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Jun.24.2021

Blood Specimen Collection: Venipuncture (Neonatal) - CE

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

Do not use a vein that is proximal to IV fluid delivery.

Do not leave a tourniquet in place longer than necessary to prevent hemoconcentration, stasis, localized acidemia, and erroneous results for certain laboratory values. Ensure that the tourniquet does not occlude arterial flow.

If unable to obtain blood cultures in a timely fashion, do not delay antibiotics.

OVERVIEW

Venipuncture is used to obtain venous blood specimens. The procedure requires understanding the anatomy of primary arterial and venous blood supplies to the extremities and the principles of aseptic technique (Figure 1)Figure 1. Venipuncture is primarily used to obtain larger quantities of blood than is feasible with a heel stick or to obtain blood for culture.

For skin preparation, there is insufficient evidence to recommend a single product for all neonates.

  • Chlorhexidine should be used cautiously because it may cause skin irritation and chemical burns in infants less than 2 months old or infants with compromised skin integrity (premature infants).undefined#ref1">1,6
  • Isopropyl alcohol is drying to the skin and less efficacious than chlorhexidine gluconate and povidone-iodine and has been associated with chemical burns in premature infants.1
  • Povidone-iodine can cause alterations in thyroid function if absorbed through the skin.1

To minimize harm from topical antiseptics in premature neonates, the antiseptic is removed with a sterile 0.9% sodium chloride solution or sterile water after the procedure is complete.1

Poor peripheral perfusion, local infection, bruising, injuries, loss of skin integrity, or any anomalies that prohibit putting pressure on the extremity are absolute contraindications to performing venipuncture.2 Caution should be used for patients with coagulation disorders.2 Potential complications of venipuncture include hematoma, infection, hemorrhage, injury caused by the needle to adjacent structures, phlebitis, and pain.2

Venipuncture also requires knowledge of which containers are used for the types of specimens being collected, the minimum required blood volumes for requested specimens, and the requirements for specimen labeling and handling.

Venipuncture has been determined to be less painful than a heel-stick procedure.3 However, this is the case only if a trained, skilled health team member is obtaining the blood specimen and multiple venipuncture attempts are not required. Selecting pain management methods requires consideration of the patient’s developmental level as it relates to clinical assessment and capillary blood sampling. Pain-management measures should be suitable to the patient’s age and developmental level.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain the reason for laboratory studies.
  • Explain how the family can assist or support the patient by holding the pacifier and by providing facilitative tucking to reduce pain.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
  2. Introduce yourself to the family.
  3. Verify the correct patient using two identifiers.
  4. Verify the practitioner’s order.
  5. Assess the patient’s current medical status and illness severity.
  6. Assess the family’s understanding of the reasons for and risks and benefits of obtaining a venous blood specimen.
  7. If appropriate, include the family in pain management (e.g., holding the pacifier, using facilitative tucking).
  8. Identify the minimum blood volumes required for specimens.
  9. Assess the patient’s pain level using a valid, reliable, clinically useful, and developmentally appropriate pain assessment instrument.
    Rationale: Pain should be assessed before all painful procedures for optimal pain management.
  10. Determine the family’s desire to be present during the procedure.

Preparation

  1. Ensure adequate lighting.
    Consider using a transilluminator or ultrasound to improve the ability to locate veins.
  2. Collect and assemble the equipment and supplies for the procedure. Use small-volume syringes to avoid vein collapse from the negative pressure created by a larger syringe.
  3. Ensure that the equipment is within easy reach and that all supplies are clearly visible.

