Should student nurses take blood? Venepuncture is not without risks. Student nurses on clinical placements in primary care are sometimes asked to take blood. Should they?
Nursing students (Training)
Primary nursing (Practice)
|Publication:||Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 New Zealand Nurses' Organisation ISSN: 1173-2032|
|Issue:||Date: Feb, 2010 Source Volume: 16 Source Issue: 1|
|Topic:||Event Code: 200 Management dynamics; 350 Product standards, safety, & recalls; 280 Personnel administration|
Undergraduate nursing students working in primary health care on clinical placement are often asked if they will take blood from a client who requires it. There is some confusion about whether this should be allowed. The purpose of this article is to dear up any confusion regarding student nurses performing venepuncture and the focus is a descriptive discussion on best practice.
Are bachelor of nursing students allowed to take blood? This is an oft-asked question. Venepuncture appears to be a relatively simple task performed by many health care workers but if unskilled people are allowed to take blood, complications can occur. These range from relatively minor injuries to potential misdiagnosis, possibly resulting in death.
Venepuncture is the act of inserting a needle into a vein to withdraw blood for diagnostic purposes. (1,2,3,4) or it may be used to administer intravenous antibiotics. (1,2,3) It is a practical skill and is used by a range of health workers. (2,3) It is probably one of the most commonly performed invasive procedures performed both in the primary and tertiary settings. (2,3,5)
Before the procedure, the client must consent to it and following the procedure all equipment must be disposed of correctly. (1)
Venepuncture could be considered a high-risk procedure for a needle stick injury. Nurses are handling blood-filled hollow bore needles, so it is essential a sharps container is located close to where the procedure is to occur. (2) Ideally the needle should be attached to a dosed vacuum system, as this reduces the likelihood of blood leaking and the incidence of needle stick injuries. (1) Nurses must use standard precautions when taking blood, to reduce the potential risk of transmission of infection from the client or between clients. Nurses should routinely wear clean non-sterile gloves. Gloves should be put on just before collecting blood and removed and discarded immediately after use. Hands should then be washed. (4)
Complications are rare but do occur. (5) Venepuncture requires the phlebotomist to navigate around nerves, tendons and arteries to find a vein from which to withdraw blood. (6) Therefore, if complications occur, they have the potential to be exceptionally disabling. Not only are there physical complications, but blood can be mislabeled or a client wrongly identified, which, in turn, may have serious consequences. It has been reported that medical staff rely on 70 percent of their blood results to make decisions regarding client care, therefore it is imperative all identification and labeling is accurate. (2,6)
Venepuncture is not a routine part of the undergraduate nursing curriculum in New Zealand so requires additional training. Discussion with nurse educators confirms there are no policies or protocols regarding undergraduate nursing students performing venepuncture. Both the primary health and district health board sectors have no policies or procedures stating whether undergraduate nursing students can take blood. There have been no policies written to enable students to undertake the procedure. If a student is working in a practice where somebody is prepared to teach the procedure, the student may have the opportunity to take blood but there are no set parameters.
Trauma to the vein results in thrombus formation. (2) Although the procedure looks simple, it is not. There are a number of considerations to take into account before withdrawing blood. These include, but are not limited to, the anatomy and physiology of the vein, which vein to use, the possibility of infection, the age of the client and consent for the procedure.
Veins in the upper limbs are the ones most often used due to their accessibility, convenience and the fact they are usually easily visualised. The most commonly used site is the antecubital fossa as the veins are "large, usually easy to palpate and well supported by muscle and connective tissue". (2) One commentator states "the best veins feel bouncy and full". (1)
Nerve injuries during venepuncture are normally mild and temporary and may be caused by direct puncture or compression. (7) If the nerve is punctured, symptoms usually occur immediately. The symptoms are sharp pain at the venepuncture site, sharp shooting pain up and down the arm, the pain sensation changing depending on the needle position, pins and needles up and down the arm, tingling in the hands and finger tips and pain that persists after the needle is removed. (2,7) Compression injuries to the nerve are caused by subcutaneous hematoma, or the tourniquet being too tight or left on too long. The symptoms of these generally occur 24-96 hours following venepuncture and include pain radiating up and down the arm and numbness and tingling in the arm or hand. (7)
It is critical the client gives consent before blood is withdrawn. Usually verbal consent is satisfactory. The client needs to give their name and date of birth and this must be checked against the details on the request form and on the blood bottles. (2) Sensitive issues such as HIV testing may require more than just verbal consent.
