L-When I initially got my placement for this semester, I was not pleased with the setting because I thought I would not learn a lot; this has definitely changed. Learning and practicing intravenous (IV) access was a skill that I wanted to have before my graduation, and I believed that I needed to be in a hospital setting for this to occur. I am not currently doing intravenous initiation with the intension of hanging fluids or medications, but I have been practicing venipuncture. Looking back, I realize that student nurses need to be open minded to their placement areas and have a good attitude because they may pass on an opportunity to form new relationships and gain new skills.
E- Doing venipuncture is significant to me because I have not done venous access before, and I realize that it has serious implications for the patients. Venipuncture, an introduction of a needle into a vein to obtain a blood sample for hematological, biochemical or bacteriological analysis, is one of the most invasive procedures in nursing (Lavery & Ingram, 2005). The fact that a sharp instrument is being introduced into a vein also means that there are serious implication for the health and safety of the nurse and the patient. Recently I had a patient who explained that she was “scared of needles”, so drawing blood from her was challenging in some way. She came in for her annual physical, and already was emotionally drained after speaking with myself and the doctor about the recent death of her father. I had asked if she was ok while cleaning her skin and she said yes, but while I was drawing the first vile of blood, I noticed that she was taking deep breaths in and out. When I asked her again how she was doing, she explained that she really did not like having blood work, and that she normally gets her blood drawn while laying down. At this point I became immediately concerned for her safety. I did not want her to become dizzy and faint, and I did not want to withdraw the needle, have her lie down only to subject her to another injection. However, I did offer her the option and she said she was ok, and that I should just continue and get it over with.
A- According to CNO (2014), nurses successfully meet the standards by having sufficient knowledge, skill and judgment to determine the appropriateness of performing a procedure at a given time for a particular client while considering the client’s overall condition as well as the risks and benefits of performing said procedure. I do feel confident performing venipunctures, but I knew the patient would rather not be injected again, and I was constantly monitoring her physical condition to check for any deterioration in her wellbeing. My assessment confirmed that continuation of the procedure would be better instead of stopping only to increase the client’s anxiety level, and then not finding a vein on the second try. Lavery and Ingram (2005) explained that anxiety and needle phobia are also associated with venipuncture syncope or loss of consciousness. In addition, loss of consciousness may cause patients to experience falls and subsequent head, neck, or dental injuries; this negative experience may also dissuade patients from having future blood work (Lavery & Ingram, 2005). Patients who have anxiety along with vasovagal reactions may also experience dizziness, sweating, weakness, and lightheadedness (Lavery & Ingram, 2005). Therefore, nurses must anticipate complications, be prepared to intervene, and recognize that in certain situations loss of consciousness may occur. Patient safety should be considered in relation to the patient's position when the venipuncture is being performed. Since this incident I have asked all other patient requiring venipuncture whether or not they have any fear of getting their blood drawn, and if so, would they like to lie down during the procedure. According to Barker (2008), individuals with needle phobia or a history of venipuncture asystole should be placed in the Trendelenburg position; feet elevated above the heart. Since I am practicing in a clinic with no moveable bed, I will have patients lay supine and elevate legs on a few pillows. The right equipment should also be used when collecting blood. Allergies should be considered, and, if the patient is allergic to latex, plasters or the apparatus, then alternatives should be sought. All equipment should be sterile, and where possible single use only (Medical Devices Agency (MDA) 1996 as cited in Bitsika et al., 2014). The blood should be collected according to facilities’ policies and procedures; it is very important that all blood be labelled at the bedside. At the clinic, I make sure all blood samples are labelled for each patient before I collect blood from another client as a part of best practice guidelines as well as a means to enhance patient safety. In this way, the right information is available for the right patient. Furthermore all personal details should be checked with the patient to ensure validity, and I do this by confirming name and date of birth with each patient.
