VEINS: Self evaluation programme

A SHARPS AND NEEDLESTICK INJURY PREVENTION,

B VENEPUNCTURE AND

C VENECANNULATION

Please read through the reading material and ensure you can complete the checklist before the next workshop session. This is not a competition: go at your own pace

A. SHARPS AND NEEDLESTICK INJURY PREVENTION

Aim: To know the correct handling of sharps and the procedures to be followed in case of a needlestick injury.

To correctly hang a bag of IV fluid

Objectives: Before this session you should be able to: describe:

  • the disease transmissible by blood
  • safety issues regarding the use and disposal of sharps
  • techniques and equipment used in avoiding needlestick injury
  • common errors when handling sharps
  • correct procedure following a needlestick injury

At the session you should be able to demonstrate:

  • planning and execution of simple tasks involving sharps
  • ability to perform manual tasks while wearing gloves

Although many hospital are moving towards needle free systems, needlestick

injury remains a very real hazard, and avoidance of injury requires constant vigilance.

CAUSES OF NEEDLESTICK INJURY

The two commonest causes of needlestick injury are:

1. Lapse in concentration

2. Lack of organisation

Both are easily preventable BY ESTABLISHING THE HABIT OF direct disposal. Always have your sharps bin so close that you can safely deposit the sharp as soon as you have removed from the patient.

Common pitfalls resulting in needlestick injury include:

  • re-capping needles
  • sharps bin is not taken to the bedside, or is placed out of reach (eg on the other side of the bed!)
  • flexible butterfly needle tubing curling up when the needle is withdrawn
  • sharps carried by hand to a distant bin
  • sharps bouncing off funnel or lid of the sharps bin
  • sharps not separated from other equipment during the procedure

PROCEDURE TO FOLLOW AFTER NEEDLESTICK INJURY

1. FIRST AID/EXPOSURE TREATMENT

  • Clean wound to encourage bleeding.

  • Skin: Rinse with cool running water.

  • Wash with soap and water or apply antiseptic.

Mucous Membranes: Irrigate with water or normal antiseptic.

Eyes: Irrigate with normal saline.

2. SUPPORT/TREATMENT

The hospital will have specific staff designated to assess your exposure and counsel you about associated risks and treatment. This should be done in private and with full confidentiality. Contact Staff Health in working hours. After-hours arrangements usually involve emergency department staff- check the details at your own hospital.

Note: You are not obliged to use staff health or the hospital counseling or blood testing facilities. If you prefer, see your own GP promptly to be assessed, and have the appropriate blood tests.  Don’t be intimidated into using hospital facilities if, for confidentiality reasons, you prefer to see your own doctor.

3. DOCUMENTATION

  • Complete an Accident/Incident report to document when the injury occurred and that it occurred at work. This is important in case of any subsequent legal action.
  • Speak to the patient whose blood was involved in the needlestick injury, explain the situation, and request permission to test their blood for HIV, Hepatitis B and Hepatitis C. Most patients will understand your concerns and consent readily. At some hospitals, if you go through staff health, this will be done on your behalf. Ask when you present to staff health.

If the patient is in clinic or day-stay, it is easier to request their permission and to take blood for testing immediately (once you have completed you own first aid).

4. FOLLOW UP

The hospital will provide follow up treatment and support.

If you choose to, see your own doctor.

SHARPS AND NEEDLESTICK INJURY – Checklist Can You:

  • 1. Demonstration of correct disposal of sharps in sharps bins.

  • Hang a bag of fluid, priming the line and join it to the patient using universal precautions.
  • Identify what you must do before you hang a bag of fluid (information not supplied)

B VENEPUNCTURE

Aim: To perform venepuncture and prepare a specimen to go to the pathology lab.

Objectives: At the end of this session you should be able to:

  • demonstrate planning, equipment collection and the performance of venepuncture on the arm model.

SITES FOR VENEPUNCTURE

The site of choice is the ante-cubital fossa Other common sites:

  • forearm veins (look on the anterior and posterior surfaces of the forearm, avoid the palmar aspect of the wrist - very painful),
  • veins above the elbow (good in thin men),
  • dorsum of the hand (more painful)  If the arms are difficult, you may need to use a foot, but the risk of DVT is present.  If nowhere else is acceptable, the femoral vein may be used (ask someone more experienced for help). Remember that the femoral vein is MEDIAL to the artery.