PROCEDURE

  1. Perform hand hygiene and don gloves. Don additional appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
  2. Explain the procedure to the family and ensure that they agree to treatment.
  3. Hold the patient using developmentally appropriate containment methods (e.g., swaddling, facilitative tucking) and use nonpharmacologic techniques (e.g., nonnutritive sucking) and pharmacologic agents (e.g., sucrose) as appropriate for pain management.8
  4. Evaluate the patient’s arms, hands, scalp, ankles, and feet for veins that are appropriate for venipuncture.
  5. Do not use veins that are indurated or that do not refill. Avoid extremities with bruising, phlebitis, dermatitis, cellulitis, fractures, or anomalies.5
    Differentiate between arteries and veins by assessing for a pulse.
    The veins of extremely low or very low gestational age neonates may be too small to support venipuncture.
  6. If veins are hard to identify, use one or more of these methods to improve visibility:
    1. Apply light pressure by encircling the extremity with one hand to facilitate vein distention or by placing a latex-free tourniquet proximal to the insertion site.2 Place a gauze pad under the tourniquet.
    2. Rationale: Applying light pressure causes vein distention, so the veins can be more readily identified and palpated. 2 Placing a gauze pad under the tourniquet decreases pinching of the skin and promotes healthy skin integrity.
      Ensure that tourniquet time is 1 minute or less.8 Tourniquet time of 3 minutes or more may alter laboratory test results.8
    3. Use transillumination or ultrasound.
    4. Ensure that equipment is appropriately cleaned after each use. Follow the manufacturer’s directions for use of equipment.
  7. Reassess the patient’s pain status, allowing for sufficient onset of action per medication, route, and the patient’s condition.
  8. Prepare the venipuncture site.
    1. Clean the skin with alcohol, then allow to dry completely.9
    2. Prepare the insertion site with greater than 0.5% chlorhexidine in an alcohol solution, using a back-and-forth motion for a minimum of 30 seconds, and allow to dry completely.4
    3. Disinfect bottle tops with 70% isopropyl alcohol (i.e., alcohol pad).9
    4. Do not touch the site after preparation unless sterile gloves are worn.4
  9. Stabilize the extremity and position the insertion site so that the needle will enter in the direction of the blood flow.2
  10. Select an appropriate-size (23-G or 25-G) butterfly retractable needle attached to an appropriate-size syringe for blood collection (Figure 2)Figure 2.2
  11. Puncture the skin at a slight angle with the bevel up just below the insertion site. Use a shallow angle for small neonates and for superficial veins and a larger angle for larger neonates and for deeper veins.3 Provide traction, if needed, to the skin below the insertion site.
  12. Rationale: A narrower angle is required with smaller neonates because they have less tissue to penetrate and their veins are superficial. 2 A greater angle is required with larger neonates because they have more tissue to penetrate and their veins are deeper. Inserting the needle with the bevel up decreases tissue damage during needle entry and exit. 2 Traction stabilizes the vein and allows smooth entry into the skin.
  13. Advance the needle until blood appears in the tubing.
  14. If blood does not appear, pull the needle back to just below the skin surface. Locate the vessel again and advance the needle again.2
  15. When blood appears, draw back on the syringe using gentle, slow pressure until the correct volume of blood is obtained.
  16. If bleeding or a hematoma occurs, occlude the vessel proximal to the insertion site. If a tourniquet is in place, release it, remove the needle, and apply pressure over the insertion site until the bleeding stops.
  17. After collecting the specimen, remove the tourniquet (if used), remove the needle, and apply gentle pressure to the puncture site with a gauze pad until the bleeding stops.
  18. Discard the needle in a sharps container at the patient’s bedside.
  19. Remove the antiseptic with a sterile 0.9% sodium chloride solution or sterile water after the procedure is complete.1
  20. Apply gauze, a piece of cotton ball, or a cotton roll to the venipuncture site.
  21. Do not use adhesive bandages on neonates.
  22. In the presence of the patient, label the specimen per the organization’s practice.7
  23. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
  24. Discard supplies, remove PPE, and perform hand hygiene.
  25. At the completion of the procedure, ensure that all choking hazards (e.g., syringe caps) are removed from the patient’s linens and placed in the appropriate receptacle.
  26. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Assess the puncture site for ongoing bleeding.
  2. Assess previously used puncture sites for hematoma and signs of infection (e.g., redness, swelling, warmth, drainage, pain at the puncture site).
  3. Assess perfusion in the extremity where the venipuncture was performed.
    Notify the practitioner if pulses are weak or absent or if a color change is observed in the extremity.
  4. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Sufficient blood specimen is collected.
  • Laboratory studies are completed and results are accurate.
  • Patient and family tolerate procedure with minimum distress.
  • Patient remains free of localized infection and bacteremia.
  • Arterial puncture is avoided.
  • Patient demonstrates acceptable level of comfort after the procedure.

UNEXPECTED OUTCOMES

  • Collected volume of blood is inadequate for needed laboratory studies.
  • Laboratory studies are not completed or results are not reliable.
  • Hemolyzed specimen produces erroneous results.
  • Patient or family is traumatized by the procedure.
  • Localized infection occurs at the puncture site.
  • Bacteremia occurs.
  • Arterial puncture occurs.
  • Patient’s pain is inadequately managed.

DOCUMENTATION

  • Type of procedure performed
  • Name and credentials of person performing procedure
  • Gauge and type of needle used
  • Site of procedure
  • Volume of blood obtained
  • Laboratory tests obtained (e.g., complete blood count, blood culture)
  • Patient’s tolerance of procedure
  • Pain score before and after the procedure and specific pharmacologic and nonpharmacologic interventions provided
  • Education
  • Unexpected outcomes and related interventions

REFERENCES

  1. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2018). Skin disinfectants. In Neonatal skin care: Evidence-based clinical practice guideline (4th ed., pp. 88-94). Washington, DC: Author. (Level VII)
  2. Bailey, T., Maltsberger, L. (2021). Chapter 15: Common invasive procedures. In M.T. Verklan, M. Walden, S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 244-269). St. Louis: Elsevier. (Level VII)
  3. Brown, T.L. (2017). Chapter 20: Pediatric variations of nursing interventions. In M.J. Hockenberry, D. Wilson, C.C. Rogers (Eds.), Wong’s essentials of pediatric nursing (10th ed., pp. 575-601). St. Louis: Elsevier.
  4. Ernst, D.J., and others. (2017). Chapter 5: Special situations. In GP41: Collection of diagnostic venous blood specimen (7th ed., pp. 41-48). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
  5. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 27: Site selection. Journal of Infusion Nursing, 44(Suppl. 1), S81-S86. (Level VII)
  6. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 33: Vascular access site preparation and skin antisepsis. Journal of Infusion Nursing, 44(Suppl. 1), S96. (Level VII)
  7. Joint Commission, The. (2021). National Patient Safety Goals® for the hospital program. Retrieved May 5, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_hap_jan2021.pdf (Level VII)
  8. Scheans, P. (2021). Chapter 13: Laboratory testing in the NICU. In M.T. Verklan, M. Walden, S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 207-218). St. Louis: Elsevier. (Level VII)
  9. Septimus, E. (2019). Collecting cultures: A clinician guide. Centers for Disease Control and Prevention. Retrieved May 4, 2021, from https://www.cdc.gov/antibiotic-use/healthcare/implementation/clinicianguide.html (Level VII)

ADDITIONAL READINGS

Barandouzi, Z.A. and others. (2020). Comparison of the analgesic effect of oral sucrose and/or music in preterm neonates: A double-blind randomized clinical trial. Complementary Therapies in Medicine, 48, 102271. doi:10.1016/j.ctim.2019.102271

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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