Professional Documents
Culture Documents
Copyright Royal United Hospital Bath For use by RUH employees only
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This book has been issued to. Date.
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Ward.
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For audit and verification purposes, please complete the above section. You
are reminded that only staff, who have completed the RUH NHS Trusts
Cannulation and venepunture Practical Skills Course and are competent in the
practical skills should assess you.
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Contents
Introduction............................................................................................................................4
The assessment Strategy for Cannulation and Venepuncture.........................................6
Section 1. Guidelines for Professional Practice................................................................8
Section 4. Venepunture.......................................................................................................24
Section 5. Cannulation........................................................................................................28
Section 8. References.........................................................................................................41
Appendix 1: Questions......................................................................................................43
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Introduction
Failure to provide this evidence may result in you being asked to rebook
your Skills Teach for another time.
4
own professional bodys Code of Professional Conduct. Furthermore it is
essential that you refer to the RUH NHS Trust IV Medicine Administration
Policy if you have any doubts as to the correct procedure for the administration
of a given medicine, ie Normal Saline Flush.
Remember, Cannulation and venepuncture are extended roles and should not
come before basic nursing care needs. Ensure you prioritise your work load
accordingly.
5
The assessment Strategy for Cannulation and Venepuncture
This section should be read in conjunction with the assessment strategy flow
chart, a copy of which can be found overleaf.
Staff in clinical areas must have completed the RUH Cannulation and
Venepuncture Competencies to enable them to assess you. Assessors do not
have to have attended the RUH training course if they are able to demonstrate
equivalent training, however they must have completed the RUH
Competencies. In this way minimum standards can be maintained Trust-Wide.
You MUST NOT be assessed by anyone who has not completed RUH
Competencies. Prior to undertaking the course please ensure that there is an
assessor in your work area and that you have ample opportunity to practice
the skills and keep up to date.
Near the end of the book is a section of questions which must be completed.
These will be marked by a member of the resuscitation and Clinical skills
Team on the day of your Skills Teach. Questions must be answered correctly.
In addition, your assessor will question you verbally to assess your knowledge
and competence in your work area.
These competencies apply to all practitioners employed at the Royal United Hospital NHS
Trust
For newly qualified nurses access to this programme is at your managers discretion
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Cannulation and Venepuncture Training Process
Supervised Practice
Candidate attends the taught skills teach 4 hour session
With a patient, the
candidate demonstrates
competence to the
Assessed as competent? assessor using the skills
and knowledge from the
YES NO pre-course workbook and
skills teach
Assessor and candidate sign off
competencies to be kept by
candidate but a copy given to Assessor addresses
learning needs and
ward or department manager
offers a further period of
supervised practice
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Section 1. Guidelines for Professional Practice
Professional responsibility:
All staff who perform venepuncture & cannulation must have received
approved trained and documented, supervised practice.
The onus is also on individuals to ensure that their knowledge and skills
are maintained, both from a theoretical and practical perspective.
All practitioners must operate within the Policies, Protocols and Guidelines
of their particular organisation.
Accountability:
The Code of Professional Conduct (NMC 2004), Guidelines for Records and
Record Keeping (NMC 2005) and your Trusts policies and guidelines will
assist you in understanding your professional accountability (RCN 2005).
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Health and Safety at Work Act
Find definitions and explain how these relate to your practice with
regards to both cannulation and venepunture.
Direct Liability:
Vicarious Liability:
9
Extended Roles
Consent
Summary
Never carry out a procedure that you have not been trained to do, signed as
competent to do or do not feel confident to do.
Remember these skills are extended roles and should not take priority over
basic nursing care. Prioritise your work load accordingly.
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Section 2. Venous Anatomy and Physiology
Identify and name the commonly used veins for venepuncture and
cannulation
Always use veins in the upper extremities before using lower extremity sites
for venepuncture. Veins of the lower limbs should only be used in exceptional
circumstances and by a trained and competent practitioner. The most
common site for venepuncture is at the antecubital fossa. The antecubital
fossa is located at the medial aspect of the elbow. At this point the median
cubital, cephalic and basilica veins lie close to the surface of the skin, this
makes them easily accessible and visible. Research has also found these
veins to minimise discomfort.
The Cephalic vein travels along the radial surface of the forearm. The
Accessory Cephalic is located on the posterior aspect of the forearm joining
the cephalic below the elbow. It is fairly easily palpated if not visible.
The Basilic vein journeys up the ulnar surface of the forearm joining with both
the median cubital and median antebrachial vein below the elbow.
