Circulatory stuff

Venepuncture/phlebotomy

Confirm correct patient

2. Explain and gain consent and answer an question 3. check for contraindications

4. preparation

5. wash hands and put apron and clean everything. Gloves is mandatory.

6. put stuff in tray

Pre-vaccum the needles

7. wash hands 8. put tourniquet one hand breathe above

9. identify vein and then wash again 10. clean site corss hatch method and leave to dry 11.

12. technique to get in

The vacuum bottles - (closed or evacuated system) Using needle to pierce skin at 30 degree. can tether the skin to allow easy entry. Check for flash black when you enter. and then put in the vacuumated bottles one by one and then shake it one side to another once down to activate substances inside. Then remove tourniquet while putting swab over. Remove tourniquet and then remove needle before applying pressure. Dispose of the needle into the sharps bin There is double ended needle. one for patient side to put in. and then the other pierces the bottle which is under vaccum. You put this bottles in one by one in the correct order of draw. and then take out once done.

normal phlebetomy (open system) Same as above. but insert needle using the technqiue learnt in arm hospital. tethering and entering until back flow seen. and then pull syringe one way. no air embolism. then apply swab and remove tourniquet. and then take off needle, and then only apply pressure. then ask patient to sqeeze. Then take off needle and dispose properly. then take the tubes and put in blood one by one in correct order. and then siwirl it up and down. put in labelling and pair up with request form and send. Discard the syringe. PAY ATTENTION TO ORDER OF DRAW

13. keep appying pressure for about 5 minutes

14. fill in the patients details in bed side 15. place in the sample along wih the request form to be taken away 16. clean up and tell patient where to dsicard awab 17. explain to the patient about any complication s and when to seek help

Site of drawing blood

Allow alcohol to dry otherwise painful do not let alcohol in can contaminate

Ask patient to close fist but do not clench or pump

let it be downwards so no backflow ore relfux

Do not bend arm. keep it straight but with swab. Takes around 5 min. Discard in yellow bin.

When suing vaccum tubes but pierce well. Blood culture bottles are always under vaccum.

Need to have doumentation with information on double pricks errors epills etc And have spill management laid out

Rejection critieria????

Rejection crtieria?

Needle stick injury

Spill management

put gown and ppe (gown, face mask and gloves)

put cotton wool etc to contain the spill

Dsiinfectant b putting freshly prepared 1% sodium hypocholride and leave for 20-30 mins

Clean area using paper towels and dispose into the yelow bag/

IV cannulation and taking off

Gather equipment

Collect the equipment required for the procedure and place it within reach on a tray or trolley, ensuring that all the items are clearly visible:

Clean procedure tray

Non-sterile gloves

Disposable apron (optional)

Tourniquet

Cannula (size appropriate to the indication for cannulation)

Sterile dressing pack (to provide a sterile field)

Cannula dressing

Luer lock cannula cap or extension set

Gauze swabs

Normal saline 0.9% (10 ml)

Syringe (10ml)

Alcohol swab (2% chlorhexidine gluconate in 70% isopropyl)

Sharps container

Gather equipment

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.

Don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: “Today I need to perform cannulation, which involves inserting a small plastic tube into your vein using a needle. This will allow us to administer fluids and medications via the cannula. You may briefly experience a sharp scratch as the needle is inserted.”

Gain consent to proceed with intravenous cannulation.

Check if the patient has any allergies (e.g. latex).

Adequately expose the patient’s arms for the procedure.

Position the patient so that they are sitting comfortably. If a bed is available, the patient can lay down for the procedure (this is sometimes preferable, particularly if the patient is prone to vasovagal syncope).

Ask the patient if they have any pain before continuing with the clinical procedure.

Preparation

1. Don gloves (if not already wearing some).

2. Open the dressing pack and place the cannula, cannula dressing and other items onto the field.

3. Prepare the normal saline flush by drawing the saline into your syringe (if you have a pre-filled flush you can ignore this step).

4. If you are planning on using an extension set, you should attach this to the flush and prime the line.

5. Choose an arm to cannulate:

You should ask the patient if they have a preference. It is preferable to use the patient’s non-dominant arm in most cases.

Pre-existing medical conditions may prevent particular limbs from being used (e.g. arterio-venous fistula, lymphoedema).

6. Place a pillow under the arm to be cannulated to make the procedure more comfortable for the patient.

7. Place a field below the patient’s arm to prevent blood spillage.

Don gloves (prior to setting up saline flush)

Set up a sterile field

Prepare the saline flush (and prime extension set if applicable)

Position the patient's arm comfortably and place a field below their arm to prevent blood spillage

Choosing a vein

1. Inspect the patient’s arm for an appropriate cannulation site:

You should select a site that is the least restrictive for the patient such as the posterior forearm or dorsum of the hand. In an emergency situation, any large peripheral vein may be used.

Avoid areas near the elbow and wrist joints (to reduce the likelihood of dislodgement as a result of the patient’s movement).

Areas of broken, bruised or erythematous skin should be avoided.

Areas in which two veins join should be avoided where possible, as valves are often present.

2. Position the patient’s arm in a comfortable extended position that provides adequate access to the planned cannulation site.

3. Apply the tourniquet approximately 4-5 finger-widths above the planned cannulation site.

4. Palpate the vein you have identified to assess if it is suitable:

Tapping the vein and asking the patient to repeatedly clench their fist can make the vein easier to visualise and palpate.

An ideal vein feels ‘springy’. A vein that feels hard is likely sclerosed, thrombosed or phlebitic (inflamed) and should be avoided.

5. Once you have identified a suitable vein you may need to temporarily release the tourniquet, as it should not be left on for more than 1-2 minutes at a time.

6. Clean the site with an alcohol swab for 30 seconds and then allow to dry completely for 30 seconds:

You should start cleaning from the centre of the cannulation site and work outwards to cover an area of 5cm or more.

DO NOT touch the cleaned site afterwards at any point, otherwise, the cleaning procedure will need to be repeated prior to cannulation.

