FOCUS

At a glance: a guide to venepuncture

in adults
Claire Ford and Katy Skarparis

which infection might be introduced during a procedure, eg

ABSTRACT opening in the skin, urethra, cannula insertion site; whereas
This article will provide clinical guidance on carrying out venepuncture on ‘Key-Parts’ are associated with the equipment that might come
an adult. It will discuss site, equipment selection and aseptic non-touch into contact with Key-Sites or other Key-Parts, eg, dressings,
technique. The aims are to increase knowledge of the anatomical structures catheters and syringe tips.These should not be touched or only
associated with venepuncture, demonstrate the clinical procedural technique touched with sterile gloves and sterile equipment.
of venepuncture, and provide an awareness of the dangers and complications There are two main variations of ANTT: standard, which is
of this invasive technique. used for uncomplicated, simple and quick procedures involving
Key words: Clinical skill ■ Nursing ■ Simulation ■ Venepuncture few Key-Sites or Key-Parts, and surgical, for those skills and
procedures that are more complex, lengthy and involve multiple

V
Key-Sites or Key-Parts.When carrying out a clinical procedure,
enepuncture is a vital procedure that is routinely an ANTT risk assessment is required to ascertain if the procedure
used in the care and management of patients necessitates the adoption of a standard or surgical ANTT approach.
and is one of the most commonly performed This involves assessing the difficulty of protecting the Key-Parts
invasive procedures (Boyd, 2022). It enables and Key-Sites associated with the skill, while also considering the
health professionals to obtain a sample of blood number and sizes of the Key-Parts, environment, invasiveness, and
for analysis by the puncture of a vein with a hollow-bore user competency (ASAP, 2021). For standard ANTT procedures,
needle, vacuum system or butterfly infusion system (Thomas, non-sterile gloves can be worn as the Key-Parts and Key-Sites
2015). These investigations typically include biochemical to are limited, such as in cannulation and venepuncture. However,
analyse certain parameters, such as potassium and sodium for surgical ANTT procedures such as urinary catheterisation
levels, haematological to determine blood measurements and wound care, sterile gloves must be worn, due to the level of
and microbiological to determine the presence of pathogens invasiveness (ASAP, 2021).
(Gallagher, 2022). As this is a procedure that nurses may be
asked to perform as part of their role, it is essential that they are Informed consent, patient preparation and
adequately trained, competent in using the correct technique pain management
and aware of any advances or changes in the underpinning Before carrying out venepuncture, and where possible, it is
evidence (Nursing and Midwifery Council (NMC), 2018) necessary to obtain informed consent.This will include ensuring
that patients are aware of the reasons for the need to take samples
Aseptic non-touch technique of their blood, what the associated risks and complications are
The aseptic non-touch technique (ANTT) is a method employed and details of the procedure and aftercare (Curr and Fordham-
to minimise the likelihood of patients contracting infections Clarke, 2022). Providing this level of information will not
during clinical procedures. As set out by the Association for only safeguard that the patient can provide valid consent, but
Safe Aseptic Practice (ASAP) (2021) it accomplishes this by will also assist in building rapport and a trusting therapeutic
safeguarding ‘Key-Parts’ and ‘Key-Sites’ from micro-organisms relationship, which could help reduce any fears or anxieties.
that might be transmitted from health personnel or nearby It is also imperative at this point to gauge how the patient is
environments.‘Key-Sites’ are classified as parts of the body into feeling about the procedure, as gaining an insight into potential
fears, (eg fear of needles – trypanophobia) (Perry et al, 2021),
anxieties or preferences will allow for adequate preparation of
Claire Ford, Assistant Professor, Adult Nursing, Department of
Health and Life Sciences, Northumbria University, Newcastle the patient and the environment prior to the procedure. This
can be achieved by asking questions such as ‘Have you had this
© 2024 MA Healthcare Ltd

upon Tyne, [email protected]

procedure before?’ and ‘How do you feel about the procedure?’.
Katy Skarparis, Assistant Professor, Adult Nursing, Department
of Health and Life Sciences, Northumbria University, Newcastle Any potential allergies also need to be determined before
upon Tyne gathering the equipment, as alternative gloves and dressings
may be required.
Accepted for publication: December 2023
It is also important to consider not only the patient’s comfort

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but also the potential to increase their pain, thus appropriate

Peter Lamb

a b
multimodal approaches to pain assessment and management
need to be undertaken in order to minimise the risks of
harm. This can include the use of pharmacological and non-
pharmacological approaches such as distraction therapy and
topical analgesics (Ford, 2019).

