VENEPUNCTURE

(PHLEBOTOMY) -
DELEGATE
ECG ©

NOTES January 2018

Contents
Introduction ............................................................................................................ 3
Delegating and accepting the clinical task.................................................................. 3
Definition and indications ......................................................................................... 3
Consent................................................................................................................... 4
Mental capacity........................................................................................................ 4
Chaperoning ............................................................................................................ 5
Confidentiality.......................................................................................................... 5
Infection control ...................................................................................................... 5
Anatomy and physiology .......................................................................................... 7
Vein structure .......................................................................................................... 8
Valves ..................................................................................................................... 9
Vein selection ........................................................................................................ 10
Site selection ......................................................................................................... 11
Veins to avoid ........................................................................................................ 12
Associated nerves .................................................................................................. 13
Preparation of the environment .............................................................................. 14
Equipment ............................................................................................................ 14
Devices ................................................................................................................. 15
Tourniquets ........................................................................................................... 15
Lab forms .............................................................................................................. 16
Preparing your patient............................................................................................ 16
Procedure .............................................................................................................. 17
Improving venous access ....................................................................................... 19
Order of draw ........................................................................................................ 20
Labelling (3) ........................................................................................................... 22
Potential complications ........................................................................................... 22
Needlestick injuries (1, 3) ......................................................................................... 23

Storage and transport ............................................................................................ 24

Documentation ...................................................................................................... 24
Unsuccessful venepuncture............................................................................... 24

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References ............................................................................................................ 25

Introduction
These delegate notes are designed to supplement your face to face training, providing you with
the theoretical foundation to enable you to safely practice venepuncture.

Delegating and accepting the clinical task

Blood tests used to be performed exclusively by medical staff, however with venepuncture
becoming one of the most common procedures in healthcare, it is a role that can now be
undertaken by all healthcare professionals, including unregistered practitioners. (1)

Venepuncture must only be carried out on the direction of a member of clinical staff. The
clinician completes a request for a blood test and then delegates to a suitably trained
colleague. The clinician remains accountable for the appropriateness of this delegation, and for
ensuring the person who does the work is competent to do so. (2)

Once delegated to, those who perform venepuncture are responsible for ensuring they have
received the correct training and have documented, supervised practice in which another
competent practitioner has deemed them competent to perform the skill unsupervised. The
onus is also on individuals to ensure that their knowledge and skills are maintained and
updated, and to recognise and work within their limitations. (1)
Venepuncture is a skill regulated by the Care Quality Commission (CQC) - practitioners must be
registered with CQC or work for an organisation registered by CQC. (13)

All staff must operate within the policies, protocols and guidelines of their
particular organisation.

Definition and indications

Venepuncture is the procedure of inserting a needle into a vein, usually to obtain blood.

Blood analysis is one of the most important and commonly used diagnostic tools available to
clinicians. A sample of blood is sent to the laboratory for one of the following types of analysis;
Haematology, Biochemistry, Immunology or microbiology. (9)

Blood test may be taken for

• Diagnostic purposes
• Monitor levels of blood components
• Assess organ function
• Monitor levels of drugs
• Monitor response to medical treatments (e.g. fluids, drugs)
• Cross match for a blood transfusion
• Screen for infection
• Genetic screening

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Consent
It is a general legal and ethical principle that valid consent must be obtained before starting
any treatment, investigation, or providing personal care for a person. (6) This includes
venepuncture. Consent must be:
a) Given by a competent person
b) Voluntary
c) Informed

Informed Consent
This is when the healthcare professional has given the patient full information about the
procedure and the risks so that they understand what they are consenting to. Practitioners
need to ensure all aspects of “informed consent” are discussed with the patient. (2)

Informed consent can be easily established in a friendly and informative manner. The
following points must be discussed: (3)

• What is involved in the procedure

• Why the blood is being taken
• Potential risks and side effects of the procedure
• When the blood results will be available
• Consequences of the procedure e.g. commencement of treatment following the results

Implied consent
We assume we have the patient’s consent when the patient sits down and rolls up their sleeve.
Implied consent should be avoided as it has no standing in a court of law. (1)

Written consent
This is not normally required for a blood test but would be required in specific circumstances,
for example if the blood was being provided for research or genetic testing.

Mental capacity (4)

The conversation around consent is a good opportunity to assess whether a patient has mental
capacity – i.e. is able to understand the conversation and make their own informed decisions.

