Venepuncture and Cannulation Study Day
Objectives
To understand Trust policies on venepuncture, cannulation & flushing
To understand professional responsibilities relating to these skills
To understand venous anatomy & physiology
To understand infection control issues relating to the skills
To understand potential complications & how to minimise the risks
To understand the importance of documentation & aftercare
To demonstrate safe & correct procedure on a training arm
Timetable
08.45
09.00
09.15
09.30
10.00
10.20
10.35
12.00
12.35
14.30
15.00
15.15
15.45
Registration
Guidelines for professional practice
Venous anatomy and physiology
Infection control issues
Laboratory perspective
Coffee
Venepuncture equipment, technique & Practice
Lunch
Cannulation equipment, technique & practice
Flushing peripheral venous cannula
Coffee
Complications, reflection & evaluation
Close
Professional Responsibilities
All staff who practise venepuncture must have
received approved training and documented,
supervised practice. The onus is also on
individuals to ensure their knowledge and skills
are maintained, both from a theoretical and
practical perspective. All practitioners must
operate within the protocols/guidelines of their
particular organisation
Who can carry out the procedures?
An Accountable practitioner! To include;
Medical Staff
Registered Nurse
Midwives
Radiographers
Other non-registered staff who have undergone
Trust approved training and have proved to be
competent
RUH Venepuncture Policy
Guidelines for Professional Practice
Duty of Care :
Health and Safety Act
Employment Law
Civilly Liable to patients
(you can be held liable for adverse effects to
patients if procedures are not followed
correctly )
Your safety, consider the risks
Guidelines for Professional Practice
IGNORANCE IS NOT A DEFENCE
It is your responsibility to keep up to date with current
practices
Extended Roles
Where do your responsibilities lie?
Professional Responsibility Summary
Never carry out a procedure that you have not
been trained to do, signed as competent to do or
do not feel confident to do.
Registered and non-registered staff have
responsibilities to act lawfully
Keep up to date with current practices
Remember these skills are extended roles and
should not take priority over basic nursing care
Venous Anatomy and Physiology
Objectives
Differentiate between an artery and a vein
Identify and name the commonly used veins for
venepuncture and cannulation
Be aware of nerves in the arm
Understand how to choose an appropriate vein
for venepuncture and cannulation avoiding
hazardous anatomical structures
Anatomy and Physiology
The most common site for venepuncture is the Antecubital Fossa
where the Median Cubital, Cephalic and Basilic veins lie close to the
skins surface making them easily accessible. They are the most
prominent, there are numerous of them and they have been shown
to minimise discomfort (Weinstein, 1997).
Always use veins in the upper extremities before using lower extremity
sites for VENEPUNCTURE. Veins of the lower limbs are usually
only used in exceptional circumstances in adults.
However! For CANNULATION you should start distally and work
proximally
Nerves of the Arm to consider..
Three main nerves run past the elbow and wrist to the hand.
Median nerve. This nerve passes down the inside of the arm
and crosses the front of the elbow.The median nerve
supplies muscles that help bend the wrist and fingers. It is
a main nerve for the muscles that bend the thumb. The
median nerve also gives feeling to the skin on much of the
hand around the palm, the thumb, and the index and
middle fingers. When the median nerve is compressed
over a long period, it can cause carpal tunnel syndrome.
Nerves
Ulnar nerve. This nerve passes down the inside
of the arm. It then passes behind the elbow,
where it lies in a groove between two bony
points on the back and inner side of the elbow.
The ulnar nerve supplies muscles that help bend
the wrist and fingers, and that help move the
fingers from side to side. It also gives feeling to
the skin of the outer part of the hand, including
the little finger and the outer half of the back of
the hand, palm, and ring finger. When the elbow
is bumped over the ulnar nerve, it's often called
hitting the "funny bone."
Nerves continued
Radial nerve. This nerve passes down the back
and outside of the upper arm. The radial nerve
supplies muscles that straighten the elbow, and
lift and straighten the wrist, thumb, and fingers.
The radial nerve gives feeling to the skin on the
outside of the thumb and on the back of the
hand and the index finger, middle finger, and
half of the ring finger.