Inspect for a suitable vein

Apply the tourniquet

Palpate the vein

Clean the site for 30 seconds and allow to dry

Inserting the cannula

1. Wash your hands again, removing gloves if these were worn for setting up the saline flush.

2. Don a new pair of non-sterile gloves.

3. Re-apply the tourniquet if removed previously.

4. Remove the cannula sheath.

5. Prepare the cannula:

Open the cannula wings if present.

Slightly withdraw and replace the needle (this will allow it to glide easier during cannulation).

Unscrew the cap at the back of the cannula and place upright in the tray (if the cannula is ported).

6. Anchor the vein with your non-dominant hand from below by gently pulling on the skin distal to the insertion site.

7. Warn the patient that they will experience a sharp scratch.

8. Insert the cannula directly above the vein, through the skin at an angle of 10-30º with the bevel facing upwards.

9. Observe for a flashback of blood into the cannula chamber, which confirms that the needle has punctured the vein.

10. Lower the cannula and then advance the needle a further 2mm after flashback is observed to ensure it’s within the vein’s lumen.

11. Partially withdraw the introducer needle, ensuring the needle end is within the plastic tubing of the cannula (you should observe blood entering the plastic tubing of the cannula as you do this).

12. Carefully advance the cannula into the vein as you simultaneously withdraw the introducer needle until the cannula is fully inserted and the needle is almost removed.

13. Release the tourniquet.

14. Place some sterile gauze directly underneath the cannula hub.

15. Apply pressure to the proximal vein close to the tip of the cannula to reduce bleeding.

16. Gently pull the introducer needle backwards whilst holding the cannula in position until it is completely removed.

17. Connect a Luer lock cap or primed extension set to the cannula hub.

18. Dispose of the introducer needle immediately into a sharps container.

19. Apply adhesive strips to secure the cannula wings to the skin. Do not obscure the insertion site with the strips, as this needs to remain visible to allow early identification of phlebitis.

There is significant variability in the recommended method of cannulation, therefore, you should always consult your local medical school or hospital guidelines.

Wash hands again

Don gloves

Remove cannula sheath

Open the cannula wings

Ensure the cannula mechanism slides smoothly

Secure the vein from below with your non-dominant hand

Ensure the needle bevel is facing upwards

Insert the cannula at an angle of 10-30º into the vein

Observe for flashback and then advance a further 2mm (approx)

Partially withdraw the introducer needle

Advance the cannula carefully into the vein

Release the tourniquet

Remove the introducer needle

Attach cannula cap or extension set

Dispose of the sharp immediately

Secure the cannula wings with some adhesive tape

Flushing the cannula

1. Inject the normal saline into the cannula using the flush you prepared earlier:

The flush should be easy to administer with minimal resistance.

Observe for signs of swelling around the site or pain during administration and stop if this occurs.

2. Close the cannula port (if ported).

3. Secure the cannula with a dressing if the cannula flush was successful.

Flush the cannula

Apply a dressing to the cannula

Label the dressing with the insertion date

To complete the procedure…

Explain to the patient that the procedure is now complete and that they should seek review if the cannulation site becomes painful or inflamed.

Thank the patient for their time.

Dispose of your PPE and other clinical waste into an appropriate clinical waste bin.

Wash your hands.

Document the details of the procedure on a cannulation chart or in the patient’s notes including:

The patient’s details: full name, date of birth and unique identification number.

The date and time that cannulation was performed.

The indication for cannulation.

The type of cannula used (e.g. 20 gauge).

The site of cannulation (e.g. dorsum of the left hand).

The date on which the cannula should be removed or replaced.

Your name, grade and contact details.

Setting up a drip

IV port at the top to pierce through the bag Drip chamber below

Tap to control flow rate...clamp!

Cover at the end

Put apron, wash hand, clean surface and tray,

Put the fluid up and hang in. Remove off protective cover from the bag. Pierce the line. Sqeeze the drip chamber to suck in. Then adjust clamp to allow fluid to come all the way with no bubbled in the tube. Secure the iv set. Open the tap from the cannula and attach the tibe in and open the camp to adjust flow rate accordingly.

Calculating

standard iv set has 20 drops per ml drop factor. So to convert ml/hr to drops/min jsut devide by 3!

Can adjust using the volumetric pump as well. Need someone to show you how the pump works and how to operate it. Volumetric pump or infusion pump

Change gloves and clean the port on the cannula for 30 sec

Fush to check patency of cannula with normal saline.

Remove protective cap from tube and attach to cannula and remove the camp slowly to get drip speed or volumbetric pump.

Using infusion pump ⇒

Check how infusion pumps works using youtube and how to use particular ones. Infusion pump vs syringe pump? One just adjust the line rate while the other adjust the pump syringe rate Syringe pump used if infusion time is more than 5 mins. Sryinge infusion vs saline infusion and controlling the rate sing devices. Infusing with saline vs infusing dirctly with syrginge eg certain antiibotics that needs slow infusion and insulin. Controlling sygringe rate vs controlling line

IV infusions and injections

take all equipments ready

check expiry dates

introduce and explaina dn coensent

see whether canula is clean and usable

check allergies

right drug, right patient, right amount, right time

apron, soap water, clean

Draw up the flush

Change neddle

draw up water using the topsy turvy method

Then isnert around 5 mls to reconsitute the antibiotic

Release the pressure to suck in the air

then shake until antiotic dissolved

then reinsert air under topsy turvy

Adnt eh withdraw

change needle

LAbel srginges now

Go to the bed site and wash hands and gloves

clean canula port

Flush saline to check patency of canula

Slowly bolus antibitoic observing aient

Flush canula again.

Dispose all waste appropriately

Sign for the drug

Observe patient

Giving it with infusion

Recoinsitute the drug as appropritte

Pierce the drug addictive port on the fluid bag And put in the drug

And then set up the drip as bove and put in

agitate the bag to mix the drug. Label it. Then put at the line as before Remeber the two neds are key parts and shouldnt be touched.

