Pre‐procedure

ActionRationale

1. 1.Show
   Explain the procedure to the patient.
   To ensure that the patient understands the procedure and gives his/her valid consent (RCN [133], C).
2. 2.Show
   Check that the identity of the patient matches the details on the patient notes.
   To ensure that the sample is correctly labelled (RCN [133], C).
3. 3.Show
   Ascertain whether the patient is allergic to skin cleanser, adhesive plaster or local anaesthetic.
   To prevent an allergic skin reaction (NMC [115], C).
4. 4.Show
   Check patient's medications. The patient should be asked if they are taking anticoagulants.
   To ensure any contraindications are considered and appropriate management is in place regarding anticoagulants (BSBR [20], C; Chetlen et al. [28], E).
5. 5.Show
   Ask the patient to change into the gown and position the patient on the couch in a position that facilitates access to the site requiring biopsy.
   To ensure the patient is comfortable and to ensure safety should the patient feel faint during the procedure. E
6. 6.Show
   Carefully wash hands using bactericidal soap and water, dry before commencement. Or decontaminate physically clean hands with alcohol‐based handrub.
   To minimize risk of infection (RCN [132], C).
7. 7.Show
   Check all packaging for use‐by date. Open and prepare the equipment on the procedure trolley.
   To maintain asepsis throughout and check that no equipment is damaged. E
8. 8.Show
   Isolate the palpable lesion between fingers.
   To enable clinician to localize lesion and assess depth and position. E
9. 9.Show
   Apply alcohol handrub and apply sterile gloves.
   Sterile gloves form part of aseptic technique. Aseptic technique should be followed for any procedure that breaches the body's natural defences (Loveday et al. [93], C).

Procedure

1. 10.Show
   Clean the area of patient's skin to be anaesthetized with the locally agreed cleansing solution.
   To reduce risk of contamination from skin flora (Gould [56], E; Scales [143], E).
2. 11.Show
   Inform the patient that a local anaesthetic will be administered intradermally and subcutaneously and that it can result in a ‘stinging’ sensation.
   To inform patient and manage anxiety (Rocha et al. [139], C).
3. 12.Show
   Draw up and then inject lidocaine 1% 2–3 cm from lesion.
   The local anaesthetic should be injected up to the lesion and backwards along the path of the needle to reduce discomfort (Rocha et al. [139], C).
4. 13.Show
   Check that the area to be incised is numb by asking patient if any pain is felt by touching the skin with a sterile needle prior to the procedure.
   To reassure patient that the local anaesthetic works (Rocha et al. [139], C).
5. 14.Show
   Pick up sterile scalpel blade with dominant hand.
   Ensure that dominant hand is free and practitioner is in the best position to make incision (Rocha et al. [139], C).
6. 15.Show
   Localize the lesion by holding a small area of skin taut between thumb and forefinger of the non‐dominant hand. Then, using the scalpel blade, break the integrity of the dermal layers. Incise scalpel blade to a depth of 5 mm maximum (Action figure 15).
   To allow entry of biopsy needle into breast tissue beneath dermal layers (Rocha et al. [139], C).
7. 16.Show
   Withdraw scalpel blade and release skin.
   To allow entry of biopsy needle into breast tissue beneath dermal layers (Rocha et al. [139], C).
8. 17.Show
   Pick up 14 G biopsy device with dominant hand and draw back into ‘cocked’ position.
   14 G biopsy needle obtains greater sensitivity than 16 G or 18 G without increasing cost (Rocha et al. [139], C; Wallis et al. [167] C).
9. 18.Show
   Introduce the biopsy needle through the puncture site in the dermis and advance toward the palpable lesion while isolating the lesion and fixing between the thumb and finger of the non‐dominant hand.
   Isolating the lesion with non‐dominant hand enables the practitioner to map the position of the lesion and to gauge where the biopsy needle is in relation to it (Rocha et al. [139], C).
10. 19.Show
    Once the biopsy needle is appropriately positioned, at least 2–3 cm away from the lesion but directed at it, release the mechanism which propels the needle forward into the lesion. Ensure that the path of the biopsy needle is running parallel or oblique to deeper structures.
    The biopsy apparatus allows for the hollow biopsy needle to be ‘fired’ into the lesion. If the needle is too close before the apparatus is deployed, the core may be taken from tissue beyond the target lesion. The practitioner must be aware of the length of throw of the biopsy needle. (Rocha et al. [139], C).
11. 20.Show
    Withdraw the needle and ask assistant to apply pressure to wound until no signs of bleeding.
    Withdraw the needle in order to access the sample (Rocha et al. [139], C).

    Applying pressure helps to stop bleeding. E
12. 21.Show
    Move the biopsy needle above the sample pot containing formalin and draw back the cocking apparatus once to expose the core biopsy. Use sterile needle to move biopsy from needle into the sample pot.
    Formalin fixes the tissue and preserves cellular architecture and composition ready for subsequent examination (Fox et al. [49], E).

    Avoid crush artefact of biopsy core. E
13. 22.Show
    Repeat steps 19–21 to obtain minimum of 4 cores if possible. Angle the biopsy needle through the lesion in different planes to increase representativeness of sample.
    The number of cores obtained may vary as lesions are not always uniform and a higher number of samples increases the accuracy of the result (Wallis et al. [167], C).
14. 23.Show
    Once the required number of samples is obtained discard the biopsy device/needle in a sharps bin.
    To reduce risk of sharps injury (RCN [129], C).
15. 24.Show
    Ensure pressure is correctly being applied by assistant and there is no active bleeding.
    To reduce incidence of haematoma post procedure (Rocha et al. [139], C).

Post‐procedure

1. 25.Show
   Close sample pot and ensure lid is on securely.
   To ensure that sample remains in pot and is uncontaminated (WHO [171], C).
2. 26.Show
   Ensure correct patient identifier label is on the sample pot.
   To ensure that the result is ascribed to correct patient. This should be done immediately and by the practitioner (NMC [114], C).
3. 27.Show
   Inspect the puncture site before applying the dressing.
   To ensure that the puncture point has sealed and that bleeding has stopped (Rocha et al. [139], C).
4. 28.Show
   Steri‐Strips should be applied to close the wound.
   To aid healing of the wound and minimize the risk of infection (Rocha et al. [139], C).
5. 29.Show
   Apply a sterile dressing over the Steri‐Strips with pressure to continue compression.
   To aid healing of the wound and minimize the risk of infection (Rocha et al. [139], C).
6. 30.Show
   Remove gloves and discard waste in the correct containers, for example sharps into a designated receptacle.
   To ensure safe disposal and avoid injury to other members of staff or the public (DH [35], C; HSE [68] C).
7. 31.Show
   Complete request form and place sample pot together with form.
   To ensure that the result is ascribed to the correct patient. Ensure correct side of body is recorded and that clinical details are correct as this may help pathological interpretation (NMC [114], C; WHO [171], C).
8. 32.Show
   Ask the patient to re‐dress.
   To ensure dignity and privacy. E
9. 33.Show
   Ensure that the patient is comfortable and arrange to be observed for swelling at biopsy site, bleeding through dressing or systematic symptoms such as dizziness or nausea for 30 minutes following injection of local anaesthetic.
   To monitor for signs that may indicate adverse reaction to the local anaesthetic such as confusion, respiratory depression and hypersensitivity (Rocha et al. [139], C).
10. 34.Show
    Assess covered biopsy site after 30 minutes for signs of bleeding.
    To ensure that the puncture point has sealed and that bleeding has stopped (Rocha et al. [139], C).