A person’s Mental Capacity may be impaired either temporarily or permanently. Temporary

impairment may be due to sedative medications or acute confusion. Longer term impairment
may be as a result of dementia, brain injury or a learning disability. Occasionally you may be
referred a patient who has dementia who will be accompanied by their relative or carer who
may have a power of attorney to make decisions on their behalf. A healthcare professional has
the ability to make some decisions in the patient’s best interest.

When assessing capacity, the first decision is whether there is impairment of the mind or brain
(either temporary or permanent). If so, does this make them unable to make a particular
decision? The person will be unable to make the particular decision if they cannot do the
following things:

1. Understand the information relevant to that decision, including understanding the likely
consequences of making, or not making the decision

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 2. Retain that information

3. Use or weigh that information as part of the decision-making process

4. Communicate their decision

If you have concerns regarding a person’s capacity to make a decision, discuss

with a clinician to get further advice

Chaperoning
Patients may find any examination distressing, in particular if it involves the need to undress or
be touched. It is good practice to offer all patients a chaperone for any examination or procedure.
The chaperone serves several functions:

1) It acknowledges the patient’s vulnerability, and provides support to the patient

2) Provides protection for healthcare professionals against unfounded allegations of
improper behavior
3) The chaperone can identify unusual or unacceptable behaviour on the part of the
healthcare professional thus protecting the patient from abuse (5)

It is important to document that a chaperone was present and either name/or initials of the
chaperone. If the patient is offered a chaperone and declines it is important to record that the
offer was made and declined.

- For more information, ECG offer chaperoning courses both onsite and online

Confidentiality
As with any aspect of care, confidentiality must be maintained. (2)

Infection control
Venepunture provides a direct portal of entry for infectious pathogens into the circulation system
plus puts the practitioner at risk of exposure the patients blood.

The following standard infection control precautions help reduce the risk of healthcare acquired
infections (HCAI’s)

• Hand hygiene
Good hand hygiene is the single most important way of preventing the spread of infection.
(7)
Hand hygiene describes processes that reduce the number of micro-organisms and
includes hand washing and use of alcohol gel. Effective hand hygiene involves making sure
all aspects of the hands have been cleaned.

If hands are visibly soiled or potentially contaminated wash hands with antibacterial soap
and water and dry with single use towels.

If hands are not visibly contaminated, clean with alcohol rub (use 3ml of alcohol rub on the
palm of the hand, and rub it into fingertips, back of hands and all over the hands until dry).

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 The National Patient Safety Agency (NPSA) have produced guidelines on how to
clean hands effectively with either soap and water or alcohol based gel. These
pictorial guidelines can be found on www.npsa.nhs.uk

To support compliance with hand hygiene in the workplace, health care workers should
meet the following standards while working: (15)
• keep nails short, clean and polish free. Artificial nails or nail extensions must not be
worn
• avoid wearing wrist watches and jewellery
• avoid wearing rings with ridges or stones (a plain wedding band is usually acceptable,
but refer to local policies)
• cover any cuts and abrasions with a waterproof dressing
• wear short sleeves or roll up sleeves prior to hand hygiene (refer to local dress code or
uniform policies)

• Personal Protective Equipment (PPE)

Standard infection control precautions advise that staff should wear protective clothing
appropriate to the clinical activity. In venepuncture, it is appropriate for clinicians to wear
gloves and a disposable apron. (9)

NICE (2012) states that “Disposable plastic aprons should be worn when there
is a risk that clothing may become exposed to blood, body fluids, secretions or
excretions, with the exception of sweat” (8)
• Gloves

The National Institute for Clinical Excellence (2012) states that: “Gloves must be worn for
invasive procedures, contact with sterile sites and non-intact skin or mucous membranes,
and all activities that have been assessed as carrying a risk of exposure to blood, body fluids,
secretions or excretions or sharp or contaminated instruments”. (8)

The World Health Organisation advise that health workers should wear well fitting,
non-sterile gloves when taking blood; they should also carry out hand hygiene
before and after each patient procedure, before putting on and after removing
gloves.

Natural latex rubber (NLR) proteins found in latex gloves can cause severe allergic
reactions – following a risk assessment, if latex gloves are selected they must be low
protein. Neoprene or nitrile are good alternatives to NLR showing comparable barrier
performance. (15)

Vinyl gloves can be used to perform many tasks in the health care environment. However,
depending on the quality of the glove, vinyl may not be appropriate when handling blood,
blood-stained fluids, cytotoxic drugs or other high risk substances. (15)

Please check the local policy for your workplace for further guidance

Put on close fitting, non-sterile gloves. Gloves should be close fitting otherwise dexterity will
be impaired. Use one pair of gloves per procedure or patient.