Anatomy of the arm

When undertaking venepuncture, it is important to understand
the anatomy and physiology of the veins, circulation and
surrounding structures (arteries and nerves), in order to
undertake safe and effective practice (McCall, 2020). The
superficial veins (median cubital, cephalic, and basilic) found in
the antecubital fossa region of the arms, are the most commonly
selected sites for venepuncture (Figure 1a), as they are easily
accessible and cause minimal discomfort for the patient (Brooks,
2017). Metacarpal veins (Figure 1b) can also be used as they are
easy to visualise, and palpate; however, the use of these veins
may be more painful and difficult in patients with poor skin
turgor (McCall, 2020).
Figure 1. Veins of the arm and hand

Table 1. Choosing the correct site Choosing the correct site and vein
Arm/hand selection
Although the arm is the most commonly used site for
venepuncture, it is important to assess the most appropriate
■ Avoid arms affected by a cerebrovascular accident
■ Avoid arms impacted post mastectomy or node dissection
site for each patient. Factors that influence the decision
■ Avoid arms affected by lymphoedema include patient preference, past medical history, age, current
■ Choose arms/hands with good capillary refill comorbidities, skin condition, vein suitability and accessibility
■ Choose the non-dominant arm (if this is patient’s preference) and reasons for use (Gorski et al, 2021).Additionally, it is essential
Vein selection to consider which arm or limb to use, which vein to select
■ Veins which are easily palpable
within that limb and then which particular site on the skin
■ Veins with largest diameter (see Table 1).
■ Avoid fragile and sclerosed veins
■ Avoid veins irritated from previous use Equipment
■ Avoid visible valves There is a wide variety of hollow-bore needles and vacuum
■ Avoid veins with fibrosis
■ Avoid veins close to arteries
systems that are available for venepuncture; therefore, it is
imperative that you familiarise yourself with the equipment
Sites selection
that is used by your trust. See Box 1 for an example list of the
■ Avoid sites affected by intravenous drug use equipment that is required.
■ Avoid sites with haematomas, oedema, or thrombus
■ Avoid sites with a fistulae or vascular graft
■ Avoid areas of inflammation Blood collection tubes and order of draw
■ Avoid areas with burns or scars Traditionally, blood samples were obtained by needle and
syringe, but advances in technology and medical devices led
Box 1. Sample equipment list for venepuncture
to this being superseded by vacuum blood collection tube
systems (Blann and Ahmed, 2014). These glass or plastic tubes
■ Gloves contain a partial vacuum, which encourages the movement of
■ Apron
blood from the vein into the tube, and the amount of vacuum
■ Alcohol gel
■ Procedural tray present will determine the amount of blood required within the
■ Disposable tourniquet container (Lister et al, 2021). The tubes also contain additives,
■ Alcohol-based cleansing product such as anticoagulants (eg, sodium citrate, lithium heparin) or
■ Needle substances to allow a serum sample to be obtained, and which
■ Tube holder
additive is used is dependent on which analysis techniques are
■ Vacuum blood collection tubes
to be conducted in the laboratory (Blann and Ahmed, 2014).
© 2024 MA Healthcare Ltd

■ Sterile gauze
■ Dressing or adhesive tpe In order to mix the blood with the contents, the tubes must
■ Sharps disposal bin be inverted, and the number of inversions will depend on
■ Request forms (signed, dated and labelled) the manufacturer’s instructions (Lister et al, 2021). It is also
■ Pillow
essential that the additives within the various tubes are not
Source: Lister et al, 2021 mixed with each other and therefore if more than one tube

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 FOCUS

is to be used, these must be used in a specific order (Thomas, manufacturers and disposed of correctly (Health and Safety
2015). Higgins (2013) suggested that within the blood analysis Executive, 2013).
continuum, errors during the collection of the samples are
where the most errors occur. Order of draw protocols should, What is the correct procedure for
therefore, be adhered to. venepuncture?
As health professionals, it is important to work within guidelines
Tourniquets and policies and use evidence-based practice (Nursing and
In nursing practice, tourniquets can be used as a means of Midwifery Council (NMC), 2018). The use of a standard
maximising successful attempts on first insertion (Shaw, ANTT for the preparation and performance of the procedure
2014). Several types can be found in practice, these should can minimise the risk of contamination and risk of infection
be disposable, easy to use and latex-free (Lister et al, 2021). (Loveday et al, 2014):
When applying the tourniquet, it is also imperative that it is ■ Communicate with the patient, gain informed consent and
removed as soon as possible (not exceeding 60 seconds) as ascertain preferences, allergies and fears
the tourniquet will cause venous stasis, localised acidaemia ■ Decontaminate hands and gather and assemble relevant
and haemoconcentration, which affect the blood for analysis equipment (Figure 2a)
(Higgins, 2013; Pagana et al, 2020). Consequently, Gorski et ■ Place the limb in a comfortable, accessible position (use a
al (2021) do not advocate the use of a tourniquet, stating that pillow if necessary)
it should be avoided if possible.Therefore, practice may differ, ■ To assess which vein to use, a tourniquet can be used to
and it is imperative that you abide by local trust policy when make the veins more visible. Make sure the tourniquet
deciding if a tourniquet is to be used.