Put the clamp all the way down to close it. Take off the cap and piece it into the bag Squeeze severeal time in the drip unit to fill it upto the mark Then unclamo slowly until it fills all the way And then open clamp

check for air bubbles and remove them

Strectht the tube and flick it with finger to make the air bubbles rise up and escape like in a bottle

If big bottles drain the saline into a sink or pot until bubbles clear

Then put on gloves and then clean the end port with alcohol wipes

Then attach to canula end port flush the canula and attached the tube

open the clamp

and set the drip flow rate appropritately Or use infusion pumps Soemtimes need to give bous directly There is soemtimes an addittive container as well attached to the normal saline bag and line lie in hospital. The drug can then be given from a port on the top in and mixed and then infused by drop rate.

Blood transfusions

Not covering emergency blood tranfusion for example in theatre and icu and etus

Consent and explaining risks (blood borne infections and negatuve reactions and the need for blood)

Verbal consent is enough for blood.

prescirbe it and write it in the drug chart ogteher with special characteristics like irradiated or not. or other components like platelet concentrate. gamma irradiate.

send out a blood request form so that the blood bank can process it Take blood sample for full blood count using correct venepuncture techqiue

If blood is later to be given - use a blood giving set and not the normal saline set as the blood one has a faster flow rate and has a mesh work

start monitoring before and during and after transfusion

contact blood bank and ask ready. get the blood. (from the time its taken from the fridge it needs to be tranfused before 30 mins)

Check the details and do pre tranfusion checks

check all details inlduing expiry detail, type of blood and inspect package for defects and leaks

complete details before and after giving

Then take the punture of the set and puncture into the blood

then sqeeuze to get the blood in

adjust the flow rate accordingly

check entire tubing

imform patient to report any adverse effects like scratching fever or any negative reaction = shivering, fever, scratching, flush, dizzy, pain in extremeties and loins, difficulty breathing

Monitor 5mins, 15 mins and every interval afterwards for any signs of negtaive reaction. If have reaction ⇒ hydrocortisone and chlophinaramine? Whats the standard response?

If theres reaction give what drugs? and inform seniours?

Monitor for upto 24 hours for delayed effects or if patients dicarged counsel on these.

First 1 min must go slow with a particular maximum rate and then afterwards increase?

But still what is the maximum rate for blood transfusion?

Blood transfusion tubing is a y tubing?

ABG and intra-arterial cannulation

Gather equipment

Gather the appropriate equipment:

Gloves

Apron

Pre-heparinised arterial blood gas syringe and bung or cap

Arterial blood gas needle (23 G)

Alcohol wipe (70% isopropyl)

Gauze or cotton wool

Tape

Lidocaine 1% (1 mL)

Subcutaneous needle (25-27 G)

Small syringe for lidocaine (1-2 ml)

Sharps container

Gather ABG equipment

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

If the patient is currently receiving oxygen therapy, note the oxygen delivery device and flow rate.

Briefly explain what the procedure will involve using patient-friendly language: “I need to take a sample of blood from an artery in your wrist to accurately assess your oxygen levels. The procedure will be a little painful, however, it should only take a short amount of time. If you want me to stop at any point, just let me know. The procedure does involve some risks which include bleeding, bruising, infection and very rarely permanent damage to the artery being sampled from.“

Check for any contraindications to arterial blood gas sampling:

Absolute contraindications: peripheral vascular disease in the limb, cellulitis surrounding the site or arteriovenous fistula.

Relative contraindications: impaired coagulation (e.g. anticoagulation therapy, liver disease, low platelets <50).

Check if the patient has an allergy to local anaesthetic (e.g. lidocaine).

Gain consent to proceed with arterial blood gas sampling.

Adequately expose the patient’s wrist for the procedure.

Position the patient so that they are sitting comfortably, ideally with their wrist supported by a pillow. If a bed is available, the patient can lay down for the procedure (this is sometimes preferable, particularly if the patient is prone to vasovagal syncope).

Ask the patient if they have any pain before continuing with the clinical procedure.

How oxygen therapy impacts ABG results

PaO2 should be greater than 10 kPa when oxygenating on room air in a healthy patient.

If the patient is receiving oxygen therapy their PaO2 should be approximately 10kPa less than the % inspired concentration FiO2 (so a patient on 40% oxygen would be expected to have a PaO of approximately 30kPa).

Modified Allen’s test

Before taking a sample from the radial artery, a modified Allen’s test should be performed to assess the collateral arterial supply of the hand from the ulnar artery. The idea behind this assessment is to make sure the patient’s hand isn’t exclusively reliant on the radial artery for its blood supply, in which case sampling should be avoided.

To perform a modified Allen’s test:

1. Ask the patient to clench their fist.

2. Apply pressure over the radial and ulnar artery to occlude both vessels.

3. Ask the patient to open their hand, which should now appear blanched. If the hand does not appear it suggests you are not completely occluding the arteries with your fingers.

4. Remove the pressure from the ulnar artery whilst maintaining pressure over the radial artery.

5. If there is adequate blood supply from the ulnar artery, the normal colour should return to the entire hand within 5-15 seconds. If the return of colour takes longer, this suggests poor collateral circulation Do not perform arterial blood gas sampling on a hand that does not appear to have an adequate collateral blood supply.

It should be noted that there is no evidence performing this test reduces the rate of ischaemic complications of arterial sampling.

Ask the patient to clench their fist

Occlude the radial and ulnar arteries

Ask the patient to open their hand

Remove pressure from the ulnar artery

Colour should return to the entire hand within 5-15 seconds if ulnar arterial supply is adequate

Preparation

Equipment

Remove all equipment from its packaging so that it is easily accessible during the procedure.

Attach the needle, with its protective cover intact, to the pre-heparinised ABG syringe.

Positioning

Position the patient’s hand preferably on a pillow for comfort with the wrist extended by approximately 20-30°.