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 • Aseptic Non-Touch Technique (ANTT)
ANTT is a process that seeks to prevent or reduce micro-organisms from entering a
vulnerable body site or during the insertion of invasive devices.
ANTT reduces the risk of an infection developing as a result of the procedure.
Adhering to an ANTT means that once the skin has been cleaned, only the sterile needle then
comes into contact with that area.

• Skin cleansing
The use of an appropriate skin disinfectant will reduce the number of micro-organisms at the
site of insertion.

Skin cleansing with 2% chlorhexidine in 70% isopropyl alcohol is recommended.

Chlorhexidine is an anti-microbial agent that has been shown to reduce the risk of infection.
Clean the site for 30 seconds and allow to dry completely (30 seconds). Apply firm but gentle
pressure. DO NOT touch the cleaned site or you will need to clean the site again. (3)

• Sharps disposal
There are a number of laws that require employers to protect health care workers from
sharps injuries. The overarching law is the Health and Safety at Work etc. Act 1974.
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013, enforce this
act.

Health and Safety regulations (2013) now state that where a sharp is required the use of
safer sharps (incorporating protection mechanisms) should be used where reasonably
practical. The term ‘safer sharp’ means medical sharps that incorporate features or
mechanisms to prevent or minimise the risk of accidental injury. For example, a range of
syringes and needles are now available with a shield or cover that slides or pivots to cover
the needle after use. (14)
The correct sharps disposal procedure should be adhered to in accordance with policies and
procedures within the workplace. To minimise the risk of injury, sharps should never be re-
sheathed and should be discarded into an appropriate sharps bin immediately after removal
from the patient. Place the sharps bin within easy reach, no more than one arms distance
away from the client. They should not be filled above two-thirds full (there is a mark on the
side indicating the fill line).

• Blood spills
Use of the vacutainer system reduces the risk of blood spillage by drawing the blood directly
into the tube however, there is still a risk of blood spills with this procedure.

Blood spills must be dealt with quickly and safely to minimise the infection risk, follow your
workplace’s written policy for blood spills.

Anatomy and physiology

The Heart

The Heart is a four-chambered pump split into - the top two chambers (atrium), bottom two
(ventricles) and into the left and right side.

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 Designua/Shutterstock.com

The role of the right side is to pump deoxygenated blood to the lungs. Blood returns to the
right atrium from the inferior and superior vena cava where it flows down into the right
ventricle and then is pumped to the lungs via the pulmonary artery.

The reoxygenated blood is returned to the left side of the heart via the Pulmonary Vein to the
left atrium, it flows into the left ventricle which then pumps the reoxygenated blood around the
rest of the body. (1) Blood is carried to the body’s tissues via blood vessels.

Arteries carry oxygenated blood away from the heart and veins carry deoxygenated
blood back to the heart.

Vein structure

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 NelaR/Shutterstock.com

Veins consist of three layers:

The tunica externa is the protective outer layer of the vein and consists of connective tissue
which surrounds and supports the vessel.
The tunica media is the middle layer of the vein and is composed of muscular tissue and
nerve fibres that can stimulate the veins to contract or relax. Stimulation of this layer by
changes in temperature, mechanical stimulation (e.g. introducing the needle into the vein) can
produce spasms which can make venepuncture more difficult.
The tunica interna is the inner lining of the vein and is constructed of smooth endothelial
cells which facilitates the passage of blood cells etc. In veins this inner lining has valves which
prevent the backflow of blood and aid the blood return back to the heart. They are present in
larger blood vessels and at points of branching (bifurcation).
Arteries have the same three layers, however because arteries transport blood away from the
heart under pressure, they have a thicker tunica media to withstand this pressure. (9)

It is very important not to inadvertently puncture an artery during venepuncture.

To do so would cause significant discomfort and complications. (1)

Valves
Valves can be seen as noticeable bulges in the veins and are usually found at bifurcation points
(junctions). The practitioner needs to learn to palpate the vein to check for the presence of
valves and ensure that venepuncture occurs away from the valve in order to facilitate collection
of the blood sample.

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Avoid valves! They will be more painful and will prevent the withdrawal of blood.

