Phlebotomy Simplified

Phlebotomy Simplified
Third Edition Chapter 10 Pediatric and Geriatric Procedures Copyright © 2019, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Chapter Learning Objectives (1 of 3)
10.1 Describe fears or concerns that children of various ages might have regarding the blood collection process List suggestions for parents and health care workers during a venipuncture or skin puncture Identify puncture sites for a heelstick on an infant, and describe the procedure.

10.4 Explain the special precautions and types of equipment needed to collect capillary blood gases Describe the venipuncture sites for infants and young children Discuss the types of equipment and supplies that must be used during skin puncture and venipuncture for infants and children.

10.7 Describe the procedure for specimen collection for neonatal screening Define five physical and/or emotional changes that are associated with the aging process Describe how a health care worker should react to physical and emotional changes associated with older patients.

Introduction Collecting blood from a pediatric and/or geriatric patient requires much clinical knowledge about, and training for, the proper techniques. Both age groups require extra care in blood collection.

Pediatric Patients Observe various techniques as they are performed by a health care worker experienced in pediatric phlebotomy. Practice the techniques to develop the necessary skills. Learn how to talk with children of various ages to calm them for a blood collection.

Figure 10-1 Our Younger Multicultural Generation
GagliardiImages/Shutterstock

Preparing Child and Parent (1 of 8)
A calm, confident approach is first step. Correctly identify the patient. Hospitalized infant usually has identification bracelet on his/her ankle. Newborns not yet named are usually identified by their last names and identification number.

Child’s past experience with blood collections. Develop a plan for a successful blood collection. Place yourself at the child’s eye level to explain and demonstrate procedure.

Figure 10-2 Talking to a Child at Eye Level

Establish guidelines with child and parent. Be honest and tell the child that the procedure will be painful. Encourage parent involvement.

Psychological Response to Needles and Pain Children between 1 and 2 years of age may react extremely to painless procedures, such as taking a temperature. Children between 3 to 5 perceive pain as a punishment for bad behavior.

Psychological Response to Needles and Pain Children between 6 to 12 are more likely to relate pain to past experiences. Children between 13 and 17 years are frequently embarrassed to show fear.

Distraction Techniques Children over 3 years respond well to distraction techniques to help them cope and lessen distress. Examples of distraction are blowing bubbles or pinwheels, counting, reading a book or looking at a video, listening to music, singing, or talking in a gentle voice about something enjoyable.

Room Location Best room location for a painful procedure is a treatment room away from the child’s bed or playroom. If the child cannot be moved to a treatment room, maintain privacy by drawing a curtain between the beds and speaking in a calm, quiet manner.

Equipment Preparation for a Friendlier Environment Use shorter needles if possible. Keep threatening-looking supplies (needles) out of sight. Place goggles or face shields on after greeting the child.

Positions for Restraining a Child (1 of 2)
Holding the child may be required to ensure that the child does not move his or her limb during blood collection. Restraining techniques should be compassionate, safe, and performed quickly. A supportive, properly instructed parent can assist with restraining while providing comfort to the child.

Figure 10-4 Supine (Lying) Position for Restraining a Child to Perform Blood Collection

Positions for Restraining a Child (2 of 2)
Neonates and infants younger than 3 months usually do not require restraint and can be managed by the health care worker alone. Swaddling helps to control and comfort an upset newborn.

Figure 10-5 Swaddling a Newborn

Combative Patients Children may become combative—kicking and thrashing—if force is used. If the risk of injury to the child or the health care worker is likely, discontinue the blood collection attempt and notify the nurse or the physician.

Decreasing the Needlestick Pain (1 of 2)
EMLA Topical anesthetic. Applied to skin as a patch or cream that is then covered with transparent adhesive dressing. Optimal anesthesia occurs after 1 to 2 hours; may last as long as 2 to 3 hours. Do not use if child is allergic to local anesthetics.

For long description, see slide 104: Appendix A
Figure 10-6 Using EMLA When a needlestick is planned, EMLA can be used to anesthetize the skin where the needlestick will occur. A. Apply a thick layer of the EMLA cream over intact skin (half of a 5 g tube). B. Cover the cream with a transparent adhesive dressing for 60 to 120 minutes. For long description, see slide 104: Appendix A

Decreasing the Needlestick Pain (2 of 2)
Oral Sucrose A 25% solution of sucrose can be prepared by mixing 4 teaspoons of water with 1 teaspoon of sugar. Carefully administer by oral syringe, dropper, nipple, or on a pacifier. A sucrose nipple or pacifier is given 2 minutes before heelsticks. Its action lasts about 5 minutes.