SITES NOT TO PREFORM VENEPUNCTURE

  • Any site that is infected, inflamed, or thrombosed

  • Any site that has a bruise/haematoma

  • On the side where a patient has had a mastectomy, or axillary node dissection, or in the same arm as an A-V fistula for haemodialysis.

OTHER PLACES TO ACCESS BLOOD

If access is extremely difficult, you may be able to obtain blood from other sites where invasive procedures have taken place:

  • Arterial line{usually found in the critically ill
  • Central venous catheter{patient in ICU or HDU only
  • Hickmanns catheter

Large bore IV cannula in situ for another purpose: care with avoiding personal contamination is required

EQUIPMENT REQUIRED AT THE BEDSIDE

There is a stocked IV trolley for the venepuncture and cannulation, which can be wheeled to the bedside.

You need:

  • Tourniquet or sphygmomanometer
  • Gloves - Nonsterile for routine venepuncture
  • Sharps bin
  • Alcohol wipes
  • Needles and syringes or vacutainer kit
  • Appropriate blood collection tubes
  • Gauge squares or cotton balls

VENEPUNCTURE TIPS

  • Place the arm in a gravity dependent position to allow for increased filling of the vessels prior to taking the sample.
  • If you are having difficulty finding a vein, take the tourniquet off for a while for the patient’s comfort, and then, instead of the tourniquet, try again with a sphygmomanometer pumped up to diastolic pressure.
  • Feel for the vein rather than just looking for it. The most obvious veins aren’t always the juiciest.
  • Look at both arms. Often the patient can tell you which arm is best. Ask!
  • If the patient is cold, ask them to warm the arm in warm water, or cover the arm with warm blankets and come back later.
  • It may help if the patient opens and closes the hand several times to ‘pump up’ the vein. .
  • To obtain blood from an oedematous patient, apply pressure to the site for 2-3 mins to push the fluid away for a short period.

THREE attempts at venepuncture should be your absolute maximum.

  • After this you will fail because of patient’s anxiety, regardless of the condition of the veins. After two or three attempts, depending on the veins left, save the remaining sites and call for help. Watch your helper - you may learn a new trick.
  • After taking blood, instruct the patient to press on the venepuncture site (with gauze or cotton), and to elevate the site, for FIVE minutes. Bending the elbow up with a bit of cotton in the antecubital fossa does not put pressure in the right place and is INADEQUATE. Don’t tap the gauze down - ask the patient to press it in place. Remember you may need that vein again!

If you pull the needle out of the vein while the tourniquet is still on, or if the vein ‘blows’ causing a haematoma, immediately undo the tourniquet, remove the needle, and press firmly on the site with some gauze until bleeding stops.

COMPLICATIONS OF VENEPUNCTURE

  • Pain

  • Bruising/haematoma - often easily avoided, see above.

  • Inadvertent arterial puncture -.

  • Nerve damage -

  • Infection

VENEPUNCTURE TECHNIQUE

  • Explain to the patient what you intend to do.
    Ask the patient if they have had blood taken before. Did they have any problems?
  • Assemble your equipment and wash your hands. Don gloves.
  • Apply the tourniquet and choose the puncture site by palpating the vein.
    It may help if the patient opens and closes the hand several times to ‘pump up’ the vein.
  • Swab the puncture site. Let the alcohol dry on the skin to avoid stinging when you insert the needle.
  • Ask the patient to keep the elbow very straight. Put some traction on the skin just below the insertion site to pull the skin tight and to stop the vein rolling around beneath the skin. Insert the syringe with straight or butterfly* needle at 30 degrees to the skin.
  • Steady the syringe with one hand and pull gently on the plunger with the other to draw blood, being careful not to pull the needle out of the vein.
  • After the blood has been drawn, undo the tourniquet first and then remove the needle.
  • Apply pressure to the puncture site with cotton or gauze. Don’t use tape or bandaid if possible. Ask the patient to hold a clean piece of gauze pressed on the puncture site, and to elevate the arm for 5 minutes.
  • To fill the sample container, insert the needle into the vacutainer through the rubber bung. The required amount of blood will automatically be aspirated into the tube. The advantage of using a vacutainer set for venepuncture is that the blood is taken directly into the tube, therefore eliminating this extra manipulation of the needle.