Vein selection (10)

The veins normally used for venepuncture are those found in the inner elbow, known as the
antecubital fossa (ACF). They are usually of a good size and are capable of providing copious
and repeated blood specimens. They are also easily accessible, thus ensuring that the procedure
can be performed safely and with the minimum of discomfort for the patient. The main veins of
choice are:

• Median cubital vein

• Cephalic vein
• Basilic vein

The median cubital vein may not always be visible, but its size and location make it easy to
palpate. It is also well supported by surrounding tissue, which prevents it from rolling under the
needle.
The cephalic vein is located on the lateral aspect of the wrist, and rises from the dorsal veins
and flows upwards along the radial border of the forearm, crossing the antecubital fossa as the
median cephalic vein. Care must be taken to avoid accidental arterial puncture, as this vein
crosses the brachial artery. It is also in close proximity to the radial nerve.
The basilic vein, originating in the ulnar border of the hand and forearm, is often avoided as a
site for venepuncture: this is for good reason. Although the basilic vein may be prominent
(particularly in men), it is awkward to access and it is not well supported by subcutaneous tissue
and tends to roll easily. These features make venepuncture of the basilic vein difficult. Care
must also be taken to avoid accidental puncture of the median nerve. (10)

Of the three veins the median cubital is the ideal choice for venepuncture. It is
easily visualized, located and palpated and is known as the “Phlebotomist’s friend”.

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 Blamb/Shutterstock.com

Site selection
The choice of vein is an important step. The best choice is a vein which appears healthy, is easily
detected, accessible and unused. The most visible vein is not always the best option. (10) As
arteries and nerves can be in similar locations care must be taken during assessment to avoid
them. (9)
Choosing the vein is a 2-stage approach which includes:
1. Visual inspection
To identify factors that could cause problems such as:
• Areas of infection
• Thin and fragile veins

2. Palpation
In order to
• Determine the location and condition of the vein
• Distinguish from arteries, tendons and nerves so reduces the risk of damage to
one of these structures
• Identify the presence of valves

To palpate - place two fingertips over the vein and press lightly. Release pressure to assess for
elasticity and rebound filling. When you depress and release an engorged vein, it should spring

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back to a rounded full state. (10) Try and use the same fingers for palpation as, over time, this
will increase sensitivity. The thumb should not be used – it is not as sensitive and has a pulse
which may lead to confusion in distinguishing arteries from veins. (10)
Choose veins which are:
Soft, bouncy, refill when depressed, well supported by subcutaneous tissue, easily detected.
Also, listen to the patient – they will be able to advise you which veins may have been successful
or unsuccessful in the past.
Arteries have much thicker walls so will feel more elastic on palpation. You will also feel a pulse
which is caused by the artery expanding in response to the blood being pumped from the left
ventricle. (1)
Tendons feel very rigid, do not have a pulse and move when the patient moves their fingers.

Veins to avoid

When making a choice, avoid veins that are: (9)

Arterial puncture
Arterial puncture is caused by inadequate assessment and poor technique. It will lead to bright
red blood pulsating into the tube. If an artery is punctured the needle should be removed
immediately and digital pressure applied for 5 minutes followed by a pressure bandage for a
further 5 minutes. The tourniquet must not be re-applied to the arm for at least 24 hours. The
patient will need to be observed, assessed and receive medical supervision, and the incident
recorded in the patient’s notes. (10)

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Associated nerves
Care must be taken during the assessment and procedure to avoid nerves. (9)

The 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.

Blamb/Shutterstock.com

The 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

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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’.

The 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. It 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.

Careful site selection and insertion of the needle will minimise the risk of nerve injury. The needle
should be inserted at less that 40° and blind probing avoided. (10)

In the event of damage to the nerve, the patient will experience sharp pain or burning sensation
down their arm and potentially numbness and tingling to fingers. The needles should be removed
immediately and guidance given if pain/numbness for more than a few hours. The event should
be documented in the patient’s notes.