Precautions to Protect the Child
PPE (gowns, gloves, and masks) worn as indicated before entering the room. Remove PPE according to policy and dispose of it in appropriately marked container. Wash your hands or sanitize them.

Pediatric Phlebotomy Procedures (1 of 4)
Microcapillary Skin Puncture Collect only the smallest amounts of blood so that the effects of reductions in blood volume are minimal. Overcollecting during phlebotomy may require packed-blood-cell transfusion in an infant. To avoid overcollection, record amount of blood collected from infant or small child.

Microcapillary Skin Puncture Collect hematology specimens first to minimize platelet clumping. Then chemistry specimens. Then blood-bank specimens. Lastly collect non-additive tubes.

Skin Puncture Sites Heel is most desirable site for skin puncture of the infant or neonate. Use the most medial or lateral plantar surface of the heel.

Figure 10-8 Heel Sites for Capillary Puncture

Skin Puncture Sites DO NOT use the central area of the infant’s heel for blood collection. For children older than 1 year, the palmar surface of the tip of the third or fourth finger is most frequently used.

Figure 10-9 Performing a Heel Stick on an Infant
Courtesy of Becton, Dickinson and Company

Heelstick Procedure (1 of 15)
Prepare and assemble supplies. Introduce yourself to the parents, explain the procedure, and use appropriate comfort techniques. Identify the infant properly. Wash or sanitize your hands according to institutional policy and then put on gloves. If required, don a gown and a mask.

Inspect the selected area and assess it for proper warmth. If it is cool or a blood gas specimen is to be collected, prewarm the foot with a warm, wet towel or a chemical heel-warming pack, according to policy. Wipe the heel dry after removing the warm towel.

A Closer Look: Heel Warming (1 of 2)
Prewarming the heel increases blood flow and arterializes the specimen. Essential for collecting specimens for capillary blood gas analysis. Warm the site with a commercial warming pack or wrap a warm, wet towel at a temperature no more than 42°C around the infant’s foot.

A Closer Look: Heel Warming (2 of 2)
Encase the towel in a plastic bag to help retain heat and keep the patient’s bed dry. Prewarm the site for 3 to 5 minutes. Depending on institution’s policy, call in advance to prewarm the infant’s heel.

Position the baby in a supine position with the knee at the open end of the bassinet. This position allows the foot to hang lower than the torso, improving blood flow.

When the baby is in an acceptable position for this procedure, clean the incision of the heel with an antiseptic swab. Allow the heel to air-dry.

DO NOT touch the incision site or allow the heel to come into contact with any nonsterile item or surface.

Figure 10-10 Jeramey Lende/Alamy Stock Photo

Remove the appropriate Tenderfoot puncture device from its blister pack, taking care not to rest the blade slot end on any nonsterile surface. Remove the safety clip. Once safety clip is removed, do NOT push the trigger or touch the blade slot.

Hold the infant’s foot firmly but gently to prevent sudden movement. Avoid excessive milking or squeezing, which causes hemolysis and dilutes the blood with interstitial and intracellular fluid. Raise the foot above baby’s heart level and carefully select a safe incision site.

Place the blade-slot surface of the device flush against the heel so that its center point is vertically aligned with the desired incision site.

Figure 10-11 David Gee/Alamy Stock Photo

Ensure that both ends of the device have made light contact with the skin and depress the trigger. After triggering, immediately remove device from infant’s heel and dispose of it in biohazard sharps container.

Figure 10-12 Chen Leopold/Alamy Stock Photo

Using only a dry sterile gauze pad, gently wipe away the first droplet of blood that appears at the incision site.

Taking care not to make direct wound contact with the collection container or capillary tube, fill to the desired specimen volume.

Figure 10-14 Keerati Preechanugoon/123RF.com

After blood collection, gently press a dry sterile gauze pad to the incision site until bleeding has ceased. This step will help prevent a hematoma from forming.

Label the specimen container and verify identification. Record the time of collection. Elevate the heel slightly above the body and ensure that bleeding has stopped. Check the infant’s heel puncture site for late bleeding or inflammation.

