About Course
Venepuncture is an important skill for anyone who works, or would like to work, in the health or social care sectors, or in the field of scientific research and study.
The difference between venipuncture and phlebotomy is their purpose.
Venipuncture is the process of puncturing a vein with a needle for any medical purpose.
Phlebotomy is venipuncture performed specifically to obtain blood samples for study.
Aim and intended learning outcomes
The aim of this Course is to provide guidance on the theory and practice of venepuncture. After this course, you should be able to:
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▶Understand and describe the anatomy and physiology relating to venepuncture.
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▶Identify issues of accountability, consent and anxiety, safety, infection control and competence in relation to this procedure.
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▶Review your clinical skill in venepuncture and benchmark against best practice.
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▶Ensure that you are aware of the possible complications of venepuncture and how to manage them.
Course Content
Learning Outcomes
▶Understand and describe the anatomy and physiology relating to venepuncture.
▶Identify issues of accountability, consent and anxiety, safety, infection control and competence in relation to this procedure.
▶Review your clinical skill in venepuncture and benchmark against best practice.
▶Ensure that you are aware of the possible complications of venepuncture and how to manage them.
Introduction to the Course
Introduction
Venepuncture describes the introduction of a needle into a vein to obtain a representative sample of the circulating blood for haematological, biochemical or bacteriological analysis. It is a common clinical skill but unlike many other clinical skills it can involve a variety of personnel including phlebotomists and clinical support workers, as well as registered nurses, midwives and medical staff.
This Course focuses on the role of the registered nurse, and thus the term ‘nurse’ will be used. The theory and practice can, however, be applied universally.
Anatomy and physiology
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Common Sites for Venepuncture
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Anatomy for technique
Professional Standards
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Nurses
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Consent
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Competence
Patient Anxiety
In an effort to reduce patient anxiety and as good practice, patients should be asked if they have had venepuncture performed previously. Particular attention should be paid to any adverse outcomes or experiences so that reassurance can be given or further action taken. Information on the need for blood tests should be fully detailed, and explain how to obtain the results and the expected time scale. This is helpful to patients and may also reduce anxiety, especially for patients undergoing investigation, and thus ensure a positive experience. It also gives the nurse the opportunity to check the correct blood test has been requested and that patients have prepared themselves physically if necessary, for example, checking that they have not eaten or drunk for a set time period before fasting blood sugar and cholesterol.
Anxiety about the procedure can be caused by a previous bad experience, a degree of ‘needle phobia’ or a dislike of medical procedures. Distraction is a useful technique for the mildly anxious, for example, the cough technique, which involves asking the patient to cough simultaneously when venepuncture is performed. Despite the mechanism remaining unclear, Usichenko et al (2004) found that the cough technique was a low-cost and effective way to reduce pain in venepuncture.
Distraction has also been explored when performing venepuncture and cannulation in children of all ages. Willock et al (2004) suggest it is an effective coping strategy particularly in older children. The use of relaxation techniques has also been identified as useful and can be easily taught to adults.
Another common method to reduce venepuncture pain is the use of topical creams, which act as local anaesthetics. Despite having cost implications they are widely used in children and could also be used for anxious adults. Neal (1997) explains that anaesthetic agents penetrate nerve fibres and block sodium channels, preventing the generation of action potentials. It is recommended that the prescribed cream is applied to more than one site should venepuncture be unsuccessful at the first site and once applied covered by an occlusive dressing, which should be wiped off before the procedure. Emla® is a common choice although the recommended time to leave it in situ varies, with some studies stating that it only becomes fully effective after 90 minutes (Selby and Bowles 1995, Patterson et al 2000).
However, when using either Emla® or Ametop® cream the user should review the common complications; paleness, redness and oedema have been reported using Emla®, and hypersensitivity has been reported with Ametop® (British National Formulary 2004). Repeated exposure to Ametop® has been shown to cause possible red raised areas and blistering, and the area should be observed every ten minutes (Willock et al 2004). Ametop® should not be left on the skin for more than 60 minutes but will last four to six hours after application.
Despite these side effects, Emla® has been shown to reduce the pain of venepuncture in adults (Hallen et al 1985) and, provided the instructions are followed, offers a solution for anxious adults. Subdermal lidocaine reduces pain when compared with not using an anaesthetic agent (Dickey 1988), however, when compared with Emla® cream it is not as effective (Lander et al 1996).
The use of therapeutic touch, a natural healing modality using gentle physical touch, has been shown to reduce patients’ anxiety, relax them and provide a distraction during venepuncture (Wendler 2002). Therapeutic touch has the advantage of being free once a practitioner has been taught the technique, which involves attendance at a certified course. However, care should be taken to ensure that patients want this intervention as some individuals in Wendler’s (2002) study had a negative experience resulting in further anxiety because the time taken to administer therapeutic touch delayed the venepuncture procedure. The use of touch by a stranger also caused anxiety in some patients. Thus, Wendler (2002) recommends further research before widespread use of the technique is adopted.
Anxiety regarding venepuncture should form part of the nurse’s assessment of the patient. Where possible, the causes of patient anxiety should be explored and actions planned to help alleviate this.
Safety
When performing venepuncture, the safety of the patient and nurse should be considered. Patient safety should be considered in relation to the patient’s position when the procedure is being performed. If the patient has a history of fainting during venepuncture, then he or she should lie down to reduce the possibility of a fall, which could have serious consequences (Black and Hughes 1997). It is essential that the person taking blood is competent in this procedure as this will also help to reduce the risk of avoidable complications. Allergies should be considered, and, if the patient is allergic to latex, plasters or the apparatus, then alternatives should be sought.
All equipment should be sterile and where possible single use only (Medical Devices Agency (MDA) 1996). The blood should be collected in accordance with local policies and procedures. Consider the order in which blood tubes are used as this can affect the results, for example, the blood tube ethylenediaminetetra-acetic acid (EDTA) contains potassium and so should be sampled last (NHS LUHD 2004). Whether addressograph labels can be used should also be clarified, and all personal details should be checked with the patient to ensure validity. The possibility of a sharps injury is a potential safety risk to patients and staff, and safe and prompt disposal of sharps is essential.
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Infection Control
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Potential complications
Preperation
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Venepuncture: preparation for care