with the Patient.Once bleeding has ceased, cover the site with a sterile adhesive plaster (checking first for allergies).Check the Patient is feeling well before allowing to stand up.Place bottles in a specimen bag and arrange delivery to the laboratory.Dispose of all equipment.


Page 10



SESSION NOTES

Potential Complications

Pain - by hitting an artery. Remove the tourniquet, then the needle, elevate the arm and apply pressure for at least 5 minutes or until bleeding has ceased. Apply a dressing and do not re - attempt or take a blood pressure on the same arm. Request a medical review.

Pain - by hitting a nerve. As for hitting an artery.

Pain can also be caused by poor technique, large bore devices, insufficient counter - traction, skin puncture before the alcohol has evaporated and applying pressure prior to removal of the needle.

Haematoma and bruising. Can be caused by too steep an angle when entering the vein or over - advancement once in the vein. Other causes may be the use of a large bore device, not releasing the tourniquet early enough, fragile veins or bendng the arm to cease bleeding after venepuncture.

Vasovagal attack (faint). Discontinue the procedure and lie the Patient down. If the Patient has a history of fainting during venepuncture it is advisable to perform the procedure with the Patient lying down

Tips for Gaining Competency

Arrange for your supervised venepunctures as soon as possible after this training session.

Initially choose Patients who are not overly anxious about the procedure.

Initially choose Patients with ‘good’ veins and who are not elderly or on medications that could affect the veins, skin or coagulation.

Initially choose Patients who require between one and three bottles of blood to be taken.


Page 11


CPD Method - Course Attendance Participatory

Date(s) - .................... Number of hours - ....................

Description of the topic(s), key points of the learning activity, how it links to my practice, what I have learnt and how I will apply it to my practice. (Retain certificate of attendance, session notes with learning outcomes as evidence.) -

To which part(s) of the NMC code the CPD related. (Prioritise people, Practise effectively, Preserve safety, Promote professionalism and trust.) -


CPD LOG AND RECORD OF TRAINING ATTENDANCE



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Nuffield Health Venepuncture Training Virtual E - Learn 2021