Label the sample tube before you leave the bedside. (Very important in avoiding potentially dangerous mix-ups.) Check the patient’s first and surname and date of birth. If you use the patient’s printed sticked labels, check that the labels are correct, and all the same.

  • Dispose of sharps and contaminated swabs/syringe. The sharps bin should have been taken with you to the bedside. Contaminated waste bins are found in the treatment room or pan room.
  • Remove gloves and Wash your hands.

C INTRAVENOUS CANNULATION

Aim: To practice of intravenous cannulation.

Objectives: At the end if this session you should be able to demonstrate:

  • state the indications for intravenous cannulation
  • describe the complications of intravenous cannulation
  • discuss the indications for replacing a cannula
  • set up a sterile field
  • prepare a patient for intravenous cannulation
  • assess cannulation sites
  • choose the correct cannula size
  • insert a cannula using aseptic technique
  • secure a cannula
  • remove a cannula
    SETTING UP A STERILE FIELD
  • Wash hands (Simple hand wash).
  • Collect your equipment, and clean the trolley surface by wiping it down with alcohol and paper towel.
  • Unwrap the outer plastic layer of the basic dressing set, taking care not to touch the contents of the set or the sterile inner surface of the packaging, or to allow the ‘dirty’ outer packaging to come into contact with your sterile field.
  • Don goggles or shield mask
  • Apply the tourniquet
  • Clean site with alco wipes if operating as a single operator. ( 0r see below)*
  • Scrub, and glove (gowning may depend on the on procedure)
  • Using one of the plastic forceps in the pack, tip the contents of the green tray out into the sterile working field. Pen any packages required for the procedure onto the sterile tray

INTRAVENOUS CANNULATION SITES.

It is best to choose the most distal point first for IV access. If this proves difficult, then you can try sites further up the arm.  If you start higher up the arm and damage the vein, then none of the sites lower down that vein can be used. Try to choose a straight portion of vein, with no obvious valves. An ideal position is the point at which two veins join to form a ‘Y’, because the veins tend to be less mobile.

SITES:

In general, avoid siting any part of the cannula over a joint. Flow through the cannula will be poor or intermittent and it will be uncomfortable and unwieldy for the patient. This is particularly tricky when siting a cannula in the back of the hand. If you must site the cannula over a joint, put an arm-board on the patient to immobilise that joint, eg: the wrist.

Common sites for insertion are:

  • Forearm veins (avoid inner aspect of the wrist – cannulae don’t last long and the median nerve may be damaged)
  • Back of the hand
  • Antecubital fossa (try to avoid)
  • Upper arm
  • Feet and legs (avoid – increased risk of thrombosis and infection).

Like venepuncture, two or three attempts should be your absolute maximum. If the patient has particularly difficult veins, or limited sites for some reason, (eg mastectomy, A-V fistula for dialysis), call for help early, so that you don’t damage the only remaining veins.

CANNULA SIZE

Choice of cannula size depends on 1) side of cannula 2) vessel size 3) age 4) type of therapy to be given (ie Is if for antibiotics, maintenance fluid therapy, blood products, fluid resuscitation, or surgical procedure?) Most brands of cannula come in two lengths. The short ones are particularly good for inserting into veins on the back of the hand, but may be available. Do not use a smaller size merely to avoid using local anaesthesia, especially in a patient about to go to theatre. Some residents are of the view that cannulas don’t hurt and thus LA can hurt ’’more than the needle." This view is rarely shared by sick patients, though you can ask them! For patients with needle phobis: use Emlar cream and advise them to rub it in for an hour, then return to do the cannulation. You will find the vein is smaller, but the patient is less likely to pull away.

