Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [165], C).
2. 2.Show
   Check that the identity of the patient matches the details on the request form by asking for their full name and date of birth and checking their identification bracelet (where appropriate). If the patient is unable to communicate then check the identity band for full name, date of birth and hospital number.
   To ensure the sample is taken from the correct patient (NPSA [166], C; RCN [202], C).
3. 3.Show
   Allow the patient to ask questions and discuss any problems that have arisen previously.
   Anxiety results in vasoconstriction; therefore, a patient who is relaxed will have dilated veins, making access easier. E
4. 4.Show
   Consult the patient as to any preferences and problems that may have been experienced at previous venepunctures.
   To involve the patient in the treatment, and to acquaint the nurse fully with the patient's previous venous history and identify any changes in clinical status (e.g. mastectomy), as both may influence vein choice (Dougherty [53], E).
5. 5.Show
   Check whether the patient has any allergies.
   To prevent allergic reactions, for example to latex or chlorhexidine (McCall and Tankersley [138], E; MHRA [145], C).
6. 6.Show
   Assemble the equipment necessary for venepuncture.
   To ensure that time is not wasted and that the procedure goes smoothly without unnecessary interruptions. E
7. 7.Show
   Wash hands using bactericidal soap and water or alcohol‐based handrub, and dry before commencement.
   To minimize risk of infection (NHS England and NHSI [155], C).
8. 8.Show
   Check own hands for any visibly broken skin, and cover any such areas with a waterproof dressing.
   To minimize the risk of contamination to the practitioner (DH [46], C; Fraise and Bradley [62], E).
9. 9.Show
   Check all packaging before opening and preparing the equipment on the chosen clean receptacle.
   To maintain asepsis throughout and check that no equipment is damaged. E

Procedure

1. 10.Show
   Take all the equipment to the patient, exhibiting a confident manner.
   To help the patient feel more at ease with the procedure. E
2. 11.Show
   Support the chosen limb on a pillow.
   To ensure the patient's comfort and facilitate venous access. E
3. 12.Show
   Apply a tourniquet to the 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 (Weinstein and Hagle [252]). The position of the tourniquet may be varied; for example, if a vein in the hand is to be used, the tourniquet may be placed on the forearm. A sphygmomanometer cuff may be used as an alternative.
   To dilate the veins by obstructing the venous return (Dougherty [53], E).

   To increase the prominence of the veins. E

   To slow down blood flow and therefore distend the veins (Garza and Becan‐McBride [66], R).
4. 13.Show
   If the tourniquet does not improve venous access, the following methods can be used. If venous access appears possible, skip to step 19.

   Either:

   The arm may be placed in a dependent position. The patient may be asked to clench their fist.

   Or:

   The veins may be tapped gently or stroked.

   Or:

   Remove the tourniquet and apply moist heat (e.g. a warm compress), soak the limb in warm water or, with prescription, apply glyceryl trinitrate ointment/patch (Weinstein and Hagle [252]).
   To improve venous access (Dougherty [53], E).
5. 14.Show
   Select the vein by careful palpation to determine size, depth and condition (Action figure 13.7).
   To prevent inadvertent insertion of the needle into other anatomical structures (Witt [263], E).
6. 15.Show
   Release the tourniquet.
   To ensure patient comfort. E
7. 16.Show
   Select the device, based on vein size, site and volume of blood to be taken. Use a 23 swg winged infusion device for small veins, metacarpal or feet veins.
   To reduce damage or trauma to the vein and prevent haemolysis (Dougherty [53], E).
8. 17.Show
   Wash hands with bactericidal soap and water or alcohol‐based handrub and allow to dry.
   To maintain asepsis and minimize the risk of infection (NHS England and NHSI [155], C)
9. 18.Show
   Reapply the tourniquet.
   To dilate the veins by obstructing the venous return (Dougherty [53], E).
10. 19.Show
    Put on gloves.
    To prevent possible contamination of the practitioner (NHS England and NHSI [155], C).
11. 20.Show
    Clean the patient's skin carefully for 30 seconds using an appropriate preparation, for example chlorhexidine 2% in 70% alcohol, and allow to dry. Do not repalpate or touch the skin (Action figure 13.8).
    To maintain asepsis and minimize the risk of infection (DH [46], C; Fraise and Bradley [62], E; Loveday et al. [128], R).
12. 21.Show
    Remove the cover from the needle and inspect the device carefully.
    To detect faulty equipment, for example bent or barbed needles. If these are present, place them in a safe container, record batch details and return to manufacturer (MHRA [144], C).
13. 22.Show
    Anchor the vein by applying manual traction on the skin a few centimetres below the proposed insertion site (Action figure 13.9).
    To immobilize the vein and to provide counter‐tension to the vein, which will facilitate a smoother needle entry (Dougherty [53], E).
14. 23.Show
    Insert the needle smoothly at an angle of approximately 30°. However, the angle will depend on the size and depth of the vein (Action figure 13.9).
    To facilitate a successful, pain‐free venepuncture. E
15. 24.Show
    Reduce the angle of descent of the needle as soon as a flashback of blood is seen in the tubing of a winged infusion device or when puncture of the vein wall is felt.
    To prevent advancing too far through the vein wall and causing damage to the vessel (Dougherty [53], E).
16. 25.Show
    Slightly advance the needle into the vein, if possible.
    To stabilize the device within the vein and prevent it becoming dislodged during withdrawal of blood. E
17. 26.Show
    Do not exert any pressure on the needle.
    To prevent a puncture occurring through the vein wall. E
18. 27.Show
    Withdraw the required amount of blood using a vacuumed blood collection system (Action figure 13.10). Collect blood samples in the draw order shown in Table 13.4.
    To minimize the risk of transferring additives from one tube to another and bacterial contamination of blood cultures (manufacturer's guidelines, C).
19. 28.Show
    Release the tourniquet. This may be necessary at the beginning of sampling as inaccurate measurements may be caused by haemostasis, for example when taking blood to assess calcium levels.
    To decrease the pressure within the vein. E
20. 29.Show
    Remove the tube from the plastic tube holder.
    To prevent blood spillage caused by vacuum in the tube (Hoeltke [88], E).
21. 30.Show
    Place a low‐linting swab over the puncture point.
    To apply pressure. E
22. 31.Show
    Remove the needle, but do not apply pressure until the needle has been fully removed.
    To prevent pain on removal and damage to the intima of the vein. E
23. 32.Show
    Activate the safety device and then discard the needle immediately in a sharps bin.
    To reduce the risk of accidental needle stick injury (HSE [96], C).
24. 33.Show
    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 the patient's current disease or treatment interferes with clotting mechanisms.
    To stop leakage and haematoma formation. To preserve the vein by preventing bruising or haematoma formation. E
25. 34.Show
    The patient may apply pressure with a finger but should be discouraged from bending the arm if a vein in the antecubital fossa is used.
    To prevent leakage and haematoma formation (McCall and Tankersley [138], E).
26. 35.Show
    Gently invert as guided by the manufacturer's instructions.
    To prevent damage to blood cells and to mix with additives (manufacturer's guidelines, C).
27. 36.Show
    Label the bottles with the relevant details at the patient's side. Never pre‐label bottles.
    To ensure that the specimens from the right patient are delivered to the laboratory, the requested tests are performed and the results are returned to the correct patient's records (NMC [165], C; NPSA [166], C).

Post‐procedure

1. 37.Show
   Inspect the puncture point before applying a dressing.
   To check that the puncture point has sealed. E
2. 38.Show
   Confirm whether the patient is allergic to adhesive plaster.
   To prevent an allergic skin reaction. E
3. 39.Show
   Apply an adhesive plaster or alternative dressing.
   To cover the puncture and prevent leakage or contamination. E
4. 40.Show
   Ensure that the patient is comfortable.
   To ascertain whether the patient wishes to rest before leaving (if an outpatient) or whether any other measures need to be taken. E
5. 41.Show
   Remove gloves and discard waste and sharps according to local policy.
   To ensure safe disposal and avoid laceration or other injury of staff (DH [48], C; Fraise and Bradley [62], E).
6. 42.Show
   Follow hospital procedure for collection and transportation of specimens to the laboratory.
   To make sure that specimens reach their intended destination. E
7. 43.Show
   Document the procedure in the patient's records.
   To ensure timely and accurate record keeping (NMC [165], C).