Another way to prevent complications and improve patient safety is to perfect the technique of venipuncture, thus, it is essential that nurses have a good understanding of the anatomy and physiology of arteries, veins and associated nerves (Lavery & Ingram, 2005). The 4-stage approach, which consists of four chronological steps: demonstration, deconstruction, comprehension, and performance, is a new method of teaching venipuncture clinical skills to new nursing student (Greif et al., 2010 as cited in Bitsika et al., 2014). During the 4-stage approach the instructor demonstrates the skill at a normal pace, then the instructor repeats the procedure in slow motion while explaining the steps, followed by the procedure being done by the instructor under the verbal guidance of the trainee, and the process completes with the trainee performing the skill on his own (Bullok, 2000 as cited in Bitsika et al., 2014). This is basically how my instructor trained me to do venipuncture; however, she did a few before I actually did any on my own. I did not start doing them independently until I felt I had the judgment to do so.
Palpating the vein is very important when considering patient safety. The nurse cannot depend on vision because you may see a vein, but without feeling it, there is no guarantee that you will be going in the right place. What's more, hitting the nerve in the underside of the wrist can cause temporary or permanent nerve damage and the patient may lose the ability to open or close his or her hand (Bitsika et al., 2014). I have seen many small veins at my placement, and in some cases I was not even able to palpate those veins and had to choose a more palpable one with successful outcomes. For the safety of patients and nurses, it is important for this skill to be performed in a proper and responsible way.
It is normal for bleeding to occur at the venipuncture site, but when not performed safely complications such as bruising and hematoma may occur. According to Galena (1992 as cited in Bitsika et al., 2014), bruising or hematoma occurs with 12.3% of all venipunctures. Nevertheless, bruising is preventable by accurate identification of a suitable vein, correct angle and insertion technique, and ensuring the tourniquet is applied with adequate pressure, or applied distal to previous puncture sites (Lavery & Ingram, 2008). Fixing the vein position by skin traction during the insertion of the needle and ensuring adequate pressure to the puncture site after needle removal will prevent further damage (Lavery & Ingram, 2005). Nurses should make no more than two attempts to obtain blood samples, and if unsuccessful, they should seek help from a more experienced staff as this will ensure patient comfort and reduced trauma to the vein (Lavery & Ingram, 2005). Serious complications such as cellulitis, phlebitis, air embolism, nerve injury, vasovagal reactions, near-syncope, and syncope are rare, but possible (Bitsika et al., 2014). Healthcare facilities have a duty to provide equipment and services to support patients who experience complications from venipuncture (Lavery & Ingram, 2005). I am aware of where the “crash cart” is in my placement area, I can collaborate with my preceptor, and in extreme cases I can call 911.
R- Accountability is an important part of any nurse's practice, and involves considering the interests of patients in complex situations (Lavery & Ingram, 2005). The courts could find a nurse negligent if a patient experiences harm because the nurse failed to care for him or her properly. When undertaking venipuncture, nurses have a professional obligation to act in the best interest of the patient and follow evidence based practice (CNO, 2014).
Safe venipunctures is necessary to have positive patient experiences. Nurses should encourage patients with “difficult veins” to drink water prior to testing, and to notify the nurse of any history of venipuncture difficulties. In an effort to reduce patient anxiety and as good practice, patients should be asked if they have had venipuncture performed before (Lavery & Ingram, 2005). Individuals with cardiac comorbidities and a history of venipuncture syncope can be referred to more advanced health care facilities to have this procedure done (Barker, 2008).
N- I have had positive experiences with venipunctures thus far, and so I will continue to practice venous access using CNO best practice guidelines. When I cannot find a palpable vein on one arm then I try to find it on the other arm. Since the incident with my patient, I ask all other patients if they have any fear of venipuncture so that I can draw blood while they are lying down. Also, I start small conversations with my patients as a means of reducing their anxiety and distracting them from any distress (Barker, 2008). If I have extreme difficulty getting blood then I ask my preceptor for help, or I refer the patient to a lab where they have more experience technicians who can help.

References

Barker, L. (2008). Venipuncture syncope--one occupational health clinic's experience. AAOHN Journal, 56(4), 139-140.

Bitsika, E., Karlis, G., Iacovidou, N., Georgiou, M., Kontodima, P., Vardaki, Z., & Xanthos, T. (2014). Comparative analysis of two venipuncture learning methods on nursing students. Nurse Education Today, (1), 15. doi:10.1016/j.nedt.2013.03.016

CNO. (2014). Decisions about procedures and authority. Retrieved from: http://www.cno.org/Global/docs/prac/41071_Decisions.pdf

Lavery, I., & Ingram, P. (2005). Venepuncture: best practice. Nursing Standard, 19(49), 55