Procedural Skills

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Cannulation
Catheterisation
Catheterisation (Female)
Venepuncture
Nasogastric tube insertion
Blood Culture
Arterial Blood Gas

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Cannulation

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Introduce self to patient by name and title Ensure you have the correct patient – check name band, DOB, CHI (in-patients) or address (primary care)* Establish whether the patient has any allergies Explain procedure to patient Gain verbal consent Identify if the patient requires local anaesthetic cream Organise gloves, gauze swabs /cotton wool, tourniquet, syringe, vial of sodium chloride and dressing Select appropriate venous cannula for procedure Check expiry dates on all packaging Decontaminate Hands* Put on gloves and apron* Take sharps bin to bedside* Apply tourniquet and select appropriate vein Swab skin with antiseptic wipe (70% isopropol alcohol) and allow to dry for 30 secs Avoid any contamination of cleaned cannulation site Fix the vein with the fingers of one of your hands Ensure bevelled edge is uppermost Enter vein with cannula at an angle of approximately 10-45 to the skin Avoid contamination of needle with hands* Advance needle and cannula for a few mm after flashback is seen If cannula fails to advance:
Release tourniquet
Place a swab/cotton wool over the cannula
Remove cannula
Dispose of cannula in sharps bin*
Apply pressure to vein for 2mins or until bleeding stops
Explain to patient and try again at a different site
Advance cannula over needle into vein until second flashback is seen Release tourniquet prior to removing needle Apply pressure to vein above tip of cannula Remove and dispose of needle safely into sharps bin* Place cap, interlink or bung on the end of the cannula Secure appropriately with sterile dressing Flush cannula with 0.9% sodium chloride Dispose of waste into clinical waste bag Decontaminate hands* Document procedure in patients notes: Date, reason for cannula, site, size/colour, number of attempts taken, signature, print name and grade and initiate pvc bundle

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Catheterisation

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Perform hand wash Collect and prepare required equipment Check identity of the patient Explain procedure to the patient and obtain informed consent Establish patient allergies (especially latex) Ensure patient privacy Assist the patient into a comfortable position and ensure not unduly exposed Place protective sheet under the patient’s buttocks and adjust lighting as necessary Put on apron Perform hand wash Open catheterisation pack and apply both pairs of gloves Apply the sterile drapes appropriately over the patient. (An aseptic technique using sterile gloves is used during this procedure). Retract the foreskin (if present) and cleanse the glans and urethral meatus with saline solution, swabbing away from the urethral orifice. Hold the penis gently and laterally behind the glans with a gauze swab. Before applying anaesthetic gel, check with patient regarding any previous allergies/reactions Anaesthetise the urethra with 11ml of local anaesthetic lubricating disinfecting gel, instilling slowly. Gently squeeze the end of the penis (or apply a penile clamp) to prevent the anesthetic from escaping the urethra. Allow 5 minutes to elapse Remove outer gloves Position receptacle for urine Pick up catheter in dominant hand and remove packaging Using the gauze swab, hold the penis at a 90 degree angle from the pelvis. Introduce catheter into meatus and continue to insert until urine flows. If resistance is felt, increase traction on the penis slightly and apply steady, gentle pressure on the catheter Once urine flows insert the catheter a further few centimetres Inflate the balloon with sterile water as per manufacturer’s instructions Withdraw the catheter slightly until resistance is felt at bladder neck Attach catheter to drainage system Ensure the foreskin (if present) is placed back over the glans Collect urine sample if required Make sure the patient is comfortable Dispose of equipment as per local policy Perform hand wash Document procedure in patient’s notes/care plan/fluid chart, including reason for procedure, catheter used (size, type, batch number, volume in balloon), anaesthetic gel used, any problems and signature of practitioner

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Catheterisation(Female)