Site preparation
Although there is some controversy about whether skin
cleansing of the site is necessary, the Infusion Nurses Society
guidelines (Gorski et al, 2021) state that skin antisepsis should
Panaway ®

Pulp medical products and

be performed prior to all venepunctures to prevent the complete waste disposal
risk of infection. It can be prepared with a cleansing agent
that is alcohol-based, such as 70% isopropyl alcohol or 2%
chlorhexidine in 70% alcohol (Loveday et al, 2014). The
technique for how the skin should be prepared must be in
accordance with the manufacturers’ instructions, which will Energy T US HELP..

efficient,
be specific to the products being used. LE .

How many
Risks and hazards
As with any clinical procedure, the trained health professional economical £’000s could
must be aware of the risks involved, for themselves, the patient
and others. Further details in relation to blood-borne infection,
sluice room you save?

sharps safety, phlebitis, arterial puncture and extravasation can 9 Patient care: Helps prevent HCAIs
be found in the accompanying article entitled ‘A guide to 9 Cost: Save £’000s on hot water
cannulation in adults’ (Ford, 2023).
9 Compliance: Dependable sluice room up-time

9 Staffing: Simpler, nicer process for staff

Safety of the practitioner
One of the greatest dangers to health professionals when 9 Logistics: Low risk upgrade from washing pans
undertaking procedures using hollow-bore needles is the risk
of contracting a blood-borne infection via a sharps injury (Health Bedpan macerators use less than 5% energy compared to washers.
Washer sterilisers require hot water or steam, typically costing
and Safety Executive, 2013). Due to the frequency of undertaking £3,000-£5,000 per machine per year, with considerable kW even

venepuncture, nurses are one of the health professional groups when on standby. Macerators in contrast would use £50-£150*.

Economical and energy efficient to run, Haigh macerators are also

most at risk (Woode et al, 2015). Health professionals can be environmentally responsible, manufactured to strict environmental
exposed to 30 potentially dangerous pathogens, including hepatitis parameters, including the use of on site solar generated energy.

B and C (European Biosafety Network, 2011). Therefore, in

order to ensure safe practice, personal protective equipment
(PPE), which is a universal precaution, must be worn. Kinlin et www.panaway.com
© 2024 MA Healthcare Ltd

al (2010) claimed that the use of gloves has been shown to be +44(0)1989 763131 (Option 2)
beneficial in reducing the transmission of blood-borne infections
by decreasing the inoculum of blood introduced during a sharps
injury. Additionally, all devices used must adhere to sharp safety *
Assumptions, additional whole life cost figures, maintenance, water and consumables usage available online.
© 2023 Haigh Engineering. Sluicemaster, Panaway, Incomaster, Haigh Quattro and Haigh Solo are Haigh Engineering Ltd. brands.
Est. 1959. Registered in the UK, No. 00639089. VAT number GB 134 1449 90

regulations, must be checked before use, as instructed by the

cost
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British Journal of Nursing, 2024, Vol 33, No 2 Find 63