Procedure

Palpation

Assess the course of the radial artery to determine where you plan to perform arterial sampling:

1. Palpate the radial artery over the wrist of the patient’s non-dominant hand to identify an ideal puncture site. You should use the tips of your fingers to clearly map out the course of the radial artery and then identify a distal site where the artery is most pulsatile. The radial artery is typically most superficial over the lateral anterior aspect of the wrist.

2. Once you have identified your planned puncture site, clean it with an alcohol wipe for 30 seconds and allow to dry before proceeding.

3. Wash your hands again.

4. Don a pair of gloves and an apron.

Palpate and assess the course of the radial artery

Clean the site for 30 seconds

Don an apron

Wash your hands

Don gloves

Local anaesthetic

Pain associated with arterial blood gas sampling can be markedly reduced by the use of subcutaneous local anaesthetic. The British Thoracic Society recommends the routine use of local anaesthetic for obtaining ABG samples except in the context of an emergency or if the patient is unconscious.

Prepare and administer lidocaine subcutaneously over the planned puncture site (aspirate to ensure you are not in a blood vessel before injecting the local anaesthetic). See our guide to subcutaneous injection for more details.

Allow at least 60 seconds for the local anaesthetic to work.

Arterial puncture

1. Remove the protective cover from the ABG needle and then flush through the heparin from the syringe.

2. Hold the patient’s wrist extended by approximately 20-30°.

3. Palpate the radial artery with your non-dominant hand’s index finger around 1cm proximal to the planned puncture site (avoiding contaminating the planned puncture site that you previously cleaned).

4. Warn the patient you are going to insert the needle.

5. Holding the ABG syringe like a dart, insert the needle through the skin at the insertion site at an angle of 30-45°.

6. Continue to advance the needle slowly towards the pulsation until you feel a sudden reduction in resistance and see a rush of blood back into the ABG syringe (this is known as “flashback”).

7. The ABG syringe should then begin to self-fill in a pulsatile manner. If this doesn’t happen, it may indicate you have gone through or missed the artery and therefore need to re-adjust your position based on your understanding of the course of the radial artery (e.g. change in angulation or slight withdrawal of the needle).

8. Once the required amount of blood has been collected, remove the needle and apply immediate firm pressure over the puncture site with some gauze. Secure the gauze with some tape and continue to apply pressure.

9. Engage the needle safety device (often a clip that covers the needle or a bung that the needle is inserted into).

10. Remove the ABG needle from the syringe and discard immediately into a sharps bin.

11. Place a cap onto the ABG syringe and carefully expel any air from the sample if present.

12. Label the ABG sample with the patient’s details.

13. Either the patient or a colleague should continue to apply firm pressure to the puncture site for 3-5 minutes to reduce the risk of haematoma formation.

Flush heparin through the needle

Insert the ABG needle

Advance the needle and observe for flashback

Allow syringe to self-fill

Remove the needle and apply immediate pressure

Engage needle safety device

Remove the needle from the syringe

Dispose of the needle into a sharps bin

Attach a cap to the ABG syringe

ABG reference ranges

pH: 7.35 – 7.45

PaCO2: 4.7 – 6.0 kPa || 35.2 – 45 mmHg

PaO2: 11 – 13 kPa || 82.5 – 97.5 mmHg

HCO3–: 22 – 26 mEq/L

Base excess (BE): -2 to +2 mmol/L

To complete the procedure…

Explain to the patient that the procedure is now complete.

Thank the patient for their time.

Dispose of your PPE and equipment into an appropriate clinical waste bin.

Wash your hands.

Take the ABG sample to be analysed as soon as possible after being taken as delays longer than 10 minutes can affect the accuracy of results.

Document the ABG results in the patient’s notes (see our guide to ABG documentation).

How to intepret an ABG including acid base stuff????????

Different cannulas

Order of draw

Butter fly cannula

Fr neonates this is the only one

IMPORTANT!!!

For back of the palm must always use a butterfly catheter and not the other one.

For neonates can insert catheter and wait till it leaks into the tube. Can squeeze hand to pump the blood out !! But since its an open system cannot take blood cultures this way Can use butterfly blood draw instead. using the butterfly needle to peirce in and then opening and drawing blood out the other side Make sure not too slow otherwise can can clot.

Blood culture taking

Gather and prepare equipment

1. Clean a procedure tray with an antiseptic wipe.

2. Collect the relevant equipment:

Apron

Non-sterile gloves

Tourniquet (single-use)

Blood sampling device with blood culture bottle adapter (e.g. winged blood collection set)

Blood culture bottles x 2 (anaerobic and aerobic):

Sharps container

Cleaning swab x 3 (2% chlorhexidine in 70% isopropyl alcohol)

Sterile gauze

Sterile plaster

Tape

Laboratory forms, labels and transportation bag

3. Remove unnecessary packaging and assemble equipment maintaining aseptic non-touch technique (ANTT) prior to placing in the procedure tray:

Attach the needle to the barrel (some blood collection systems come pre-assembled).

Remove the caps from the blood culture bottles and clean the top of each with a separate cleaning swab (2% chlorhexidine in 70% isopropyl alcohol), allowing to dry before proceeding with bottle inoculation.

Don gloves (optional at this stage)

Clean the equipment tray

Gather equipment

Prepare the blood collection system

Remove the bottle cap

Clean the bottle cap

Repeat the process for the second bottle

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.

Don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: “Today I need to take a blood sample, which involves inserting a small needle into your vein. You may briefly experience a sharp scratch as the needle is inserted.”

Gain consent to proceed with blood culture collection.

Check if the patient has any allergies (e.g. latex).

Adequately expose the patient’s arms for the procedure.

Ask the patient if they have any pain before continuing with the clinical procedure.

Choosing an arm

1. Choose an arm to perform venepuncture on:

You should ask the patient if they have a preference.