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Perform hand wash Collect and prepare required equipment Check identity of the patient Explain procedure to the patient and obtain informed consent Establish patient allergies (especially latex) Ensure patient privacy Assist the patient into a comfortable position and ensure not unduly exposed Place protective sheet under the patient’s buttocks and adjust lighting as necessary Put on apron Perform hand wash Open catheterisation pack and apply both pairs of gloves Apply the sterile drapes appropriately over the patient. (An aseptic technique using sterile gloves is used during this procedure). Using saline cleanse the vulval area swabbing from above downwards Identify the urethral meatus Insert 6mls of local anaesthetic lubricating disinfecting gel into urethra Allow 5 minutes to elapse Remove outer gloves Position receptacle for urine Pick up catheter in dominant hand and remove packaging Insert into urethral orifice for about 6-8cm until urine flows. Once urine flows insert the catheter a further few centimetres Inflate the balloon with sterile water as per manufacturer’s instructions Withdraw the catheter slightly until resistance if felt Attach catheter to drainage system Collect urine sample if required Make sure the patient is comfortable Dispose of equipment as per local policy Perform hand wash Document procedure in patient’s notes/care plan/fluid chart, including reason for procedure, catheter used (size, type, batch number, volume in balloon), anaesthetic gel used, any problems and signature of practitioner

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Venepuncture

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Introduce self to patient by name and title Ensure you have the correct patient – check name, DOB, CHI (in-patients) or address (primary care) or Typenex number (unknown identity)* Explain procedure to patient and ask about preferred site / side Gain verbal consent Select appropriate container(s) and needle for procedure Organise gloves, tourniquet, gauze swabs/cotton wool, tape Take sharps bin to the bedside*d Decontaminate hands* Put on gloves (disposable non-powdered latex not vinyl) and apron* Apply tourniquet and select appropriate vein Swab skin with antiseptic wipe (70% isopropol alcohol) and allow to dry for 30 secs Ensure bevelled edge of needle is upmost Enter vein with needle at an angle of approximately 15-30 to the skin Avoid contamination of needle with hands* Collect blood in appropriate containers If unsuccessful, gently manoeuvre needle to attempt to collect blood If blood collection fails:
Release tourniquet
Place a swab/cotton wool over the needle
Remove needle
Dispose of needle in sharps bin*
Apply pressure to vein for 30-60 seconds or until bleeding stops
Explain to patient and try again at a different site / side
Release tourniquet prior to removing needle. Remove needle and cover area with swab/cotton woole Dispose of needle safely into sharps bin* Apply pressure to site for 30-60 seconds or until bleeding stops, with swab/cotton wool Keep arm extended and elevated Write details (name, DOB, CHI, ward, time, initial, date or apply sticky label if Test Requesting in use) on blood bottles at the side of the patient Place blood sample(s) into sealed polythene bag (one bag per patient) Dispose of gloves into clinical waste bag Decontaminate hands* Check that bleeding has ceased

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Nasogastric Tube

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Introduce self to patient by name and title Ensure you have correct patient: check name band, DOB, CHI/address Explain procedure to patient & Gain verbal consent Organise: apron, gloves, NG tube, NG drainage bag, glass of water, gauze swabs, lubricating gel, 50ml (catheter tip) syringe, pH testing strips, tape to secure tubing Decontaminate hands Put on apron and gloves Position Patient

Sit patient upright with chin slightly forward and in line with sternum> Measure approximate length of tube take proximal end tubing

• Bridge of nose to tragus of ear to xiphisternum
• Select appropriate marker on the tube from the patient’s measurements. Explains to patient that they will need to swallow when specified to help the tube go down Lubricate tube and insert into patent nostril. Gently advance tube towards the occiput. Ask patient to swallow when they feel the tube at the back of their throat.

