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, and 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
   Use alcohol handrub once again and put on 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).
9. 9.Show
   Attach the 10 mL syringe to the sterile 14 G needle and replace onto sterile area.
   The syringe is to enable the practitioner to create a vacuum effect. E

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
   Palpate and fix the clinical lesion between the fingers of your non‐dominant hand.
   To enable practitioner to map lesion and better position the needle. E
3. 12.Show
   Warn the patient that the needle aspiration is about to be performed.
   To manage patient anxiety and expectation. E
4. 13.Show
   Introduce the needle into the approximate area of the lesion.
   To ensure that cells are retrieved from the correct area (Wright [174], E; Fornage et al. [48], E).
5. 14.Show
   Once the needle is inserted, pull back on the syringe approximately 3–4 mL in order to create a vacuum.
   The vacuum ensures that cells cut from the lesion by the needle are pulled back into the hollow core of the needle (Wright [174], E; Fornage et al. [48], E).
6. 15.Show
   Keeping the vacuum in place, move the needle backwards and forwards through the lesion without removing the needle from the breast entirely.
   Repeated passes through the target lesion ensure a higher chance of obtaining representative cells (Wright [174], E; Fornage et al. [48], C).
7. 16.Show
   Release the vacuum gently by allowing the syringe to return to normal state.
   Vacuum should be released while the needle is still within the breast to stop the obtained cells from being pulled up into the barrel of the syringe. Cells within the barrel of the syringe cannot be transferred to the slide (Wright [174], E; Fornage et al. [48], C).
8. 17.Show
   Withdraw needle from breast once vacuum fully released and release skin being held by non‐dominant hand.
   Withdraw needle in order to release cells onto slide (Wright [174], E; Fornage et al. [48], C).
9. 18.Show
   Ensure gauze and pressure are applied to the puncture site by an assistant while you are able to complete procedure away from patient.
   To minimize bleeding and bruising (Wright [174], E; Fornage et al. [48], C).
10. 19.Show
    In order to get cellular material from needle onto slide, disconnect needle from syringe and fill syringe with air by pulling the plunger back.
    To gain air into syringe, which will expel cells from barrel of needle onto slide (Wright [174], E; Fornage et al. [48], C).
11. 20.Show
    Reconnect syringe to the needle while ensuring the sharp is facing away from you and you are steadying the needle by the plastic cuff.
    To gain air into syringe, which will expel cells from barrel of needle onto slide (Wright [174], E; Fornage et al. [48], C).
12. 21.Show
    Push air from syringe back through the needle with needle directed at slide.
    To expel cells onto slide (Wright [174], E; Fornage et al. [48], C).
13. 22.Show
    Repeat steps 19 and 21 onto 4 slides if there is enough material.
     

Post‐procedure

1. 23.Show
   Spread cell sample on each slide using a clean slide to apply gentle downward pressure and glide along the stained slide.
   To spread cellular material out and achieve a monolayer. Clumping of cells will mask results (Wright [174], E; Fornage et al. [48], C).
2. 24.Show
   If 4 good samples appear to have been obtained, 2 should be air dried and 2 should be fixed with formalin.
   To achieve clear slides with intact cells for assessment. E
3. 25.Show
   Label all slides with patient identifying details, procedure description and date using a pencil.
   To ensure results are ascribed to correct patient. Pen will wash off in laboratory work‐up so pencil must be used, E (NMC [114], C).
4. 26.Show
   Place slides into slide container and label the outside of this with patient ID label.
   To ensure results ascribed to correct patient (WHO [171], C).
5. 27.Show
   Use needles to draw up sodium chloride 0.9% into the syringe and then to push out sodium chloride into the universal container.
   To obtain any cellular material that has been pulled up into barrel of syringe and to clean all material from needle barrel. E
6. 28.Show
   Label universal container with patient identifying details, procedure description, location and date/time.
   To ensure results are ascribed to correct patient (NMC [114], C).
7. 29.Show
   Inspect skin wound and apply small sterile plaster.
   To ensure that bleeding has stopped and that pressure can be released (Wright [174], E; Fornage et al. [48], C).
8. 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).
9. 31.Show
   Advise patient to remove plaster later that day or the following day.
   To manage anxiety and reassure patient. E
10. 32.Show
    Ensure arrangements are made for patient to come back for or receive results as per local guidelines.
    To manage anxiety and expectations. E
11. 33.Show
    Ensure patient has an awareness of possible results expected.
    To ensure good communication and manage expectations (ABS [6], C).
12. 34.Show
    Ensure patient can contact appropriate person if they experience any difficulties following the fine‐needle aspiration.
    To manage anxiety. E