The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [413]
To promote blood flow and therefore distend the veins (Gunwardene and Davenport 1990, E; Lenhardt et al. 2002, R3).
12 If the tourniquet does not improve venous access the following methods can be used.
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, for example a warm compress, soak limb in warm water or, with medical prescription, apply glyceryl trinitrate ointment/patch (Weinstein and Plumer 2007). To improve venous access (Dougherty 2008, E).
13 Select the vein using the aforementioned criteria (see Action Figure 13). To prevent haemoconcentration and pooling of the blood (Hoeltke 2006, E).
14 Release the tourniquet. To ensure patient comfort. E
15 Select the device, based on vein size, site, and so on. To reduce damage or trauma to the vein (Dougherty 2008, E; RCN 2010, C).
16 Wash hands with bactericidal soap and water or bactericidal alcohol handrub. To maintain asepsis, and minimize the risk of infection (DH 2007a; Fraise and Bradley 2009, E).
17 Reapply the tourniquet. To dilate the veins by obstructing the venous return (Dougherty 2008, E).
18 Put on gloves. To prevent possible contamination of the practitioner (NHS Employers 2007, C).
19 Clean the patient’s skin carefully for 30 seconds using an appropriate preparation, for example chlorhexidine in 70% alcohol, and allow to dry. Do not repalpate or touch the skin (see Action Figure 19). To maintain asepsis and minimize the risk of infection (DH 2007a; Fraise and Bradley 2009, E). To prevent pain on insertion (Fraise and Bradley 2009, E; Dougherty 2008, E; RCN 2010, C).
20 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 2005, C; RCN 2010, C).
21 Anchor the vein by applying manual traction on the skin a few centimetres below the proposed insertion site (see Action Figure 21). To immobilize the vein. To provide countertension to the vein which will facilitate a smoother needle entry (Dougherty 2008, E).
22 Insert the needle smoothly at an angle of approximately 30°. However, the angle will depend on size and depth of the vein (also see Action Figure 21). To facilitate a successful, pain-free venepuncture. E
23 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 vein wall and causing damage to the vessel. E
24 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
25 Do not exert any pressure on the needle. To prevent a puncture occurring through the vein wall. E
26 Withdraw the required amount of blood using a vacuumed blood collection system or syringes (see Action Figure 26). Collect blood samples in the following order:
blood culture
coagulation
serum tube with or without clot activator or gel separator (glass, non-additive tubes can be filled before the coagulation tube)
additive tubes such as:
(a) gel separator tubes (may contain clot activator or heparin)
(b) heparin tubes
(c) EDTA
all other tubes (Garza and Becan-McBride 2010).
To minimize the risk of transferring additives from one tube to another and bacterial contamination of blood cultures (manufacturer’s guidelines, C).
27 Release the tourniquet. In some instances 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
28 Remove tube from plastic tube holder. To prevent blood spillage caused by vacuum in the tube (Campbell et al. 1999, E).
29 Pick up a low-linting swab and place it over the puncture point. To