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 FOCUS

is appropriately applied 7-10 cm above the chosen site. ■ Remove the vacuum collection tube and invert as per
However, it should only be tight enough to impede venous manufacturer’s instructions
return and not obstruct arterial flow. Asking the patient to ■ Once all the required blood has been obtained, hover the
open and close their fist, or using gravity and hanging the gauze over the needle site (do not press down yet)
patient’s arm down, may also encourage venous filling ■ Retract the needle and put pressure on the site with the gauze
■ Palpate with two fingers or the thumb, to find the best ■ Click the safety cap (over the needle) with your thumb
available vein (Figure 2b). NB veins do not pulsate and dispose of it in the sharps container
■ Decontaminate hands and apply PPE (Ford and Park, 2018; ■ Remove PPE, wash hands, label specimens and document
2019) the care, noting any witnessed difficulties.
■ Clean the chosen site with the alcohol-based preparation
equipment and allow it to dry (Figure 2c). Do not re-palpate, Top tips
as this will increase the risk of contamination The following information has been collated by Northumbria
■ Remove the sheath from the needle and inspect for damage University staff in relation to some of the common errors that
■ Warn the patient they will feel a sharp scratch students encounter when undertaking venepuncture.
■ Use one hand to apply traction on the skin a few ■ Missed vein: ensure you use your fingers to anchor the
centimetres below the site and avoid touching the clean vein, this will stop the vein from moving and will also
area (Figure 2d) stretch the skin for better visibility. If you also choose one
■ With the bevel upwards, insert the needle at about a of the largest veins, then the likelihood of missing the vein
10-30 degree angle (this will vary depending on the will be reduced
manufacturer’s guidelines). Some needle equipment will ■ Blood spray: ensure you advance the needle tip far enough
allow you to see if you are correctly situated in the vein into the vein, if the tip has entered before the rest has
with a visual flashback – if this is not the case, you will advanced under the skin, you have only achieved partial
have to attach the vacuum collection tube to observe for needle insertion, and leakage may occur. Avoid superficial
successful blood flow veins to help reduce the likelihood of this occurring
■ Attach the vacuum collection tube to the device connected ■ Blood stops flowing: this is probably due to the angle of
to the end of the needle (plastic holder) (Figure 2e) insertion or if the tip of the needle has made contact with
■ Allow the required blood for that specific collection container a valve, the vein wall or if the vein has collapsed.To remedy
to be collected, and as soon as blood runs freely, release the this, gently advance or reposition the needle
tourniquet (Figure 2f) ■ Spatter of blood that then stops: you have possibly pushed
Phtots property of Northumbria Uiversity

a b c
© 2024 MA Healthcare Ltd

d e f

Figure 2. Venepuncture procedure using a vacuum blood collection tube

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the needle too far, and it has exited the vein on the posterior
side. Remove the needle and apply pressure KEY POINTS
■ Simulation-based education (SBE) is a widely used teaching ■ Venepuncture is a widely practised invasive procedure, which uses an
method in healthcare education that uses patient simulators, aseptic non-touch technique and requires a sound understanding of
task trainers (such as those used in the images in Figure 2) and anatomy and physiology
virtual technologies. It has been proven to be an effective way ■ This skill is associated with several risks for both health professionals
to support clinical placement, prepare health professionals carrying out the procedure and the individual who requires the intervention
for their future work, and address the necessary qualities
■ For students, the opportunity to practise this skill in clinical practice is
and proficiencies that nurses and other health professionals
sometimes difficult; therefore, alternative education and learning strategies
need to possess, and improves knowledge and behaviours,
such as simulation can prove extremely beneficial in acquiring and
particularly related to clinical skills, when compared with
maintaining practice
traditional training techniques (NMC, 2023).

Conclusion Essentials of nursing practice. 3rd edn. Sage; 2022. ISBN: 9781529732191
Venepuncture is a clinical skill, which requires health professionals (pages 403-422)
Gorski LA, Hadaway L, Hagle M et al for Infusion Nurses Society. Infusion
to have a sound understanding of the underpinning principles, therapy standards of practice, 8th edn. Journal of Infusion Nursing. 2021; 44(1
as well as a comprehensive awareness of the technique aligned Suppl): S1–S224.
Health and Safety Executive. Sharp Instrument in Healthcare Regulations 2013:
with the clinical procedure.Therefore, although it is important guidance for employers and employees. Health Services Information Sheet 7.
to review local and national guidelines and associated literature, 2013. https://www.hse.gov.uk/pubns/hsis7.pdf (accessed 11 January 2024)
it is also vital to use every opportunity to practise this skill in Higgins C. Understanding laboratory investigations: A guide for nurse, midwives
and healthcare professionals. 3rd edn.Wiley-Blackwell; 2013. ISBN: 978-
clinical practice, in addition to using alternative education and 0470659519
learning strategies such as simulation-training aids, in order to Kinlin LM, Mittleman MA, Harris AD, Rubin MA, Fisman DN. Use of gloves
and reduction of risk of injury caused by needles or sharp medical devices in
maintain contemporary practice. BJN healthcare workers: results from a case-crossover study. Infect Control Hosp
Epidemiol. 2010;31(9):908–917. https://doi.org/10.1086/655839
Lister SE, Hofland J, Grafton H,Wilson C.The Royal Marsden manual of clinical
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community care. ASAP; 2021
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CPD reflective questions

■ What anatomical knowledge and patient assessment skills do you need to consider essential before attempting venepuncture? How does
this knowledge help in reducing the risks associated with this procedure?
© 2024 MA Healthcare Ltd

■ How do you ensure the proper selection and utilisation of equipment, and are there any recent advancements in equipment that you
should be aware of and incorporate into your practice?
■ In your practice, how do you effectively communicate with patients about the procedure, obtain informed consent, and provide them with
information about potential risks? How can you improve your patient communication and education regarding venepuncture?

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