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Practice Nurse

Routine Tests Part 2

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Routine tests and monitoring are key to the day-to-day work of practice nurses and intrinsic to the management of long term conditions, health screening and promotion and the management of minor illnesses and injuries. It is therefore important that nurses maintain their practical and clinical skills to the highest standards.

 Venepuncture, otherwise known as phlebotomy, is one of the most commonly performed invasive procedures.

 The process involves inserting a needle into a vein to take a representative sample of the circulating blood, which is analysed for diagnostic, monitoring or screening purposes.

This resource, consisting of five assessment questions at basic level, tests your knowledge of the theory of, and best practice for, taking a blood sample. Complete the resource, including reading the featured articles and undertaking some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

On completion of this resource, you should have an understanding of:

The importance of informed patient consent

Infection control relevant to venepuncture

The adverse events that can arise and how to deal with them safely and effectively

1. Nursing and Midwifery Council. Code of professional conduct: standards for conduct, performance and ethics, 2008 

http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf

2. Gabriel J. Venepuncture and cannulation: considering the ageing vein. British Journal of Nursing. 2012;21(Suppl 1):22-28

 Diane Baylis, Medical Protection Society

RCGP General Practice Foundation: General Practice Nurse Competencies

http://www.rcgp.org.uk/membership/practice-teams-nurses-and-managers/~/media/Files/Membership/GPF/RCGP-GPF-Nurse-Competencies.ashx

Essentials of Primary Care Nursing – 5 one day workshops

http://www.educationforhealth.org/shop.php/courses/75/essentials-of-primary-care-nursing

A patient has been sent to see you to have some blood tests to assist with diagnosis following a recent history of tiredness and lethargy. The patient is refusing to have blood taken as they don’t like needles and they also worry about appearing foolish. Do you?

It is always important never to pressure a patient and to maintain their privacy and dignity.

 Making light of their concerns could be perceived as patronising and will not be helpful. Deferring the blood test is not advisable as this will lead to a delay in diagnosis. If you accept a patient’s refusal too readily you have missed the opportunity to ensure that this is an informed choice. Opening up a discussion, taking time with your patient to make them fully aware of all the facts, and to answer any questions they may have, will assist them with making the best decision regarding their consent for the blood test.

1. Nursing and Midwifery Council. The code: Standards of conduct, performance and ethics for nurses and midwives, 2008 

 Diane Baylis, Medical Protection Society

Think about an occasion when you were required to take blood from a patient who acknowledged a fear of needles. How did you handle the situation? In the light of your reflection, what improvements could you now make to your approach and process for assisting people who have a fear of needles?

Question 1

What does the abbreviation IPaC stand for?

Infection Prevention and Control (IPaC) is a core element of quality, patient safety and governance systems. It should be the primary aim of all nurses, midwives and healthcare assistants.1 With any procedure involving body fluids particular attention should be paid to IPaC. With regards to venepuncture this should include hand hygiene, aseptic technique, protective clothing and sharps disposal.

http://www.rcn.org.uk/development/practice/infection_control

NICE CG 139. Infection, Prevention and control of healthcare-associated infections in primary and community care

NICE QS 61. Quality Standard, Infection Prevention and Control

Where is your workplace policy for infection control kept? Is it easy to access? Take some time to read through your workplace policy for infection control. When is this next due to be updated? Who in your place of work is the responsible lead for infection control?

Question 2

Which one of the following statements is correct?

It is essential to confirm the patient’s details using a minimum of two forms of identification, carefully checking the request form for which samples are required. Ensure your patient’s comfort and then select an appropriate vein to take the sample from, avoiding affected sides following cerebral vascular accidents (CVAs) or post mastectomy where lymphatic drainage may be affected. Also avoid sites where peripheral vascular devices or fistulas are in situ, or where bruising, infection, inflammation or scarring is present. You should also consider that taking a sample close to a site where intravenous fluids are being administered may affect the result. A combination of visualisation and palpation should be used to determine vein choice as this ensures veins are selected rather than arteries or tendons, and enables valves to be avoided which could hinder flow.

Samples should be taken in the following order, to avoid haemolysis:

A single use tourniquet should be applied to the upper arm 5–10cm above the proposed puncture site. It should be tight enough to impede the venous flow, but not occlude arterial flow (a radial pulse should still be present). It can also be helpful to ask the patient to open and close their hand to encourage venous filling, thus dilating the vein.

1. Becan-McBride K. Laboratory sampling: does the process affect the outcome? Journal of Intravenous Nursing 1999;22(3):137–142

Nottingham University Hospitals NHS Trust. Guideline for venepuncture using the Vacutainer system, 2013

http://www.nottingham.ac.uk/mhs/documents/clinical-skills/nuh-guidelines/venepuncture.pdf

Access the guideline above. How does this compare with your local guidelines/practice protocol?

Which other members of staff in your place of work are involved in venepuncture? Discuss together how you all approach process and procedure. You may identify some individual/collective training and update needs which can be conveyed to line manager, practice manager or other person responsible for staff training and development.

Question 3

Which of the following statements is correct?

It is the clinician’s responsibility to be able to deal with any adverse effects that may occur during the process. When damage to a nerve occurs (indicated by the onset of symptoms of numbness) the patient should always be reviewed by a clinician. Should a patient experience a vasovagal attack call for help 

 and then lay the patient down and elevate legs. If haematoma formation occurs remove the needle and apply pressure for 3 minutes. If there is bleeding following procedure, apply pressure initially and if not resolving, apply a pressure bandage. Arterial puncture will need pressure to be applied for at least 

If you have delegated the procedure to a healthcare assistant, it is your responsibility to ensure that they know how to proceed in the event of an adverse event. Following initial training of a healthcare assistant a period of supervision and assessment of competency is required to consolidate theoretical knowledge, and practitioners should comply with the policies and procedures of their organisation.

 If the task has been delegated to you, you should be confident that it is within your competence to perform it.

1. Nursing & Midwifery Council. Delegation. 

http://www.nmc-uk.org/Nurses-and-midwives/advice-by-topic/a/advice/Delegation/

The developing role of the HCA in general practice

The changing role of the healthcare assistant

Access the RCN link here to find out more information about governance standards for Education and Training:

http://www.rcn.org.uk/development/health_care_support_workers/professional_issues/education_and_training

Question 4

It is not good practice to complete all details on forms and bottles in advance of a patient’s blood test. Confusion may arise regarding patient identity, with the wrong forms or bottles used, with potentially disastrous consequences.

There are various different collection systems available such as Vacutainer®, Monovette® or Vacuette®, so ensure you are familiar with the system used within your local area, remembering that the bottle lid colour (determining the presence or absence of preservative) differs between systems. Once the last sample has been collected, release the tourniquet, remove the needle and place a swab over the site, applying pressure. Dispose of equipment safely and appropriately and immediately label the samples, completing all the relevant information and – as the gold standard procedure dictates – double check any cross matched samples. Attend to the patient’s comfort, applying a dressing if required and give relevant advice on post procedure care including when and how results will be available. Do not assume that this has been discussed and arranged with the doctor. Ensure that the completed forms contain the practice contact information including the surgery contact telephone number in case any urgent messages need to be conveyed regarding the results.

Registered nurses should regularly review current evidence-based guidelines to make certain that not only are their skills being maintained so they continually work within the NMC Code,1 but also to make sure protocols and policies are kept up to date with the latest guidance.

The importance of clinical protocols and training

Your place of work should have a protocol for taking blood. Do you know where to source this? Read through the protocol and note the date when this is next due to be reviewed and updated.

Routine Tests Part 2

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