Preparation of the environment (3, 10)

Ensure the environment has been prepared taking into the consideration the following points-
• Quiet
• Comfortable
• Appropriate temperature - a cold environment will cause vasoconstriction and will be difficult
to palpate the vein
• Clean and tidy
• Well lit
• Private
• 2 chairs
• Sink

Equipment (3)

Place equipment safely and within easy reach on a trolley or tray and have spare equipment to
hand. You will need:
• Specimen request form
• Disposable tray
• Alcohol hand gel
• Alcohol swabs (refer to local policy)
• Non-sterile gloves
• Apron
• Tourniquet
• Gauze swabs
• Sterile needle or winged device
• Single use vacutainer needle holder
• Vacuumed specimen tubes
• Sterile plaster
• Sharps box
• Leak proof specimen bags

Check expiry dates and packaging to ensure sterility has been maintained. All sterile equipment
must be single use. (3)

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Devices
There are a number of vacuum systems that can be used for taking blood samples. This is the
safest method for taking blood – offering a completely closed system for the process so reducing
the risk of contamination. They are simple and cost effective. (10) Blood collection systems with
safety devices are now readily available and should be used for all procedures. (12)

The standard needle gauge to use is 21 gauge which enables blood to be withdrawn at a
reasonable speed without undue discomfort to the patient or damage to the blood cells. (10) For
smaller veins, if the needle is too large it can damage the vein so a smaller gauge (23 gauge)
may be needed.

Remember - The smaller the gauge of the needle the larger the gauge number

Safety needle (21 gauge) and vacutainer holder

• Easy to use with larger veins

• Cheaper than butterfly devices

Winged infusion device (butterfly) – 21-23-gauge needle

• Good for blood drawing from patients with small or fragile veins
• Allows better precision than needle

Care must be taken to choose the right gauge needle. If the needle is too large for the vein
for which it is intended, it will tear the vein and cause bleeding (haematoma); if the needle is
too small, it will damage the blood cells during sampling. (3)

Tourniquets

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There are several types of tourniquet available. The tourniquet material should be cleanable
and latex free. Single use tourniquets should be used where possible. (12) Fabric tourniquets
that cannot be cleaned should not be used. (3)

The tourniquet should be applied 7-8cm above the antecubital fossa with enough pressure to
impede venous flow – if the radial pulse cannot be felt, the tourniquet is too tight. Careful
attention needs to be paid to the length of time the tourniquet remains in place. The tourniquet
should not be left on for longer than 90 seconds - leaving a tourniquet on for longer may cause
damage to blood cells that can cause potassium to be released thus leading to inaccurate blood
results. (1)

Lab forms (11)

Traditionally paper “blood forms” were used to request blood tests. Many clinical settings now
use computer based systems - with the clinician completing an electronic request form that the
practitioner then prints off when the patient attends for the blood test appointment.

Blood request forms must contain the following information:

• Surname and forename
• NHS number (depending on local policy)
• Date of birth
• Gender
• Sample date and time
• Name of clinician requesting blood
• Specimen type
• Tests required
• Relevant clinical details

These blood forms will often advise the practitioner what colour bottle they will need for the test.

In your preparation for venepuncture, check the request for the specific test(s) required. Be
certain that you understand what type of blood specimen is required, what tube is needed and
the amount of specimen required (if in doubt, call the appropriate lab).

Preparing your patient (3)

Ensure the following steps are followed:

• Introduce yourself and ask patient to confirm their name and date of birth
• Check the lab form matches the patient identity

• Check for allergies, phobias, previous problems, preferred arm/contraindications

• If the patient is anxious or afraid, reassure the person and ask what would make them
more comfortable
• Make the patient as comfortable as possible
• Discuss procedure and gain informed consent

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Also:
• Offer chaperone
• Check whether they have fasted or altered their medication regime if necessary

Procedure (3, 10)

Action Rationale
Pre-procedure
Wash hands To ensure hands are not contaminated to
prevent cross infection.
Approach patient in a confident manner To ensure that the patient understands the
and explain and discuss the procedure with procedure and gives his/ her valid consent.
the patient.
Allow the patient to ask questions and Anxiety results in vasoconstriction;
discuss any problems which have arisen therefore, a patient who is relaxed will have
previously. dilated veins, making access easier.
Consult with patient regarding arm To involve the patient in the treatment. To
preference. Check for allergies. acquaint the nurse fully with the patient’s
previous venous history and identify any
changes in clinical status e.g. Mastectomy.
Check the identity of the patient matches To ensure sample taken from the correct
the details on the request form by asking patient.
their full name and date of birth (and if
available check their identity bracelet).
Assemble the equipment necessary for To ensure time is not wasted and that the
venepuncture. procedure goes smoothly without
unnecessary interruptions.
Carefully wash hands using soap and water To minimize the risk of infection.
or bactericidal hand rub and dry before
commencement.
Check hands for visibly broken skin and To minimise the risk of contamination to the
cover with a waterproof dressing. practitioner.
Check all packaging before opening and To maintain asepsis throughout and check
prepare equipment on the chosen clean that no equipment is damaged.
receptacle/ area.
Procedure
Take all the equipment to the patient To make the patient at ease with the
exhibiting a competent manner procedure.
Support the chosen limb on a pillow To ensure patient’s comfort and facilitate
venous access.
Apply the tourniquet to the upper arm on
the chosen side, making sure it does not To dilate the veins by obstructing venous
obstruct arterial flow. (If the radial pulse return.
cannot be palpated then the tourniquet is
too tight).
Select the vein by careful palpation to To prevent inadvertent insertion of the