Pre-existing medical conditions may prevent particular limbs from being used (e.g. arterio-venous fistula, lymphoedema, a stroke affecting the movement of a limb).

Do not perform venepuncture on an arm that has an intravenous infusion in progress as this may interfere with the sample.

2. Place a pillow under the relevant arm.

Choosing a vein

1. Inspect the patient’s arm for an appropriate venepuncture site:

The median cubital vein in the antecubital fossa is commonly used for venepuncture.

Areas of broken, bruised or erythematous skin should be avoided.

Areas in which two veins join should be avoided where possible, as valves are often present.

2. Position the patient’s arm in a comfortable extended position that provides adequate access to the planned venepuncture site.

3. Apply the tourniquet approximately 4-5 finger-widths above the planned venepuncture site.

4. Palpate the vein you have identified to assess if it is suitable:

Tapping the vein and asking the patient to repeatedly clench their fist can make the vein easier to visualise and palpate.

An ideal vein feels ‘springy’. A vein that feels hard is likely sclerosed, thrombosed or phlebitic (inflamed) and should be avoided.

5. Once you have identified a suitable vein you may need to temporarily release the tourniquet, as it should not be left on for more than 1-2 minutes at a time.

6. Don an apron (if not already wearing one) and wash your hands again using alcohol gel and the World Health Organisation’s hand hygiene technique shown in our guide.

7. Don gloves.

8. Thoroughly clean the planned venepuncture site:

Use 2% chlorhexidine in 70% isopropyl alcohol to disinfect the patient’s skin and allow to dry.

If the patient’s skin is visibly soiled use soap and water to clean the site.

Once the skin has been disinfected you should not touch the site again (even with gloves on).

Apply a tourniquet

Identify a suitable vein

Medial cubital vein

Don apron and wash hands

Don gloves

Clean the skin

Insertion of the needle

1. Re-apply the tourniquet if removed previously.

2. Unsheathe the needle.

3. Anchor the vein from below with your non-dominant hand by gently pulling on the skin distal to the insertion site.

4. Warn the patient that they will experience a sharp scratch.

5. Insert the needle through the skin at a 30-degree angle or less, with the bevel facing upwards. You should see flashback into the needle’s chamber and feel a sudden decrease in resistance as the needle enters the vein.

6. Advance the needle a further 1-2 mm into the vein after flashback is noted to ensure you are within the lumen.

7. Lower and anchor the needle to the patient’s skin using the wings of the butterfly needle.

8. Use your other hand to attach the aerobic blood culture bottle to the adapter, piercing the blood culture septum and allowing the bottle to fill with 10ml of blood (using the bottle’s graduation lines to accurately gauge sample volume).

9. Remove the aerobic bottle and then attach the anaerobic bottle, also filling it with 10ml of blood. Make sure to continue to anchor the needle to the skin as you remove the first bottle from the barrel by gently pulling and twisting. If no blood begins to flow into the bottles, try slightly withdrawing or adjusting the angle of the needle.

10. Release the tourniquet.

11. Withdraw the needle and then apply gentle pressure to the site with some gauze or cotton wool.

12. Ask the patient to hold the gauze or cotton wool in place whilst you dispose of the needle into a sharps container.

13. Apply a dressing to the patient’s arm (e.g. cotton wool, gauze, plaster).

14. Discard the used equipment into the appropriate clinical waste bin.

Insert the needle and observe for flashback

Secure the needle

Attach the aerobic blood culture bottle to the adapter

Fill the aerobic blood culture bottle

Detach the aerobic blood culture bottle

Attach the anaerobic blood culture bottle

Fill the anaerobic blood culture bottle

Detach the anaerobic blood culture bottle

Release the tourniquet

Apply pressure with gauze

Engage needle safety device

Dispose of needle into sharps bin

Apply a plaster

To complete the procedure…

Explain to the patient that the procedure is now complete and that they should seek review if the venepuncture site becomes painful or inflamed.

Thank the patient for their time.

Document the patient’s details on the blood sample bottles at the bedside (using either pre-printed or handwritten labels).

Dispose of PPE appropriately and wash your hands.

Send the blood samples to the lab for analysis in an appropriate plastic leak-proof bag with the completed laboratory request form.

Document the details of the procedure in the patient’s notes:

Reason for sample

Time and date of sample

Site the sample was obtained from

Your name, signature and contact details

Putting in a central venous line

First put anesthesists lignocaine aound it always aspirate first to see whether theres blood

then use transducer to locate the vessel

then go in with the needle and keep aspirating until you aspirate blood

should be venous blood

then insert the guidewire inside allt he way till mark

then take the needle out and then put catheter

if catheter cant pierce through skin make a nick using a blade

Then insert catheter all the way till mark until guidewire comes out

then take off the guidewire

careful with the guidewire since its got blood

then stitch the cateter in place on either side

then do chest x ray and ultrasound to check for location and any complications

This is different from the arterial line placement used for kidney dialysis.. vb

Arterial Line placement

like frequent abgs

can do the above to test the blood supply of the hand. By putting a pulse oximeter trace and then occluding the artery and seeing any difference. Or can use modifed allens test.

Subcuteaneous injections (SC injections)

Subcutaneous (SC) injections pierce the epidermis and dermis of the skin to deliver medication to the subcutaneous layer. It is a common route of delivery for medications such as insulin and low molecular weight heparin (LMWH). This subcutaneous injection guide provides a step-by-step approach to performing a subcutaneous injection in an OSCE setting, with an included video demonstration. This should not be used as a guide to administering injections to actual patients without first consulting your local medical school or hospital guidelines and undertaking the necessary training.

Download the subcutaneous injection PDF OSCE checklist, or use our interactive OSCE checklist.

Gather equipment

Gather the appropriate equipment:

Non-sterile gloves

Apron

Equipment tray

Syringe (the smallest syringe that will accommodate the medication volume)

Injecting needle (26–30 gauge): a standard length is 13-16mm. ¹

Drawing-up needle (also known as a blunt filter needle): filters out sub-visible particles of glass, rubber and other residues when drawing up medications from ampoules.