The tube is advanced during swallowing; getting the patient to sip water at this stage may help. Advance the tube through the pharynx until the predetermined mark has been reached. Assess position

aspirate a few ml of gastric contents and check pH (with pH indicator paper as the first line check) or check chest x-ray (second line test). Secure tube. Attach drainage bag. Ensure the patient is left comfortable. Dispose of waste in clinical waste bag Decontaminate hands Document procedure in patients notes

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Blood Culture

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Introduce self to patient by name and title Ensure you have the correct patient – check name, DOB, CHI (in-patients) or address (primary care) or Typenex number (unknown identity) Explain procedure to patient and ask about preferred site / side Gain verbal consent Clean hands if leaving the patient zone Obtain trolley and clean surfaces with a neutral detergent wipe e.g clinitex wipe Obtain sharps box and tray and clean with clinitex wipe Select appropriate container(s) and needle for procedure Organise gloves, disposable tourniquet, gauze swabs/cotton wool, tape, Clinell Wipe the tourniquet if disposable tourniquets are not readily available Take sharps bin to the bedside on a clean trolley Decontaminate hands* -either hand wash or alcohol gel if hands visibly clean Put on apron then gloves (disposable non-powdered latex not vinyl) After removing caps clean rubber caps for 30 seconds and allow to air dry (bottles cleaned with separate wipes) Apply tourniquet and select appropriate vein Apply 2% chlorhexidene in 70% alcohol to 5cm radius with friction to ensure good clean Ensure bevelled edge of needle is upmost Enter vein with needle at an angle of approximately 15 to the skin Avoid contamination of needle with hands- No touching “critical” sterile parts Release tourniquet prior to removing needle Remove needle and cover area with swab/cotton wool Apply pressure to site for 30-60 seconds or until bleeding stops, with swab/cotton wool Keep arm extended and elevated Collect blood in appropriate containers, Blood Culture Samples always first Fill aerobic bottle first to prevent air entering the bottle from the syringe Distribute 20 mls of blood evenly between both culture bottles Dispose of needle safely into sharps bin and syringe Write patient details on sample containers Place blood sample(s) into sealed polythene bag (one bag per patient) Dispose of gloves into clinical waste bag, and then dispose of apron (pull and break ties) and finally Decontaminate hands* before leaving patient zone

If blood collection fails

Release tourniquet Place a swab/cotton wool over the needle Remove needle Dispose of needle in sharps bin Apply pressure to vein for 30-60 seconds or until bleeding stops Explain to patient and try again at a different site / side

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Arterial Blood Gas

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Select appropriate equipment for procedure (ABG syringe pack, equipment tray with attached sharps bin,* gloves, gauze swabs /cotton wool, request form and ice if indicated) Consider use of topical local anaesthetic Introduce self to patient by name and title Ensure you have the correct patient, check name, DOB, CHI (in-patients) or address (primary care) Explain procedure to patient Gain verbal consent Decontaminate Hands Put on gloves Ask patient to keep arm still or ask for assistant to hold arm Choose and palpate appropriate artery with fingers Perform Allen’s procedure Swab skin with antiseptic wipe (70% isopropol alcohol) and allow to dry 30s Set plunger to recommended sample volume (1.6ml for 3ml syringe) Palpate artery with two fingers Enter artery with needle at an angle of approximately 45 degrees to the skin directed into the proximal part of the artery Ensure the bevel edge is upmost Avoid contamination of needle with hands Allow syringe to fill with arterial blood

If no blood appears:

Slowly withdraw needle and re-advance until flash back seen If no flashback is seen place a swab/cotton wool over entry site Withdraw needle and apply pressure to artery for 5mins or until bleeding stops Dispose of needle and syringe in sharps bin Explain to patient and try again at another site

Remove needle and syringe and apply pressure to artery for 5 mins or until bleeding stops Remove needle from syringe safely disposing of needle into sharps bin Remove any air bubbles from the syringe Put cap on syringe and mix thoroughly Dispose of gloves into clinical waste bag Decontaminate hands Put patient details on syringe at bedside Send on-ice to lab immediately or take to analyser