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determine size, depth and condition. needle into other anatomical structures.
Release the tourniquet. To ensure patient comfort.
Select the device, based on vein size, site To reduce damage or trauma to the vein and
and volume of blood to be taken. Use a 23g prevent haemolysis.
winged infusion device for small veins.
Wash hands with bacterial soap and water To maintain asepsis and minimize the risk of
or use bactericidal alcohol hand rub. infection.
Put on gloves. To prevent possible contamination of the
practitioner.
Clean the patients skin using appropriate To maintain asepsis and minimise risk of
skin preparation (70% alcohol, 2% infection.
chlorhexidine impregnated swab for 30
seconds) and allow to dry for further 30
seconds.
Re-apply the tourniquet. To dilate the veins by obstructing venous
return.
Anchor the vein by applying manual To immobilise the vein. To prevent counter
traction on the skin 2-5cm below the tension to the vein which will facilitate a
proposed insertion site. smoother entry.
Insert needle smoothly at angle of 30 To facilitate a successful, pain-free
degrees or less– the angle will depend on venepuncture.
size and depth of vein.
Reduce the angle of descent of the needle To prevent advancing too far through vein
as soon as a flashback of blood is seen in wall and causing damage to the vessel.
the vacutainer device or when entry to the
vein wall is felt.
To stabilise the device in the vein and
Slightly advance the needle into the vein if
possible. prevent it from becoming dislodged during
withdrawal of blood.
Do not exert any pressure on the needle. To prevent a puncture occurring through a
vein wall.
Withdraw the required amount of blood To minimize the risk of transferring additives
using vacuumed blood collection system in from one tube to another and bacterial
correct order (see ‘order of draw’ section contamination of blood cultures.
for more info).
Release the tourniquet. To decrease pressure on the vein.
Place swab over the puncture point. To apply pressure.
Remove the needle but do not apply To prevent pain on removal and damage to
pressure until the needle has been fully the interna of the vein.
removed.
Apply digital pressure directly over the To prevent leakage and haematoma
puncture site. Pressure should be applied formation.
until bleeding has ceased; approximately 1
minute or longer may be required if current
disease or treatment interferes with clotting
mechanisms.
The patient may apply pressure with the
finger but should be discouraged from
bending the arm.
Activate safety device and then discard the To reduce the risk of accidental needlestick
needle immediately in the sharps bin. injury.
Gently invert the blood tubes as per To prevent damage to blood cells and to mix

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 manufacturer’s instructions. with additives.
Label the bottles with the relevant details To ensure that the specimens from the right
at the patient’s side. patient are delivered to the laboratory, the
requested tests are performed and returned
to the patient’s records.

Post procedure
Inspect the puncture point before applying To check the puncture point has sealed.
a dressing.
Confirm whether the patient is allergic to To prevent an allergic reaction.
adhesive plaster.

Apply an adhesive plaster or alternative To cover the puncture point and prevent
dressing. leakage or contamination.
Ensure that the patient is comfortable. To ascertain whether patient wishes to rest
before leaving or whether any other
measures need to be taken.
Discard waste – making sure it is placed in To ensure safe disposal. To prevent re-use of
the correct containers. Remove gloves and equipment.
clean hands.
Follow local procedure for collection and To make sure specimens reach their
transportation of specimens to the intended destination.
laboratory.
Document the procedure in the patient’s To ensure timely and accurate record
records. keeping.

Improving venous access

Several techniques can be used to improved venous access
Try Reason
Lowering the arm below the heart Increases blood flow to the vein
Clenching the fist To encourage venous distention – avoid
pumping which can damage cells and
release potassium which would affect blood
results
Warming arm gently Encourages veins to dilate and fill.

If someone is dehydrated, their veins may be sunken/flat and hard to palpate.