Metacarpal veins located on the dorsum of the hand are often readily visible.
For venipuncture, these veins are used as a last resort, except for small
infants.
However for cannulation the dorsum veins should be attempted first, moving
proximally to the antecubital fossa (ACF). In an Emergency, the veins in the
ACF will be used.
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Study the picture on page 12 and try to identify your own veins at the
antecubital fossa. Attempt to locate your own vein without looking, only by
palpation.
Studying the picture below, note how close the arteries are to the veins.
Think about how you may differentiate between veins and arteries?
Why do you think it is important to differentiate between the two?
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Which veins would you chose to use and why?
The Tunica Externa (the outer layer) A fibrous layer of connective tissue,
collagen and nerve fibres that surrounds and supports the vessel.
The Tunica Media (the middle layer) A muscular layer containing elastic
tissue and smooth muscle fibres.
The Tunica Intima (the inner layer) A thin layer of endothelium that
facilitates blood flow and prevents adherence of blood cells to the vessel wall.
Trauma to the endothelium encourages platelet adherence and thrombus
formation.
The walls of veins are thinner and less elastic than the corresponding layers of
arteries. Veins include valves which aid the return of blood to the heart by
preventing blood from flowing in the reverse direction.
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14
Differences between arteries and Veins
ARTERIES
VEINS
It is important to check for and locate the patients pulse to ensure that you are
not attempting to cannulate or take blood from an artery. Veins do not have a
pulse.
How will you know when you have taken blood from or cannulated an artery
and what action should you take following this?
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Nerves of the arm
Three main nerves run past the elbow and wrist to the hand.
The Median 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. When the median nerve is
compressed over a long period it can cause carpal tunnel syndrome.
The Ulnar 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 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 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. The radial nerve 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.
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Study the picture of the nerves: Which nerves do you think you need to
be aware of when taking blood from the antecubital fossa?
When assessing your patient to obtain blood or for cannulation you need to
choose an appropriate vein. It is essential that you assess for a suitable vein
to ensure for;
1. Successful treatment
2. Viability of venepuncture site
3. to help reduce mechanical phlebitis and chemical phlebitis
Visible
Palpable
Bouncy
Soft
Well supported
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Refills when depressed
Straight and non-toruous
Sites to avoid include:
To palpate a vein
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 back to a rounded full state. Palpate the
position where the cannula tip will rest, not just the point of insertion. If the vein
is not straight then it will be difficult to advance the cannula.
Veins that may appear suitable on inspection, can prove otherwise upon
palpation.
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What questions will you ask your patient that will help you decide on which
vein to use?
Accurate vein assessment is essential in matching your skill level with the
patients condition. It is not appropriate for the novice to attempt
venepuncture on patients with fragile or difficult veins. It is expected that the
novice would become confident and competent before attempting to access
more difficult veins. Discuss vein and patient assessment with your assessor.
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Section 3. Infection Prevention and Control
The Royal College of Nursing (RCN) Standards for Infusion Therapy specify
that Use of aseptic technique, observation of universal precautions, and
product sterility are required in infusion procedures (Royal College of Nursing,
2003).
Objectives
National Institute for Clinical Excellence (2003) 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.
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How will you prevent infection and cross infection in your own Practice?
NICE (2003) also 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. Therefore ensure you
take adequate precautions when cannulating or for venepuncture.
Good hand hygiene is the single most important way of preventing the spread
of infection (Josephson, 2004). Please familiarise yourself with the 7 stages of
handwashing. For more information from the World Health Organisation for
hand washing please following the below link.
http://webserver/clinical_directory/infection_control/links.asp?menu_id=4
Wearing clean gloves rather than sterile gloves is acceptable for the insertion
of peripheral intravascular catheters if the access site is not touched after the
application of skin antiseptics.
What systems and or care plans are in place to reduce the risk from
Cannulation and Venepuncture? What do you have in your areas?
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During invasive clinical procedures including the use of invasive medical
devices, patients depend upon healthcare workers to protect them from
harmful microorganisms. This critical clinical competency is termed:
ASEPTIC TECHNIQUE
This is the most commonly performed critical infection prevention skill in health
care. The aseptic non touch technique is an initiative aimed at ensuring the
essential actions of aseptic technique occur every time. Cannulation and
Venepuncture are skills that require this technique in order to protect the
patient from harmful microorganisms.