Gauze or cotton swab

Sharps container

The medication to be administered

The patient’s prescription

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: “Today I need to administer some medication, this will involve an injection under the skin. You may briefly experience a sharp scratch as the needle is inserted. The procedure does involve some risks which include bleeding, bruising, a persistent lump at the injection site and a small chance of infection or serious allergic reaction.”

Check the patient’s understanding of the medication being administered and explain the indication for the treatment.

Gain consent to proceed with the subcutaneous injection.

Check if the patient has any allergies.

Ask if the patient has a preferred injection site. If the patient is receiving regular subcutaneous injections, ensure that the injection sites are rotated.

Adequately expose the planned injection site for the procedure.

Position the patient so that they are sitting comfortably.

Ask the patient if they have any pain before continuing with the clinical procedure.

Final checks

Before proceeding, check the seven rights of medication administration.

1. Right person: ask the patient to confirm their details and then compare this to the patient’s wrist band (if present) and the prescription. You should use at least two identifiers.

2. Right drug: check the labelled drug against the prescription and ensure the medication hasn’t expired.

3. Right dose: check the drug dose against the prescription to ensure it is correct.

4. Right time: confirm the appropriate time to be administering the medication and check when the patient received a previous dose if relevant.

5. Right route: check that the planned route is appropriate for the medication you are administering.

6. Right to refuse: ensure that valid consent has been gained prior to medication administration.

7. Right documentation of the prescription and allergies: ensure that the prescription is valid and check the patient isn’t allergic to the medication you are going to administer.

Once all of the above have been confirmed prepare the medication.

Performing the subcutaneous injection

1. Wash your hands and don some gloves (if not already done).

2. Draw-up the appropriate medication into the syringe using a drawing-up needle.

3. Remove the drawing-up needle and immediately dispose of it into a sharps bin, then attach the needle to be used for performing the injection.

4. Choose an appropriate site for the injection: ¹

Abdomen: avoid injecting within a 2-inch radius around the umbilicus (this is the preferred site if administering low molecular weight heparin).

Upper outer aspect of the arm

Outer aspect of the upper thigh

Upper buttock

Do NOT use a site that is scarred, inflamed, irritated or bruised.

If multiple injections need to be administered, use different sites for each subsequent injection. If frequent injections are administered, rotate injection sites.

5. Position the patient to provide optimal access to your chosen site.

6. Cleaning the site:

WHO does not recommend the routine use of alcohol-based cleansing wipes prior to administration of subcutaneous medication as this can predispose an individual to develop hardened skin at the injection site. ²³

If the skin is visibly soiled it should be cleaned with soap and water.

Routine cleaning is not usually required prior to subcutaneous injection.

In older patients and those who are immunocompromised, skin preparation using an alcohol-impregnated swab (70% isopropyl alcohol) may be recommended.

7. Pinch a 5cm fold of skin between the thumb and index finger, using your non-dominant hand (pinching the skin increases the depth of the subcutaneous tissue available).

8. Warn the patient of a sharp scratch.

9. Pierce the skin at a 45-90° angle, aiming to remain in the subcutaneous tissue layer. Insert the needle quickly and firmly, with the bevel facing upwards.

10. Inject the contents of the syringe whilst holding the barrel firmly. Aspiration is not recommended for subcutaneous injections, as there are no major blood vessels in the subcutaneous tissue and the risk of inadvertent intravenous administration is minimal.5 You should, however, always follow your local guidelines.

11. Remove the needle and immediately dispose of it into a sharps container.

12. Apply gentle pressure over the injection site with a cotton swab or gauze and avoid rubbing the site.

13. Replace the gauze with a plaster.

14. Dispose of your equipment into an appropriate clinical waste bin.

Don apron

Wash your hands

Don gloves

Confirm medication details

Draw up medication

Attach the needle

Choose an appropriate injection site

Remove the needle cover and expel air bubbles

Pinch the patient's skin between your thumb and index finger

Pierce the skin with the needle (45-90°)

Inject the medication

Withdraw the needle

Apply pressure over the site

Apply a plaster

Dispose of the needle into a sharps bin

To complete the procedure…

Explain to the patient that the procedure is now complete.

Thank the patient for their time.

Discuss post-injection care:

Warn the patient that it is normal for the injection site to be sore for one or two days. Advise that if they experience worsening pain after 48 hours they should seek medical review.

Reiterate the potential complications of subcutaneous injections including haematoma formation, persistent nodules, local irritation and rarely anaphylaxis.

Dispose of PPE appropriately and wash your hands.

Document the details of the procedure and the medication administered.

IM (intramuscular injections )

Gather equipment

Gather the appropriate equipment:

Non-sterile gloves

Apron

Equipment tray

Syringe (the smallest syringe that will accommodate the medication volume)

Injecting needle (21–23 gauge): a standard length is 25mm.

Drawing-up needle (also known as a blunt filter needle): filters out sub-visible particles of glass, rubber and other residues when drawing up medications from ampoules.

Alcohol wipe (70% isopropyl)

Gauze or cotton swab

Sharps container

The medication to be administered

The patient’s prescription

Gather equipment

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: “Today I need to administer some medication, this will involve an injection into your muscle. You may briefly experience a sharp scratch as the needle is inserted. The procedure does involve some risks which include bleeding, bruising, a persistent lump at the injection site and a small chance of infection or serious allergic reaction.”

Check the patient’s understanding of the medication being administered and explain the indication for the treatment.

Gain consent to proceed with the intramuscular injection.

Check for any contraindications to performing an intramuscular injection:

Bleeding disorders (e.g. haemophilia)

Anticoagulant use (e.g. warfarin, apixaban)

Check if the patient has any allergies.

Ask if the patient has a preferred injection site. If the patient is receiving regular intramuscular injections, ensure that the injection sites are rotated.

Adequately expose the planned injection site for the procedure (e.g. deltoid).

