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
   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).
4. 4.Show
   Ascertain whether the patient is allergic to skin cleanser, adhesive plaster or local anaesthetic.
   To prevent an allergic skin reaction (NMC [115], C).
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
   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
9. 9.Show
   Select the area to be biopsied. Commonly selected sites are the most abnormal‐appearing site within a lesion or the edge of an actively growing lesion. Position of resultant scar should also be borne in mind.
   To obtain a good representative tissue sample and minimize scar effect (Zuber [180], E).
10. 10.Show
    Select the appropriate size punch biopsy instrument. Punch biopsy needles range from 2 to 10 mm. 3–4 mm is usually sufficient for a good sample size.
    To ensure that an adequate sample is taken (Zuber [180], E).
11. 11.Show
    Wash hands and put on non‐sterile gloves.
    To minimize risk of infection (RCN [132], C).

Procedure

1. 12.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. 13.Show
   Inform the patient that a local anaesthetic will be administered and that it can result in a ‘stinging’ sensation.
   To ensure the patient is fully informed and is aware of what to expect (Rocha et al. [139], C).
3. 14.Show
   Inject lidocaine slowly into subdermal tissues.
   To minimize pain or discomfort for the patient undergoing a punch biopsy of the nipple or cutaneous breast lesion (Zuber [180], E).
4. 15.Show
   Draw up lidocaine 1% in 5 mL syringe through 14 G needle.
   To ensure the correct preparation. E
5. 16.Show
   Check that the area to be biopsied is numb by asking patient if any pain is felt when touching the skin with a sterile needle prior to the procedure.
   To assess the effectiveness of the local anaesthetic prior to making the incision, to ensure that the procedure is pain free (Rocha et al. [139], E).
6. 17.Show
   Warn the patient that the punch biopsy instrument is about to be placed on the skin of the breast/nipple and that they may feel a pushing sensation.
   To reduce the risk of the patient moving, and to prepare them for what to expect. E
7. 18.Show
   When satisfied that the area to be biopsied is anaesthetized, the skin surrounding the biopsy site is stretched with the thumb and index finger of the non‐dominant hand.
   To stabilize the area before performing the punch biopsy. When the skin relaxes after the biopsy is performed, an elliptical‐shaped wound remains. E
8. 19.Show
   The punch biopsy needle should be held vertically over the skin by the dominant hand and rotated downward using a twirling motion created by the first two fingers on the dominant hand (Action figure 19). Once the instrument has penetrated the dermis into the subcutaneous fat, or once the instrument reaches the hub, it can be removed carefully and removed from the patient. The sample does not come away with the biopsy needle.
   To obtain an adequate specimen from the appropriate area (Zuber [180], E).
9. 20.Show
   Ensure safe disposal of biopsy needle into sharps container.
   To ensure safe disposal and avoid injury to other members of staff or the public (DH [35], C; HSE [68], C).
10. 21.Show
    Using the local anaesthetic needle held in the non‐dominant hand, raise the cylindrical skin specimen from the biopsy site. The use of forceps is discouraged. Iris scissors held in the dominant hand can be used to cut the specimen free from the subcutaneous tissues. The cut should be made below the level of the dermis.
    To retrieve a good, intact sample and to avoid crush artefact or damage to the sample (Zuber [180], E).

Post‐procedure

1. 22.Show
   The specimen should then be placed into an appropriate formalin container, and labelled with the patient details, area biopsied, side, date and time.
   Formalin fixes the tissue and preserves cellular architecture and composition ready for subsequent examination (Fox et al. [49], E).

   To ensure that the specimen is assigned to the correct patient. E
2. 23.Show
   Place sterile gauze onto the biopsy site and apply digital pressure until bleeding has ceased.
   To reduce the risk of leakage and to allow the puncture site to close (Rocha et al. [139], C).
3. 24.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], E).
4. 25.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], E).
5. 26.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], E).
6. 27.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. 28.Show
   Ensure that the patient is comfortable and arrange to be observed for 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], E).

   To monitor for continued bleeding (Rocha et al. [139], E).