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Troubleshooting (10)

Order of draw
There are different types of tubes used in blood drawing. Each tube is identified by the colour
stopper and additive within the tube, each additive has a particular function.

When taking blood samples, it is essential to take them in the correct order to avoid cross-
contamination of additives between the tubes. As colour coding and tube additives may vary,
verify recommendations with your local laboratories. (3) Most manufacturers will have a coloured
chart available that will show which blood bottle is required for the test and the correct order of
draw. It is recommended that this chart is displayed in your clinical area to prevents mistakes
being made. (1)

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Example of order of draw chart

Take in order starting at top of chart first and working down.

Each bottle must be gently inverted several times to mix the blood with the additives thoroughly.
Do not shake the tubes as this will damage the blood cells and invalidate test results.

= One inversion

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 (3)
Labelling
• Do immediately after you’ve taken the sample, never before
• Label bottles with information required by the lab – typically patient’s surname, forename,
date of birth plus date and time of when blood collected
• Complete request form including time sample taken
• Finally sign/initial the form in bottom right corner.
• Do all this before leaving the patient

Potential complications (3, 9, 10)

There are a number of potential problems associated with the practice of venepuncture:
Phlebitis
Infection at the venepuncture site is rare. Following good infection control practice will reduce
the risk of phlebitis. The site should be covered for 15-20 minutes after the procedure.

Accidental damage
To the nerve, tendon or artery if these have not been identified during visual
inspection/palpation. This can result in pain and damage/complications for the patient as well
as loss of confidence for the practitioner. This is rare (1:10,000 venepunctures). To minimise
damage to the other structures the angle of the needle insertion should be less than 40° and
blind probing should be avoided.

Haematoma
This is caused by the infiltration of blood into the tissues and this is the most common
complication arising from venepuncture. This may occur as a result of poor technique on the
part of the practitioner including

• Overshooting the vein

• Failure to release the tourniquet before removing needle
• Inadequate pressure on the venepuncture site once the needle has been removed
• Bending the arm on completion of the procedure

Selecting a needle gauge smaller than the vein will reduce the risk of puncturing the vein.

If a haematoma occurs during the procedure remove the blood bottle, release the
tourniquet, remove the needle and apply pressure for 2-3 minutes.

Prolonged bleeding time

This may be due to a medical condition (clotting disorder such as haemophilia) or drug therapy
(e.g. anticoagulation medication). Practitioners should ensure they are aware of the

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patient/client’s relevant drug and medical history prior to performing venepuncture.

Incorrect or lack of details on the request card and/or sample

This increases the likelihood of errors occurring; any discrepancies will cause the sample to be
rejected by the laboratory, necessitating repetition of the procedure.

WARNING: the wrong patient details on the card can result in a patient receiving
unnecessary or dangerous treatment. All samples must be correctly labelled and the
details must correspond with those on the request card. The patient’s details, both
on the request form and the specimen bottle should be ascertained using the Trust’s
policy for the positive identification of patients.

Insufficient sample/wrong specimen bottle

The laboratory will not be able to process the sample necessitating repetition of the procedure.
However, if it was difficult to obtain the blood sample from the patient, check with the laboratory
staff whether they might be able to process the smaller sample without it compromising the
results.

Needlestick (sharps) injury

Use of vacutainer systems helps to reduce the incidence of this occurring. Needles must not be
re-sheathed, and practitioners must adhere to the Trust sharps policy. In the event of a
needlestick injury, please refer to the section of needlestick injuries.

Blood spillage
Use of the vacutainer system reduces the risk of blood spillage since the blood is drawn directly
into the evacuated sample tube. However, there is a risk of blood spurting from the vein when
venepuncture commences. Please refer to section in ‘Infection Control’ for the procedure of
cleaning blood spills.

Needle or blood phobia

If the patient has a needle or blood phobia it might make it harder to take blood from them.
They might also faint at some point during the procedure. It is important to establish whether
the patient has had previous problems with venepuncture. Approaching the patient in a
confident manner and giving clear and comprehensive information may help to reduce the
patient’s level of anxiety. (1) Distraction is a useful technique for the mildly anxious.

Fainting
In the event of a faint, if possible lie the patient down with their legs raised. This will ensure the
blood is returned to the brain where it is needed. Slowly sit the patient back up after several
minutes to ensure they have recovered.