Main nerves of the Arm
Differences between arteries and veins
ARTERIES
Take oxygenated blood from the
heart to tissues
Have thick walls
Small Lumen
Elastic
No valves
Deep seated (Usually)
Do not collapse
High pressure
VEINS
Take deoxygenated blood from
the tissues to the heart
Thin walls
Large lumen
Less elastic
Have valves to prevent any
backflow of blood
Lie closer to the skin
Tendency to collapse
Low blood pressure
Vein Structure Anatomy
The structure of a vein is as follows;
The walls (outer structure) of veins consist of
three layers of tissues that are thinner and less
elastic than the corresponding layers of arteries.
Veins include valves that aid the return of blood
to the heart by preventing blood from flowing in
the reverse direction.
Vein and Artery Structure
Tunica Intima (inner lining) ; has a smooth lining,
is fragile and sensitive. Valves are present here
in veins.
Tunica Media (Middle lining) ; Smooth muscle,
elastic tissue which can constrict and dilate.
Less thick in veins
Tunica Externa or Adventitia; thick layer of
connective tissue
Suitable Veins
Visible
Palpable
Bouncy
Soft
Well supported
Refills when depressed
Straight and non-toruous
Sites to avoid…
Evidence of venous fibrosis;
Evidence of haematoma/oedema formation;
Evidence of localised infection/inflammation;
Any vascular access device;
Fistulae or vascular grafts.
Limbs with fractures
Small, visible but impalpable veins
The affected side in patients postmastectomy or postcardiovascular accident.
Anatomy and Physiology Summary
Only perform venepuncture and cannulation on
healthy tissue
Be aware of the artery at the Antecubital Fossa
Be aware of the nerves at the Antecubital Fossa
In some individuals the artery lies over the vein
so remember to check if there is a pulse!
If your ever not sure, then always ask.
Infection Control Issues
Why do you think Infection Control is a relevant
issues with regards to venepuncture and
cannulation ??
Sharps Safety (RUH Sharps Policy)
Take sharps bin to
patient
Sharps must be
disposed of
immediately
Fill to line only
Never re-sheath
needles
Report sharps
injuries as per RUH
policy
Key Principles for sharps
1.
2.
3.
4.
5.
6.
Never attempt to use a sharp without preparation for its
disposal
Never re-sheath a needle (Even a clean one)
Never carry loose sharps in your hand- always use a
plastic tray
Never expect someone else to dispose of your sharps
Never leave sharps to dispose of later
Never underestimate the implications of a sharps injury
Key Principles Sharps
ALWAYS
1.
Wear appropriate personal protective equipment
2.
Assemble devices with care
3.
Be especially vigilant during emergency situations and
procedures
4.
Ask for assistance when taking blood from uncooperative
patients
5.
Dispose of sharps as soon as possible
6.
Report all incidents involing contaminated sharps
7.
Report all near misses and examples of bad practice
8.
Prohibit hand to hand passing of sharps devices.
Infection control key points and summary
Always use ANTT when performing
venepuncture and cannulation as will reduce the
risk of patients developing bacteraemias
Tourniquets should be single use
Remember the correct disposal of equipment as
per RUH policy
Sharps injuries do happen!! Think personal
protective equipment and your safety
Venepuncture
Equipment, Technique and Practice
4 stage techniques
1. Visual picture of skill demonstrated in real time
2. Explanation of demonstration
3. Student talk through whilst performed by trainer
4. Student talks through and demonstrates the
skill
BUT FIRST A FEW KEY POINTS
Patient Consent
How do we gain consent from our patients?
How do we correctly identify our patients?
What about confused or unconscious patients?
Venepuncture Checklist
Have you checked and confirmed the identity of the patient?
Have you obtained verbal informed consent?
Has the use of local anaesthesia been considered?
Have you selected all equipment required?
Does the patient have any IV infusion in progress in the limb you propose
to use?
ANTT
If the tourniquet is non-disposable, is it socially clean and has it been
laundered at 60˚c within the last 7 days?
Have you disposed of any waste including sharps, in accordance with
trust policies?
Have you documented the procedure?
Venepuncture key points
How many attempts will you have at any one
given time for a single patient?
What will you do if you have been unsuccessful?
Where do you document the procedure?
Order of Collection
Blood Cultures, then
Blue Top
(Clotting screen)
Orange/ beige top
(Chemistry profile)
Lavender top
( Full Blood Count (FBC))
Labelling of blood bottles
1.