Position the patient so that they are sitting comfortably.

Ask the patient if they have any pain before continuing with the clinical procedure.

Final checks

Before proceeding, check the seven rights of medication administration.

1. Right person: ask the patient to confirm their details and then compare this to the patient’s wrist band (if present) and the prescription. You should use at least two identifiers.

2. Right drug: check the labelled drug against the prescription and ensure the medication hasn’t expired.

3. Right dose: check the drug dose against the prescription to ensure it is correct.

4. Right time: confirm the appropriate time to be administering the medication and check when the patient received a previous dose if relevant.

5. Right route: check that the planned route is appropriate for the medication you are administering.

6. Right to refuse: ensure that valid consent has been gained prior to medication administration.

7. Right documentation of the prescription and allergies: ensure that the prescription is valid and check the patient isn’t allergic to the medication you are going to administer.

Once all of the above have been confirmed prepare the medication.

Performing the intramuscular injection

1. Wash your hands and don some gloves and an apron (if not already done).

2. Draw-up the appropriate medication into the syringe using a drawing-up needle.

3. Remove the drawing-up needle and immediately dispose of it into a sharps bin, then attach the needle to be used for performing the injection.

4. Choose an appropriate site for the injection such as:

Deltoid

Ventrogluteal

Vastus lateralis

Do NOT use a site that is scarred, inflamed, irritated or bruised.

See the end of the guide for further information regarding the most commonly used injection sites.

If multiple injections need to be administered, use different sites for each subsequent injection. If frequent injections are administered, rotate injection sites.

5. Position the patient to provide optimal access to your chosen site.

6. Cleaning the site:

When administering a vaccination, the site does not need to be routinely cleaned prior to injection unless the skin is visibly soiled (in which case you would need to clean the site with soap and water).

There is some debate as to whether the skin should be cleaned with an alcohol wipe prior to administration of intramuscular medication, with WHO stating that cleaning is likely unnecessary. Many hospitals, however, still recommend routinely cleaning with an alcohol wipe to reduce the risk of hospital-acquired infections, so you should adhere to your local medical school and hospital guidelines.

7. Gently place traction on the skin with your non-dominant hand away from the injection site, continuing the traction until the needle has been removed from the skin. This application and subsequent removal of traction is known as the ‘Z-track technique’ and helps to keep the administered medication within the muscle. When the traction applied to the skin is released, the alignment of the subcutaneous and muscle layers shifts, locking the medication into the muscle layer.

If the patient is elderly with reduced muscle mass or the patient is emaciated, do not apply traction, instead, bunch the muscle up to ensure adequate bulk before injecting.

8. Warn the patient of a sharp scratch.

9. Holding the syringe like a dart in your dominant hand, pierce the skin at a 75-90° angle. Insert the needle quickly and firmly, with the bevel facing upwards, leaving approximately one-third of the shaft exposed (however this varies between sites and patients).

10. Aspirate to ensure the needle is not placed within a blood vessel:

If blood appears, remove the syringe and prepare a new injection (explaining the reason for this to the patient).

It is recommended that you aspirate before performing deep intramuscular injections, such as those involving medications, as they are associated with a higher risk intravascular administration.

If administering a vaccination via a shallow intramuscular injection, UK guidance suggests there is no need to aspirate prior to injection of the vaccine.

11. If aspiration does not reveal evidence of intravascular needle placement, inject the contents of the syringe whilst holding the barrel firmly. Inject the medication slowly at a rate of approximately 1ml every 10 seconds.

12. Remove the needle and immediately dispose of it into a sharps container.

13. Release the traction you were applying to the skin, locking the medication into the muscle layer (Z-track technique).

14. Apply gentle pressure over the injection site with a cotton swab or gauze and avoid rubbing the site.

15. Replace the gauze with a plaster.

16. Dispose of your used clinical equipment into an appropriate clinical waste bin.

Wash hands again

Don apron

Don gloves

Check the details of the medication to be administered (e.g. type of medication/dose/expiry date)

Ensure the medication's and patient's details match the prescription

Draw up the medication (using a drawing-up needle)

Dispose of the drawing up needle

Attach the injection needle

Position the patient sitting on a chair

Palpate to identify the appropriate site for injection

Clean the site using an alcohol swab (this is not required for vaccines/medication given via shallow IM injection)

Apply gentle traction below the injection site

Insert the needle at 75-90°

Insert the needle into the muscle

Aspirate the syringe to ensure the needle is not located within a vessel (not required for shallow IM injections)

Inject the contents of the syringe slowly at a rate of 1ml per 10 seconds

Remove the needle

Release the traction

Apply gentle pressure to the site with some gauze

Dispose of the sharp

Apply a plaster

Remove your gloves

Remove apron and dispose of all clinical waste appropriately

To complete the procedure…

Explain to the patient that the procedure is now complete.

Thank the patient for their time.

Discuss post-injection care:

Warn the patient that it is normal for the injection site to be sore for one or two days. Advise that if they experience worsening pain after 48 hours they should seek medical review.

Reiterate the potential complications of intramuscular injections including haematoma formation, persistent nodules, local irritation and rarely anaphylaxis.

Dispose of PPE appropriately and wash your hands.

Document the details of the procedure and the medication administered.

Injection sites

Below is a brief overview of the common sites used for intramuscular injections.

Deltoid site

The deltoid muscle is relatively easy to locate and access, making it an ideal site for intramuscular injections. The deltoid site is most commonly used for the administration of small volume intramuscular injections such as vaccines.

Procedure

1. Position the patient sitting on a chair with their arm relaxed.

2. Expose the patient’s upper arm and shoulder.

3. Palpate the lower edge of the acromial process and administer the intramuscular injection approximately 2.5cm below this.

Deltoid intramuscular injection site 5

Ventrogluteal site

The ventrogluteal site provides access to the gluteus medius and minimus muscles whilst avoiding nerves and blood vessels, making it an ideal candidate for most intramuscular injections including those involving higher volumes of medication.