CANNULA SIZE GUIDE

24,22 Children, cytotoxics
22 Minor procedures with LA only, small veins, daily cannula changes
18 Maintenance Fluids including blood, general/major regional anaesthesia possible, antibiotics
16,14 Fluid resuscitation, multiple trauma major volume-losing surgery
14 Rapid infusion sets to be used

COMPLICATIONS OF INTRAVENOUS CANNULATION

  • Pain (especially if sited over a joint)

  • Bruising/Haematoma

  • Localised Infection

  • Phlebitis

  • Thrombosis of the vein

  • Systemic septicaemia
  • Poor fixation: losing the line during an emergency

INTRAVENOUS CANNULATION – TECHNIQUE Summary

PROCEDURE

HINTS

Prepare patient

Explain procedure reiterate the indication

Gather equipment and wash hands

Ensure you have everything you need so that asepsis is maintained once you start the procedure

Apply tourniquet. Palpate the vein and visualise which way the needle will run along it. Choose and clean puncture site.

Allow alcohol to dry on the skin (or it will sting).

Shave hairy arms if necessary.

Put on gloves.

Nonsterile gloves for routine cannulation.

Draw up local anaesthetic and insert subcutaneously at the chosen site using a 25 G needle.

Draw up 1ml of 1% lignocaine into a 2ml syringe. You only need to insert about 0.3ml. DON’T RECAP!!

Uncap the cannula and check that the plastic cannula slides along the metal stylet easily.

Minimises risk of puncturing the vessel wall on the other side.

Stretch the skin tight over the site.

This minimises vessel movement.

Hold cannula with the bevel up. Insert the cannula at 30 degrees to the vessel.

Minimises risk of puncturing the vessel wall on the other side.

Observe hub of cannula for flashback of blood, then drop the cannula down to the horizontal and advance the whole apparatus along the line of the vain another few millimetres.

Flashback indicates that the stylet is in the vessel. To be sure that the cannula is also in, you must advance the whole apparatus a few more millimetres into the vessel. (see diagram below)

Hold the metal stylet still, and slide the cannula off the introducer into the vessel up to the cannula hub.

Cannula should slide easily if you are in the vessel correctly.

Remove tourniquet.

 

Using three fingers along the line of the vein, press on the vein above the cannula and remove the stylet. Apply the cannula cap or anti-reflux valve.

Occluding the vein impedes the blood flow.

Flush cannula with 5ml normal saline or commence infusion.

Warn the patient, if the vessel has shut down in response to cannulation, this may hurt. Confirms patency and prevents blood clotting in the cannula.

Secure the cannula with op-site or steri-strips and op-site.

Occlusive dressing reduces the risk of infection and ensures the cannula does not fall out**

Dispose of sharps and other waste.

Sharps bin and contaminated waste bin as appropriate.

Wash hands.

 

**NB: Poorly secured cannulae will be the commonest reason you are called to resite a catheter

INDICATIONS FOR REPLACING A CANNULA

1. Cannula site is inflamed.

2. Cannula has "tissued". This means the tip of the cannula is no longer in the vein and anything put through the cannula will enter the tissues that surround the vein.

3. Cannula blocked. Check this for yourself by gently attempting to flush the cannula with Normal Saline in a 5ml syringe. Sometimes the tip of the cannula is sitting up against the vein wall or a valve, and you can rescue it by pulling the cannula back a few millimetres, flushing it, and taping it down securely in the new position.

4. Cannula has been in for three days.

Skills checklist This combines skills for venepuncture and cannulation

 

yes

no

Knows the causes of needlestick injury

   

Knows the strategies to avoid needlestick injury

   

Knows the procedure to deal with needle stick injury

   

Knows the sites for venous blood collection and venepuncture

   

Knows the criteria for cannula choice and dressings

   

Knows the complications of cannulation and venepuncture

   
     

Assembles required equipment ahead of the procedure

Tourniquet, gloves, sharps bin, alco-wipes or prep tray, needles syringes, blood collecting bottles, iv fluids ready (prn) ,dressings

Chooses an appropriate size needle/cannula for venepunture/ cannulation

   

Optimises patient conditions (lying down, not cold)

   

Explains procedure in patient appropriate language

   

Maintains contact with the patient during the procedure

   

Maintains asepsis

   

Secures the cannula

   

Writes up follow up orders

   

These workshops resourced a combination of material prepared for Medical students in USYD in ACT by M Done and material prepared by the USYD College of Nursing

BACK to the main student webpage