Sources of Routes of
contamination Contamination
Free from all Free from marks and Free from pathogens
microorganisms stains and organisms, in
sufficient numbers to
cause infection
This is not achievable This is not a This is achievable in
in the health care satisfactory standard typical health care
setting for invasive clinical settings
procedures or
maintenance of clinical
devices
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A lack of respect for microorganisms transference via equipment
utilization. Examples within Venepuncture and Cannulation Include;
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Section 4. Venepunture
You may perform this skill a number of times before you are signed off by
your assessor. There is no set number of successful attempts prior to sign
off. Skill development will differ with experience, exposure and manual
dexterity.
Please access the Royal Marsden on the RUH Desktop for a detailed
description of how to perform Venepunture. This will be expanded upon in your
skills teach.
Tourniquets are single patient use only and are latex free. Do not use your
own material tourniquet. This is not acceptable. Remember 3 minutes is
maximum time for tourniquet application. Organization is the key to
being successful within the given time frame.
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Blood bottles have specific solutions in each tube to enable the blood to be
analised in the laboratories. It is therefore important to take the blood in a
specific order to reduce any cross contamination of solutions. The RUH use
the BD Vacutainer System with the following order of draw.
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In your preparation for venepuncture, check the requisition for 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.
All tubes must be mixed to allow accurate testing in the laboratory. Blue and
mauve tops should be gently rotated 3-4 times. All other tubes should be
rotated 6-8 times.
How to Label...
1. Use ICE label if available otherwise a black pen
2. Include full name, D.O.B, Ward, date and time
3. Write the time of collection on the request form and initial the form
4. Place the tubes in the bag and attach the blood form and seal
Venepunture Checklist:
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Venepuncture Key Points and Summary
Always use vacutainer equipment when taking blood, never a needle and
syringe.
Always label blood bottles immediately after taken, ideally by the the
bedside of the patient.
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Section 5. Cannulation
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Your answers to the above could have included some or all of the following;
maintaining hydration
restoring fluid and electrolyte balance
providing fluids for resuscitation
administering blood or blood components
administering drugs such as antibiotics.
Doctors assistants
Radiology Department Assistants
Health Care Assistants
The cannula chosen should be the smallest to meet the clinical need. The
larger the lumen of the catheter the faster the flow rate. The indication for
cannulation should be considered and the cannula chosen accordingly. For
example, emergency colloid or blood replacement after a post-partum
haemorrhage will require a 16gage grey cannula whereas a line for
intermittent intravenous bolus injections of antibiotics could be 18g green or
20g pink. The larger the amount and type of fluid over a given time will
highlight to you as to the size of cannulae.
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22 gauge (blue) for difficult veins, slow intravenous fluids, or intravenous drugs
in a patient who can take oral fluids (31mls/min)
THINK;
Purpose of infusion,
Type of infusate and
length of treatment
The site should be inspected daily (Hart, 1999) for signs of complications,
such as infection or phlebitis and also to check that the cannula is still firmly
secured and the dressings intact. VIP scores and care plans should be
completed every shift. Refer to section 5 for detailed complications.
30
Royal College of Nursing (2003) provides detailed information about
documentation required in relation to infusion therapy. Here are some of the
main points applied to peripheral IV cannulation:
Once sited the cannula should be flushed with 0.9% normal saline. The site
should be regularly inspected for signs of phlebitis.
Peripheral cannulae should be re-sited every 48-72 hours to reduce the risk of
phlebitis, but this may be difficult in patients with difficult veins.
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Section 6. Potential Complications
Objectives
Complications
Haematoma (Bruising)
If a haematoma begins to
form, release the tourniquet,
remove the needle from the
vein and apply firm pressure
to the site.
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Infection
Local cellulitis or
septicaemia are
complications of
venepuncture. Strict aseptic
technique will reduce the
risk of patients developing a
bacteraemia. Inform medical
staff Immediately if infection
is suspected.
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Phlebitis (irritation)
All iv cannulae must be
checked daily for signs of
infusion phlebitis & a VIP
score documented.
Two of the most common
causes of infusion phlebitis
are chemical (due to fluid or
drug) & mechanical (due to
cannula). Consider removing
the cannula & inform medical
staff.
Fuller & Winn (1998) have provided evidence to suggest that the risk of
phlebitis is increased for:
Clinical Signs:
Pain
Erythema (Redness)
Swelling
Infection
Extravasation
This has been defined as
Clinical signs:
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Burning sensation
Pain
Some resistance to giving of a bolus injection or slowing of an infusion.
Tissue sloughing but this often takes a few days or a few weeks to become
apparent.