Dispose of used skin-puncture devices in a sharps container with a biohazard label. Check infant’s bed for any equipment or trash left behind.

Discard blood-soaked gauze sponges, grossly contaminated items, and gowns or gloves used in isolation rooms in biohazard waste containers. Dispose of gowns and gloves not from isolation rooms in the regular trash. Wash or sanitize your hands after removing the gloves. Transport specimens in timely manner.

Capillary Blood Gases (1 of 2)
Arterial blood is the specimen of choice for blood gas testing. Skin puncture blood less desirable. It contains blood from capillaries, venules, and arterioles, and fluids from surrounding tissue.

Capillary Blood Gases (2 of 2)
Skin puncture open collection system. Specimen is temporarily exposed to room air. Allows for a brief exchange of gases (both O2 and CO2) before sealing the specimen from the air.

Collection for Capillary Blood Gas Testing (1 of 9)
Blood for capillary blood gas analysis is collected from small children and babies for whom arterial punctures can be too dangerous. They are collected from the lateral posterior area of the heel or the ball of the finger.

Prepare and assemble supplies. Introduce yourself to the parents, explain the procedure, and use appropriate comfort techniques. Identify the infant properly. Warm the site according to the institution’s procedures.

Wash or sanitize your hands according to the health care institutional protocol, and then put on gloves. If required, don a gown and a mask. Use a heparinized safety plastic capillary tube for the collection.

Figure 10-17 SAFE-T-FILL® Capillary Blood Collection Tubes—100% Plastic for Safety Courtesy of RAM Scientific, Inc., Needham, MA

Perform the capillary (skin) puncture and wipe away the first drop. Fill capillary tube with blood end-to-end to obtain the stated fill volume of tube. Specimen must be collected with no air bubbles, which can cause inaccuracies in the values obtained from specimen.

Cap one end of the capillary tube, insert a small metal filing (referred to as a “flea” or “mixing wires”) into the filled capillary tube. Place the magnet over the tube and cap the other end of the tube. Use the magnet to draw the metal filing (flea) back and forth across the length of the tube to mix the specimen.

Figure 10-18 Capillary Blood Gas Tube, Metal Filing (Flea), and Plastic Caps

Label the tube and notify laboratory personnel of the urgent blood gas test to be performed. Press skin puncture site with a clean gauze sponge until the bleeding stops. Elevate the heel slightly above the level of the body, and assure that bleeding has stopped.

Check the infant’s heel puncture site for late bleeding or inflammation. Dispose of the used skin-puncture devices in a sharps container with a biohazard label. Check infant’s bed for any equipment or trash left behind.

Discard blood-soaked gauze sponges, grossly contaminated items, and gowns or gloves used in isolation rooms in biohazardous waste containers. Dispose of gowns and gloves that are not from isolation rooms in the regular trash.

Wash or sanitize your hands after removing the gloves. Deliver the sample immediately to the laboratory. Delays of more than 15 minutes at room temperature will affect the results.

Fingerstick on Children
Usually preferred for children older than 1 year. May be necessary if child has damaged veins from repeated venipuncture or if the veins are covered with bandages or casts. Do not perform a finger stick if finger is swollen, edematous, cyanotic, infected.

Figure 10-19 Collecting Blood via Fingerstick from a Toddler

Neonatal Screening Neonatal screening is important for the early detection, diagnosis, and treatment of certain genetic, metabolic, and infectious diseases. Blood spot testing for screening is performed before a newborn is 72 hours old.

Collection of Capillary Blood for Neonatal Screening (1 of 10)
Prepare and assemble supplies. Introduce yourself to the parents, explain the procedure, and use appropriate comfort techniques. Identify the infant properly. Fill out the information on the newborn screening card.

Figure 10-20 Courtesy of Wadsworth Center, New York State Department of Health

Warm the site according to the institution’s procedures. Wash or sanitize your hands with an alcohol hand rinse according to institutional policy; then put on gloves. If required, don a gown and a mask.

To prevent contamination, do not touch with hands or gloves any part of the filter paper circles before, during, or after collection. Do not allow the filter paper to come in contact with substances (alcohol, formula, water, powder, antiseptic solutions, or lotion).