2.
3.
4.
How to label…
Use a ball point pen
Include full name, D.O.B, Ward, date and time
Write the time of collection on the request form
and initial the form
Place the tubes in the bag and attach the blood
form and seal
THINK IS THIS BLOOD NEEDED
URGENTLY? WHAT ARRANGMENTS WILL
YOU NEED TO MAKE?
Any Questions?
Venepuncture summary and key points
Always gain consent
Always wear gloves when carrying out venepuncture and
cannulation
Always use vacutainer equipment when taking blood,
never a needle and syringe
Always label blood bottles immediately after taken
Always follow trust policy and guidelines
Always perform the skill under direct supervision by a
trained member of staff competent in the skill and who
uses them regularly, until such time that you are signed off
as competent
Venepuncture. LETS PRACTICE!
Peripheral Cannulation
Aim and Objectives
AIM
To provide a guide to peripheral intravenous cannulation
and advice on the continuing care of patients with such
devices in place.
Objectives
Each practitioner will be able to:
Ensure that a short peripheral cannula is the appropriate
device for intended need
Decide the size/type of device to be used
Choose an appropriate insertion site
Prepare the appropriate equipment
Complete the procedure safely
Conclude the care episode
Cannulation
Why is cannulation necessary for some patients?
What size cannula?
Before beginning it is important to choose
the correct size of cannula. The
options, in order of decreasing bore
size are;
16 gauge (grey) for surgical
emergencies (170mls/min);
18 gauge (green) for blood transfusions
or larger volumes (80mls/min);
20 gauge (pink) for maintenance of
intravenous fluids; and
22 gauge (blue) for difficult veins, slow
intravenous fluids, or intravenous drugs
in a patient who can take oral fluids
(31mls/min)
Cannula selection
The cannula chosen should be the smallest to meet the
clinical need.
Clearly the larger the lumen of the catheter the faster the
flow rate. The indication for cannulation should be
considered and the cannula gauge chosen accordingly.
For example emergency colloid or blood replacement
after a post partum haemorrhage will require a grey
cannula whereas a line for intermittent intravenous bolus
injections of antibiotics could be green or pink.
Think; purpose of infusion, type of infusate, length of
treatment
Insertion site
Commonly chosen sites include:
Veins in the back of the hand or forearm.
In an emergency any available large peripheral vein may
be used e.g. median cubital vein in the anti-cubital fossa.
If the cannula has to be positioned over a joint a splint
may be required to ensure continuing satisfactory flow.
Cannulation documentation
What needs to be considered with regards to the
documentation of cannula?
What aftercare considerations are there?
Any Questions?
Cannulation. LETS PRACTICE!!
Potential Complication
Objectives
To understand the potential complications of
Venepuncture and Cannulation
To understand how to deal with such
complications if they should occur
Potential complications
Syncope / fainting
Haematoma / bruising
Petechiae / broken capillary blood vessels
Haemolysis
Infection
Infiltration
Extravasation
Occlusion
Embolus
Complications continued
Haematoma
If a haematoma begins to form, release the
tourniquet, remove the needle from the vein and
apply firm pressure to the site.
The incidence of haematoma after venepuncture
can be decreased by applying pressure to the
site after the needle is removed. Carefull
technique should reduce the risk of developing a
haematoma.
Complications continued
Petechiae
A petechiae is a small (1-2mm) red or purple spot
on the body, caused by a minor haemorrhage
(broken capillary blood vessel)
This often occurs in patients with a coagulopathy
but can also occur if the tourniquet is left
tightened for prolonged periods of time
Complications continued
Haemolysis
Haemolysis can affect some results (e.g.
potassium), although it may be a result of the
patients disease process it is most often the
result of poor technique. Remember to invert
the blood tubes gently to mix the blood.
Complications continued
Infection
Local cellulitis or septicaemia are uncommon
complications of venepuncture- remember strict asceptic
technique during venepuncture and cannulation will
reduce the risk of patients developing a bacteraemia.
REMEMBER ANTT!! All patient with an intravenous
access device in place must have the cannula site checked
daily for signs of infusion phlebitis. Two of the most
common causes of infusion phlebitis are chemical and
mechanical; therefore the correct choice of a suitable
access device for a particular patient is vital (Freytes
2000).