Infection is a possible complication of venepuncture and is related to poor preparation of the skin. The skin is the largest organ in the body and is the largest protective barrier against infections, so skin preparation before any breaks to this barrier is imperative. (8) Crucial considerations to prevent infection are related to the solution used as a skin cleanser, the technique used to clean the skin, ie whether it be back and forth friction or concentric circles to apply the skin cleanser, and the time the solution is left on the skin to dry. The puncture wound caused by the needle can also cause infection at the venepuncture site. Shaving the skin prior to taking blood is not recommended. The micro abrasions as a result of shaving increase the possibility of infection. Scissors should be used to clip hairy sites. (4)
As a person ages, so do their veins. Often veins in older people are easy to see but may be mobile. As the skin ages the muscle layer reduces and does not support the vein as it did, making it more difficult to take brood. The veins also become more fragile and may be thrombosed. Pathological changes may cause the veins to become paper thin, which reads to laceration of the vein wall during venepuncture. (2) Nurses need to use basic venepuncture skills when withdrawing blood from an elderly client with fragile veins and this may be as simple as altering the angle of insertion of the needle. (3)
Multiple venepuncture attempts
Other factors to consider are anxiety, and the presence of fractures, skin conditions and illnesses. Nurses must be aware of a client's demeanour, as a significant number of people have anxiety related to needle insertion. Nurses need to have skills to reduce this anxiety, as negative experiences exacerbate this anxiety and multiple venepuncture attempts make the anxiety worse. Multiple attempts agitate the client, compromise the respect the client has for the nurse and increase needle phobia. The number of attempts a nurse makes to access a vein significantly affects the client's experience. It is recommended that facilities have guidelines for the number of attempts a nurse may make to access a vein. The Journal of Infusion Nursing standards of recommended practice recommends only two insertion attempts by any one nurse. (3) Not only are multiple venepuncture attempts distressing to the client, they also delay treatment and add costs to the health care facility.
When a client has an obvious skin condition that arm should not be used. If a client has an intravenous infusion running, the opposite arm should be used to take blood. If this is not possible, the infusion should be stopped and blood should be taken from below the infusion site. (2) A client who has a fractured arm or has had a previous stroke should not have blood taken from that limb. Veins in the affected arm of women who have had a mastectomy should be avoided. Illnesses such as dehydration, diabetes or cardiovascular disease leading to fragile veins need to be taken into account before withdrawing blood. (3)
There is much more involved to taking blood than just popping a needle into an arm and then withdrawing a syringe full of blood. If student nurses are going to perform venepuncture they must have a good knowledge of the anatomy and physiology involved, be aware of possible complications and how to avoid them, and all other considerations highlighted in this article. They need a period of supervision before they become competent and must be aware of their own limitations. As one author aptly asked: "Would you let a hairdresser with no training cut your hair?" (6)
Taking all these points into consideration, it is clear that safe and effective venepuncture is more than a simple task-based skill. Unless undergraduate nursing students have had education in the areas outlined above, they should not be allowed to perform this procedure.
(1) Harris, J. (2008) How to perform venepuncture. Midwives; December 2008/January 2009, 16.
(2) Scales, K. (2008) A practical guide to venepuncture and blood sampling. Nursing Standard; 22: 29, 29-36.
(3) Walsh, G. (2008) Difficult peripheral venous access: Recognising and managing the patient at risk. Journal of the Association for Vascular Access (JAVA); 13: 4, 198-203.
(4) Smith, S., Duell, D. & Martin, B. (2000) Clinical nursing skills: Basic to advanced skills (5th ed.). New Jersey: Prentice Hall.
(5) Barker, L. (2008) Venepuncture syncope one occupational health clinics experience. American Association of Occupational Health Nurses Journal; 56: 4, 139-141.
(6) Ernst, D. (2008). States fail to follow California's read in certifying phlebotomist. Medical Laboratory Observer; 407, 40-41.
(7) Arbique, J. (2007). Reducing the risk of nerve injuries. Nursing 2007; 20-21.
Sue Floyd, RN, BN, MN, is the nursing practicum manager/cervical screening co-ordinator in the Faculty of Health and Sport Science, Eastern Institute of Technology, Napier.
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