Needlestick injuries (1, 3)

Injuries from needles used in medical procedures are sometimes called needlestick injuries or
sharps injuries. Sharps can include other medical supplies such as scalpels. A sharps injury is an
incident in which the sharp penetrates the skin. Sharps contaminated with infected patient’s
blood can transmit up to 20 types of diseases including hepatitis B, hepatitis C and HIV
If you sustain a needlestick injury follow this process immediately:
• Encourage the wound to bleed
• Wash the wound using running water and plenty of soap
• Don’t scrub the wound while you are washing it
• Don’t suck the wound

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 • Dry the wound and cover it with a waterproof plaster or dressing
You should then attend the nearest A&E department or contact your employer’s Occupational
Health service.
The healthcare professional treating you will assess the risks to your health and ask you about
your injury. Samples of your blood may be tested for Hepatitis B, Hepatitis C or HIV. Your
healthcare professional may also arrange to test samples of the other person’s blood if they
give their consent.
If you are deemed to be at low risk, you may not need any treatment. If there’s a higher risk,
you may need:
• Antibiotic treatment
• Further vaccination against Hepatitis B
Avoid a needle stick injury at all cost by good practice when dealing with sharps and remaining
vigilant throughout all procedures
Practitioners undertaking venepuncture must be vaccinated against hepatitis B

Storage and transport

Samples should be securely stored in a designated sample collection area, away from direct light
and heat sources (e.g. window sill) and out of reach of patients. The local laboratory guidance
indicates which sample types should be refrigerated and which should be stored at room
temperature.

Documentation
Professional and succinct records must be maintained; not only for clinical reasons, but also
documentation acts as a safeguard against formal complaints or, in extreme cases, legal action.
Document:
• Chaperone offered/present - with name/initials
• Consent gained
• Blood sample taken
• Which arm and site – e.g. left ACF
• Note any issues

Unsuccessful venepuncture
There should be no more than 2 unsuccessful attempts by the same practitioner on one patient
at any given time. If the attempts are unsuccessful, the patient must be reassured and referred
to another more experienced practitioner.
The healthcare professional requesting the sample must be informed if the sample
was not taken and it might delay or affect treatment.

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 NOTES -

References

1
Brooks, N. (2014) Venepuncture and Cannulation. MK: Cumbria

2
Nursing and Midwifery Council (NMC) (2015) The Code- Professional standards of practice
and behaviour for nurses and midwives (online)
Available at –https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-
code.pdf

3
World Health Organisation (2010) WHO Guidelines on drawing blood: best practices in
phlebotomy. [online] Available at
http://www.who.int/injection_safety/phleb_final_screen_ready.pdf

4
Mental Capacity Act (2005) (online). Available at -
http://www.legislation.gov.uk/ukpga/2005/9/section/3

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5
Medical protection Society (2016) (online). Available at -
https://www.medicalprotection.org/uk/resources/factsheets/england/england-factsheets/uk-
chaperones

6
Department of Health (2010) Reference Guide to consent for examination and treatment
(online). Available at -
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_10
3653__1_.pdf

7
World Health Organisation (2009) WHO guidelines on Hand Hygiene in Healthcare; a
summary (online). Available at
http://apps.who.int/iris/bitstream/10665/70126/1/WHO_IER_PSP_2009.07_eng.pdf

8
National Institute for Clinical Excellence (2012) Infection: Prevention and control of
healthcare-associated infections in primary and community care. (online) Available at
http://www.nice.org.uk

9
Lavery, I. Igram. P. (2005) Venepuncture: best practice. Nursing Standard. 19,49. 55-65.

10
Dougherty L. Lister S. (2015) Royal Marsden Clinical Procedures (6th Ed). Blackwell
Publishing: London.

11
Hospitals and Science, NHS England (2016) (online) Available at
http://hospital.blood.co.uk/media/27451/mpd1108.pdf

12
Royal College of Nursing (RCN) (2016) Standards for infusion therapy (4th Ed.) (online).
Available at - https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/

13
Care Quality Commission (2018) Guidance for providers http://www.cqc.org.uk/guidance-
providers/regulations-enforcement/regulation-4-requirements-where-service-provider#full-
regulation

14
Health and safety Executive (2013) Health and Safety (Sharp instruments in Healthcare)
regulations 2013 (online). Available at – http://www.hse.gov.uk/pubns/hsis7.pdf

15
Royal College of Nursing (RCN) (2017) Essential practice for Infection Prevention and
Control. Guidance for nursing staff (online). Available at - https://www.rcn.org.uk/professional-
development/publications/pub-005940

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