Necrosis
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Treatment of extravasation is difficult so it is essential that every measure is
taken to ensure its prevention.
Ensure that the cannula has been sited correctly using the smallest gauge
possible.
If the cannula has been in situ for more than 72 hours make sure that it is
replaced and preferably on a different limb.
Administer vesicant medicines first, after testing for placement by flushing.
If in doubt stop and resite cannula.
Lamb (1999)
Embolism
Causes
36
Clinical features
Air embolism: the clinical features of air embolism are associated with
vascular collapse: dyspnoea, hypotension and tachypnoea (Josephson, 2004).
Cannula embolism: the patient may complain of severe, sudden pain at the
IV site. There will be absent or reduced blood return when checking for
placement. If the fragment lodges in the lungs or heart there will be
hypotension, chest pain, tachycardia, cyanosis and possible loss of
consciousness (Josephson, 2004).
Infiltration
Infiltration is the inadvertent administration of non-vesicant medication or
solution into the surrounding tissue instead of into the intended vascular
pathway (Royal College of Nursing, 2003).
Causes
These include:
cannula too large for diameter of vein.
puncture of distal wall of vein during cannulation.
poorly secured cannula e.g. too loose and mechanical friction from cannula
causes vein puncture; taping that is too tight above the cannula tip can act as
a tourniquet, disrupting flow and rupturing the vessel wall.
over-manipulation of the cannula.
delivery of fluid at high rate or pressure. (Josephson, 2004)
Clinical features
These include skin blanching, oedema, skin cool to touch, possibly pain
(Infusion Nurses Society, 2000, cited in Royal College of Nursing, 2003).
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Key Points to remember
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Section 7. Flushing of Peripheral Venous Cannulae
The cannula once successfully in situ must then be flushed with a 0.9%
Normal Saline 5-10ml, to ensure that all the blood products are flushed out of
the cannula to prevent occlusion. Flushing peripheral venous cannula is an
integral part of its insertion and therefor the competency.
A 0.9% saline flush must be prescribed. A verbal order must never be taken
under any circumstances for this.
All intravenous medicines must be double checked and this must be done
rigorously prior to administration. Two persons will carry out the check one of
whom will be a Registered Nurse or Doctor. (See sections 3.1, 4.3, 4.4 and 4.5
and Appendix 4 of the Trust Administration of Intravenous Medicines policy.)
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wristband of the patient against the drug prescription chart. A verbal
confirmation must also be made as per Trust peripheral cannulation policy.
The authorised non-registered staff must check that there are no faults in the
ampoules and equipment prior to use.
Use aseptic non touch technique (ANTT) and refer to the Infection
Prevention and Control Policy.
The Medicines chart must be signed by the person administering the flush and
countersigned by the checking practitioner
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Section 8. References
Department of Health (2003) Winning Ways, Working together to reduce Health Care
Associated Infection in England
Department of Health (2007) Saving Lives: reducing infection, delivering clean safe
care. (available on the Department of Health website at: www.dh.gov.uk).
Hart, S. (2007) Using an aseptic technique to reduce the risk of infection. Nursing
Standard. 21,47, 43-48
Josephson, D.L. (2004) Intravenous infusion therapy for nurses. Principles and
practice (2nd edition), Clifton Park: Thomson Delmar Learning.
Lavery, I. Igram, p (2005) Venepuncture: best practice. Nursing Standard. 19,49. 55-
65.
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Lamb, J. (1999) Local and systemic complications of intravenous therapy, in
Dougherty, L. & Lamb, J. (1999) (Eds) Intravenous Therapy in Nursing Practice,
Churchill Livingstone, Edinburgh
Wilson, J.A. (1994) Preventing infection during IV therapy, Professional Nurse, 9(6),
pp.388-390, 392.
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Appendix 1: Questions
43
heart
Questions continued
The Median Nerve passes down the inside of the arm and
crosses behind of the elbow
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Appendix 2: Student Note Page
46
Appendix 3: Record of Supervised Practice
Practice to be carried out after completion of Trust approved training, and until
member of staff feels competent.
Name of nurse:
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Appendix 4: Competency Assessment for Peripheral Venous
Cannulation
1. Knowledge Assessor
Can the staff member:- to initial
and date
1.1 Identify local policies and national Yes / No
guidelines regarding peripheral venous
cannulation.