Perform capillary (skin) puncture as previously mentioned. Wipe away the first drop of blood with a sterile gauze sponge. Allow another large blood drop to form. Lightly touch the printed side of the filter paper with the blood drop, and fill each printed circle on one side only.

Allow the blood to soak through and completely fill the circle with a single application to the large blood drop. If the circle does not fill entirely, wipe the heel and express another larger drop onto a different circle.

Do not add a second drop of blood to a previously used circle. Dry blood spots on a clean, dry, flat, nonabsorbent surface for a minimum of 4 hours.

Direct application of blood from the heel to the card is the technique of choice. Press skin puncture site with a clean gauze sponge until bleeding stops. Elevate the heel above the body.

Check the infant’s heel site for late bleeding and inflammation. Dispose of used skin-puncture device in a sharps container with a biohazard label. Check infant’s bed for any equipment or trash left behind.

Discard blood-soaked gauze sponges, grossly contaminated items, and gowns or gloves used in isolation rooms in biohazard waste containers. Dispose of gowns and gloves not from isolation rooms in the regular trash. Wash your hands after removing gloves.

Complete the information on the screening card so that follow-up can be done if the results are abnormal. Place the screening card in an appropriate envelope and send it to the laboratory within 24 hours.

Interferences in Newborn Screening Collections (1 of 2)
Blood specimen not properly dried before mailing. Filter paper circles not completely filled, not saturated with blood, or not all circles filled. Contamination of filter paper circles before or after blood collection.

Interferences in Newborn Screening Collections (2 of 2)
Blood applied to both sides of filter paper. Excess blood applied (usually occurs with a capillary tube). Heelstick squeezed or milked, resulting in “tissue diluted” specimens. Alcohol not wiped off heelstick site before puncture is made.

Venipuncture on Children (1 of 4)
Used when larger quantities of blood are needed. The veins of the antecubital fossa or the forearm are the most accessible and are chosen for most toddlers and children.

Figure 10-24 Veins in the Arm

Venipuncture is indicated for blood sampling for routine laboratory tests, erythrocyte sedimentation rate (ESR), blood cultures, cross-matching, coagulation studies, and drug and ammonia levels.

Procedure for performing venipuncture on children is similar to that for adults (see Chapter 8).

Special considerations may include: Necessary preparation of the child and parent Assistance in restraining the child Use of special pediatric-size needles or safety winged infusion sets.

Geriatric Patients (1 of 10)
Geriatric population is growing at an amazing rate. 75 million United States citizens are the “baby boomer” generation born between 1946 and 1964.

Health care workers will be providing health care services for patients having various types of chronic diseases and disorders (e.g., diabetes, cardiovascular diseases, COPD, arthritis).

This patient population will increasingly need point-of- care testing and other health care services in their homes, nursing homes, rehabilitation centers, and other long-term-care facilities.

Figure 10-25 Increasing Geriatric Population in the United States
The number of older citizens is rapidly increasing because of the advancing age of the baby boomer generation. Source: Ron Chapple/Getty Images

Physical Problems Common in Older Individuals Hearing loss Impaired verbal communication Failing eyesight Loss of taste, smell, and feeling Memory loss

Physical Problems Common in Older Individuals Skin tissue becomes thinner making venipuncture difficult Muscles become smaller affecting angle of venipuncture penetration Increased susceptibility to accidental hypothermia Increased sensitivities and allergies

Emotional Problems Associated with Aging Loss of career, spouse, close friends, or relatives Fading physical and mental abilities Can be reflected by depression or anger at life in general

Considerations in Home Care Blood Collections Extra supplies and equipment Positively identify the patient Special positioning of patient for venipuncture Use hand disinfectant before blood collection

Considerations in Home Care Blood Collections Wait for puncture site to stop bleeding Properly discard all trash and used supplies

Considerations in Home Care Blood Collections Label specimens and place them in leakproof containers with biohazard sign Check appropriate temperatures for transport

Considerations in Home Care Blood Collections Take security precautions Document delayed specimens

Copyright This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

Appendix A Long Description for Figure 10-6 When a needlestick is planned, E M L A can be used to anesthetize the skin where the needlestick will occur. Photo A shows how to apply a thick layer of the E M L A cream over intact skin, half of a 5 gram tube. In photo B, a health care worker covers the cream with a transparent adhesive dressing for 60 to 120 minutes. Return to presentation

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