Cannulation and Infusion Complications
INFILTRATION –
Inadvertent administration of a non-vesicant solution or drug into
the tissues (Weinstein 1997). Venous access devices must be
secured in away that does not impede fluid/blood flow and allows
the insertion site to be monitored.
EXTRAVASATION –
Inadvertent administration of a vesicant solution or drug into the
tissues (Weinstein 1997)). Tissue necrosis may follow, therefore it
is vital that cannulae are assessed as patent prior to use and
monitored closely.
Infiltration and extravasation
How will you tell if this occurs?
1. Pain when flushing
2. Possible swelling distally to the cannula
3. Pressure when attempting to flush
Prevention
1. Close observation
2. Regular flushing
3. Careful fixation
REMEMBER VIP SCORE EVERY SHIFT!!
Complications continued
OCCLUSION –
Cannulae may become occluded when infusion
containers ‘run dry’ or flush solutions are not
administered appropriately (Dougherty and
Lamb 1999). Cannula’s must never be forcibly
flushed.
Remember VIP SCORES!!
Complications continued
Embolus, air or blood
Ensure all connections are tight.
Never reintroduce stylet
If clotted then remove
Careful when drawing up the flush to prevent air bubbles.
Questions
1.
2.
3.
4.
What action should you take in the event of an
injury to a nerve?
Remove the needle immediately and apply
pressure
Seek medical help
Give an explanation to the patient
Make sure the incident is documented and fill
out an incident form
Questions
1.
2.
3.
4.
What action should you take in the event of
puncturing an artery?
Remove device immediately and apply pressure
until bleeding stops and then apply an
appropriate dressing
Seek medical help
Document in the notes
Give an explanation to the patient
Complications summary
Remember never to rush
Careful technique will reduce incidents of
complications
Document all attempts as per trust policy
Only two attempts for the same patient episode.
Always ask someone if you are not sure.
Any Questions?
Key points
You need to be signed of by a competent
practitioner before you are able to practice the
skills alone, that includes competencies for;
Venepuncture
Cannulation
Flushing
There is also a competency for sending blood for
cross match or group and save. Speak to a
competent staff member in your ward areas.
Objectives
To understand Trust policies on venepuncture, cannulation & flushing
To understand professional responsibilities relating to these skills
To understand venous anatomy & physiology
To understand infection control issues relating to the skills
To understand potential complications & how to minimise the risks
To understand the importance of documentation & aftercare
To demonstrate safe & correct procedure on a training arm
References and further reading
Campbell, H et al (1999) A practical
guide to venepuncture and
management of complications, British
Journal of Nursing 8 (7) 426-431
Heywood Jones, I (1994)
Venepuncture –using vacuum tubes,
Community Outlook 7, 21-22
Griffths, E. (1999) Venepuncture.
Practice Nursing 10 (1) 23-25
Scales, K (2008) A practical guide to
venepuncture and blood sampling.
Nursing standard, 22 (29) 29-36
Witt, B (2004) The Royal
Marsden Hospital Manual of
Clinical Nursing Procedures.
6th ed. Oxford, Blackwell
pp774-785
RUH Venepuncture Policy
(2009) accessed via intranet
Lavery, I (2003) Peripheral
venous cannulation and
patient consent. 17 (28) 4042
References continued
NHS National Patient
Safety Agency (2007)
“right patient, right blood”
BDS 19 Preparing to
administer blood/ blood
components to patient
and administering a
transfusion of blood
DoH (2006) Saving Lives:
High Impact Interventions
No. 1 Preventing the risk
of microbial contamination
The Royal Marsden
(2006) Clinical Nursing
Procedures 6th Ed,
Blackwell Publishing LTD
Clinical Governance 17,
Collection of Blood
Samples
Campbell, L (1998) IVrelated phlebitis,
complications and length
of hospital stay
References continued
Jackson, A (1997)
Performing peripheral
intravenous cannulation.
Professional Nurse. 13 (1)
21-25
Jackson, A (2003)
reflecting on the nursing
contribution to vascular
access. British journal of
nursing 12(11) 657- 665
Scales, K. (2005) vascular
access. A guide to
peripheral venous
cannulation. Nursing
standard 19 (49) 48-52