Yes / No
Yes / No
1.3 Differentiate between a vein and an
artery Yes / No
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i. Air embolism
ii. Infection
iii. Haematoma
iv. Extravasation
v. Infiltration
vi. Phlebitis
vii. Faulty equipment
viii. Incorrect cannula fixation
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2. Procedure Assessor
to initial
Did the staff member:- and date
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Assessors name: Assessors signature:
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Appendix 5: Peripheral Venous Cannulation Procedure Guidelines
All staff have a responsibility for ensuring that the principles outlined within this
document are universally applied. This policy applies to all members of staff
who are involved in any aspect of the development and use of procedure
development.
1. Preparation
Equipment required
i. Sharps bin container tray.
vii. Chloraprep
xi. 10 ml syringe
*Patients in nursed in isolation rooms should have a sharps bin inside their
room as per Isolation policy.
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2. Procedure prior to cannulation
Put on apron and Wash hands with soap and water or alcohol gel as per Trust
hand hygiene policy.
Wipe plastic tray with soap and water or a detergent wipe if not socially clean
and dry.
Ask the patient to confirm their name and date of birth. Do not ask, Are you?
If verbal confirmation of the identity is not possible, check patients identity with
a second practitioner.
Explain procedure to patient and obtain verbal consent in accordance with the
Trust policy on obtaining consent.
If the patient requires topical local anaesthetic this must be prescribed and
applied as directed. If administered non-registered practitioner this must be
supervised by a doctor or nurse.
3. During Cannulation
Prepare equipment and arrange in the plastic tray, checking all packaging for
expiry date, tears and other damage.
Ensure correct positioning of the patient under adequate lighting and that the
limb which is to be cannulated is well supported. Avoid unbalanced bending
53
and unsure you are in a comfortable and safe position. As per Trust Back care
when carrying out cannulation and venepuncture information
If required, apply a single use tourniquet six to eight inches above the insertion
site (Campbell 1995).
Bony prominences such as at a joint and the inner arm must be avoided.
Anywhere other than the hand of a patient in renal failure must not be
cannulated because of an existing fistula or potential future need for
one.
If the patient is cold to the touch, use measures for increasing venous
dilation such as the soaking of arms in warm water (which must then be
dried before cannulation is carried out), or by wrapping the arm/hand in a
blanket.
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Nurses, radiographers, Doctors Assistants, radiology department
assistants, health care assistants, and other non-registered authorized
practitioners must not cannulate the lower limbs. However, exceptionally
some nurses who have undertaken extra training and assessment of
competence may carry out cannulation of lower limbs where a local
protocol exists to allow them to do so.
Open the sterile dressing towel and place it under the patients arm except
where the patient is going to have the cannula inserted for a period of less
than 30 minutes.
Clean the patients skin along and around the selected vein for at least 30
seconds using Chlorhexidine 2% w/v and Isopropyl in 70% alcohol
(Chloraprep Sepp). Allow to dry for at least 30 seconds.
Take hold of the cannula and remove the needle guard, visually checking the
cannula for any faults.
Anchor the vein to be accessed by applying manual traction to the skin a few
centimetres below the proposed insertion site.
Ensuring that the cannula and bevel of the stylet/introducer are both facing
upwards, insert the cannula at the correct angle according to the depth of vein.
Wait for flashback of blood into the flashback chamber of the stylet/introducer.
55
Level the device by decreasing the angle between the cannula and the skin
and advance the cannula a few millimetres to ensure entry into the lumen of
the vein.
Withdraw the stylet slightly and a second flashback of blood should be seen
along the shaft of the cannula.
Maintaining skin traction with the non-dominant hand and using the dominant
hand, slowly advance the cannula off the stylet/introducer and into the vein
Apply digital pressure to the vein above the cannula tip and remove the stylet.
NB. Never reintroduce a stylet/introducer into a cannula.
Seal cannula with extension or administration set; or sterile luer lock cap.
Observe the site for signs of swelling or leakage, and ask the patient if any
discomfort or pain is felt.
Apply the appropriate dressing to secure the cannula. Remove gloves, wash
hands with soap and water or alcohol hand rub as appropriate.
Flush the cannula with 5-10mls of sodium chloride 0.9% for intravenous use.
56
Document the procedure using the appropriate trust documentation, at time of
publishing this is the Adult Peripheral Venous Cannula (PVC) Care Record.
Any failed attempts should be documented in the patients care records.
The only exception to this is where a cannula is in situ for 30 minutes or less
(E.g. CT/MRI).
57
Appendix 6 : Equipment Alerts
N.B Always ensure that you understand the equipment that you are
using and its risks to patients.
58