Procedure

1. The patient can be positioned prone, semi-prone or supine for this procedure, so choose whichever is most comfortable for the patient.

2. Place the palm of your hand over the greater trochanter of the patient’s hip, with your thumb pointing anteriorly.

3. Extend your index finger to touch the anterior superior iliac crest and point your middle finger towards the iliac crest to form a V-shape.

4. Insert the needle between your index and middle fingers (i.e. within the V-shape).

Ventrogluteal intramuscular injection site 5

Vastus lateralis site

The vastus lateralis muscle is relatively easy to locate and access making it an ideal site for intramuscular injections. The vastus lateralis site is most commonly used for immunisations in infants up to the age of 7 months. Patient’s at risk of anaphylaxis are also often taught to use this site for administering adrenaline intramuscular injections (i.e. Epipen).

Procedure

1. To locate the site, divide the front thigh into thirds vertically and horizontally to make nine squares and inject into the outer middle square. 4

Nasogastric tube insertion

Gather equipment

Gather the relevant pieces of equipment and place into a tray:

Nasogastric tube (fine bore)

Disposable gloves

Lubricant and gauze: to lubricate the tip of the NG tube.

Disposable bowl: to be used in the event of vomiting.

Paper towels: to allow the patient to wipe around their mouth if needed.

Large syringe: to obtain an aspirate from the NG tube.

pH testing strips: to assess the pH of the aspirate.

Dressing: to secure the NG tube.

A glass of water for the patient (if swallow is deemed safe).

Local anaesthetic spray: to numb the oropharynx.

Gather equipment

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: “At the moment you’re having trouble swallowing food in the normal way. Because of this, we need to place a fine tube through your nose going into your stomach to allow us to provide you with nutrition. The procedure will be uncomfortable, but it shouldn’t be painful or take very long. If at any point it becomes too uncomfortable and you want me to stop, just tap on my arm.”

Gain consent to proceed with NG tube insertion.

Check if the patient has any allergies (e.g. latex).

Ask the patient if they have any pain before continuing with the clinical procedure.

Position the patient sitting comfortably on a chair or bed.

If a patient has suffered head trauma and a base of skull fracture has not been ruled out, NG tube insertion should be avoided due to the potential risk of entering the cranial vault.

Measurement of the insertion length

1. Position the patient sitting upright with their head in a neutral position.

2. Don a pair of non-sterile gloves.

3. Estimate how far the NG tube will need to be inserted: measure from the bridge of the nose to the ear lobe and then down to 5cm below the xiphisternum.

Position the patient sitting upright

Don gloves

Measure the NG tube from the bridge of the nose -> to the ear lobe -> to 5cm below the xiphisternum

Note the insertion length

Insertion of the NG tube

1. Lubricate the tip of the NG tube.

2. If available, a local anaesthetic should be sprayed towards the back of the patient’s throat.

3. Warn the patient you are about to insert the NG tube.

4. Insert the NG tube through one of the patient’s nostrils.

5. Gently advance the NG tube through the nasopharynx:

This is often the most uncomfortable part for the patient.

If resistance is met, rotating the NG tube can aid insertion. Avoid forcing the NG tube if significant resistance is encountered.

If the patient becomes distressed, pause to give them some time to recover.

Intermittently inspect the patient’s mouth to ensure the NG tube isn’t coiling within the oral cavity.

6. Continue to advance the NG tube down the oesophagus: ask the patient to take some sips of water and then swallow as this can facilitate the advancement of the NG tube. Avoid giving patients a drink if their swallow is deemed unsafe, due to the risk of aspiration.

7. Once you reach the desired nasogastric tube insertion length, fix the NG tube to the nose with a dressing.

Lubricate the tip of the NG tube

Gently insert the NG tube into the nostril

Advance the NG tube to the desired length

Inspect patient's mouth for evidence of coiling

Secure the NG tube

Aspiration of the NG tube

1. Attempt to aspirate gastric contents:

If aspiration is successful, test the pH: a value of <4 suggests correct placement.

If aspiration is unsuccessful or the pH is >4 the patient will require a chest x-ray (CXR).

Some hospitals require a CXR regardless of pH, so check your local guidelines.

Acceptable pH ranges also vary between hospitals, so always check your local guidelines.

2. Once the NG tube is deemed safe for use, the radiopaque guidewire can be removed.

Attempt to aspirate gastric contents and assess pH

Close the NG tube port

Dispose of the used equipment

Wash your hands

To complete the procedure…

Explain to the patient that the procedure is now complete and reassure them that the NG tube will become more comfortable over the next few hours.

Thank the patient for their time.

Offer the patient paper towels to clean their face and nose.

Dispose of used equipment, including PPE, into a clinical waste bin.

Wash your hands.

Let the nursing staff know if the NG tube is currently safe to use.

Document the details of the procedure in the patient’s notes:

Your personal details including your name, job role and GMC number.

The date and time the procedure was performed.

Confirmation that verbal consent was obtained.

The indication for NG tube insertion.

The insertion length of the NG tube.

The pH of the aspirate or the failure to obtain an aspirate.

CXR interpretation (if performed): “NG tube visible dissecting the carina and sitting below the left hemidiaphragm”.

Any complications experienced during the procedure.

Whether the NG tube is currently safe to use.

Removing off an IV cannula

Just need alcohol swabs to remove the plaster off without any pain.Put alcohol swab on the corner as you peal out. Always letting the edges get it while pealing off And then just take off the cannula and immeditely after use a swab to appply pressure and hold for about 5 mins to stop bleeding. Applying pressure to prevent hematoma formation.

Iv catheters should be changed every 72 to 96 hours. 3 to 4 days.

Parenteral feeding and catehteraisation?

Catheterisation and blood tranfusion done by the doctor. Any other procedures to be learnt ????? Put and see the medicine book and srugery book has all list of procedures to know independantly or under supervision or to observe. Go trhough a list.