Peggy
Peggy (68 years old) has gone to her GP for an urgent blood test.
On arrival she becomes quite disorientated and when the practice nurse comes to take blood she becomes combative and tearful.. Because the bloods are urgent - think about how you would approach Peggy and what clinical holding techniques would you adopt with this important medical investigation.
Framework
Intro and approach including consent.
Any concerns?
Peggy is agitated and disorientated. Part of the nurses role is to calm Peggy and try and gain consent. Discuss potential positioning with her. Identify any distraction techniques that may help.
Also offer Peggy the opportunity to lie down instead of being seated.
Generally, it is less painful and more effective to take blood from the ante cubital fossa.
Procedure being performed
Venepuncture
Purpose and benefit of hold
Restriction of Peggy's arm, to keep Peggy safe and her arm secure to enable a safe venepuncture technique to be performed
Characteristics of hold
This action restricts movement and allows for immobilisation of the limb. Peggy has chosen to lie down.
The holder secures Peggy's arm by restricting movement of her shoulder by placing their shoulder on top of hers. This action helps to maintain Peggy in a lying down position.
The holder prevents movement by placing their flat hand on Peggy's upper arm. They also prevent flexion by gently holding Peggy's wrist with their thumb over the wrist (not squeezing this joint).
There may be a slight movement in Peggy's arm - but this will not prevent the venepuncture from being undertaken.
Evaluation of Risk factors and action taken
If Peggy starts to become agitated and combative - offer her a stress ball and other sensory items to hold in her left arm.
Also a second person could hold this arm/ distract her.
It is important not to squeeze or apply pressure to Peggy's wrist or upper arm as this could lead to bruising.
The holding action should not apply pressure to the limb, it's purpose is to immobilise the limb.
Number of people required to apply this technique and their roles
2 possibly 3
1 nurse to hold Peggy.
1 nurse to perform Venepuncture.
If possible, a third member of staff to comfort, reassure and use distraction techniques with Peggy and to hold her left arm if needed.
How many attempts will be made
If Peggy is still calm and it is a difficult venepuncture another attempt could be made following a patient assessment and consent from Peggy being given.
When and why would you stop the procedure
If Peggy becomes unduly distressed
If Peggy's vital signs become outside the normal range for her ie tachycardia, hyperventilation and hypertension
If there is a danger that force needs to be applied to immobilise (ie the people doing the holding are struggling to do so safely)
If there is a potential for harm to Peggy and/or the people involved in the holding
If there are not enough people available to perform the hold safely
Reflection
For all holding episodes, consider the following questions:
- Do I feel satisfied with my care delivery?
- Could I justify my decisions to a 3rd party
- If I were giving this care again, what would I do differently and how would I have achieved this
- How flexible have I been in my decision making?
To support your practice decisions refer to the Clinical Holding Flowchart to Support Decision Making (PDF).
