Blood Specimen Collection: Venipuncture (Neonatal) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

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. Be sure that the tourniquet does not occlude arterial flow.

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

Take precautions with a patient who takes medications that increase the risk for bleeding.^{undefined#ref5">5}

OVERVIEW

Venipuncture is used for 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). Venipuncture is primarily used to get larger quantities of blood than is feasible with a heel stick or for blood for culture.

For skin prep, there is not enough evidence to recommend a single product for all neonates. Be aware that:

• Chlorhexidine should be used cautiously because it may cause skin irritation and chemical burns in infants less than 2 months old or premature infants.¹
• Isopropyl alcohol is drying to the skin, does not work as well as chlorhexidine gluconate and povidone-iodine, and has been linked 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, 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. To prevent spurious results, the proper sequence of adding blood to vacutainers must be followed (Figure 2).

A combination of nonpharmacologic and pharmacologic strategies can be used to treat pain associated with venipuncture. Distraction, offering a pacifier, and swaddling are nonpharmacologic strategies. Sucrose administration and topical anesthetics may be used with distraction to minimize pain with venipuncture.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, 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. Determine if the patient’s family has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
2. Review the family’s previous experience and knowledge of venipuncture for labs and understanding of the care provided.
3. Assess the patient’s current medical status and illness severity.
4. Assess the family’s understanding of the reasons for and the risks and benefits of drawing a venous blood specimen.
5. Identify the minimum blood volumes required for specimens.
6. Review the types of specimen tubes and order of tube collection based on needed blood specimens (Figure 2).
7. Assess the patient’s pain status using a developmentally validated pain scale.

   Rationale: Pain should be assessed before all painful procedures for optimal pain management.

8. Find out the family’s desire to be present during the procedure.

Preparation

1. 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.
2. If a topical anesthetic will be used, apply it per the manufacturer’s instructions.

   Rationale: Topical anesthetics have varied times to peak effect. Follow the manufacturer’s instructions for time from application to procedure.

3. Enlist the help of an assistant, as needed, to position the patient and limit movement during the procedure.

PROCEDURE

1. Hold the patient using developmentally appropriate 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.
2. Evaluate the patient’s arms, hands, scalp, ankles, and feet for veins that are best for venipuncture.

   Do not use veins that are painful to palpation, have open wounds, or are compromised (e.g., previously cannulated, bruised, or reddened, or those that have phlebitis or anomalies).³

   The veins of extremely low or very low gestational age neonates may be too small to support venipuncture.

3. 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.

      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.

      Be sure that tourniquet time is 1 minute or less.⁶ Tourniquet time of 3 minutes or more may alter laboratory test results.⁶

   2. Use ultrasound if available.

      Be sure that equipment is cleaned after each use. Follow the manufacturer’s directions for use of equipment.

4. Reassess the patient’s pain status, allowing for sufficient onset of action per the medication, route, and the patient’s condition.
5. Clean the site with a single-use applicator and antiseptic solution per the manufacturer’s instructions.⁴
6. Allow the area to air-dry.

   Do not touch the site after preparation unless sterile gloves are worn.

7. Stabilize the extremity and position the insertion site so that the needle will enter in the direction of the blood flow.²
8. Select a 23-G or 25-G butterfly retractable needle attached to a syringe for blood collection (Figure 3).²
9. 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. Provide traction, if needed, to the skin below the insertion site.

   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.

10. Advance the needle until blood appears in the tubing.
11. 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
12. When blood appears, draw back on the syringe using gentle, slow pressure until the needed volume of blood is obtained.

    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.

13. 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.
14. Retract the needle into the butterfly device.
15. Discard the needle in a sharps container.
16. Remove the antiseptic with sterile 0.9% sodium chloride solution or sterile water after the procedure is complete.¹
17. Apply gauze to the venipuncture site.

    Do not use adhesive bandages on neonates.

18. Label the specimen(s) in the presence of the patient.⁵
19. Place the labeled specimen in a biohazard bag and transport it to the laboratory.

MONITORING AND CARE

1. Assess the venipuncture site for ongoing bleeding.
2. Assess perfusion in the extremity where the venipuncture was performed.

EXPECTED OUTCOMES

• Sufficient blood specimen is collected.
• Laboratory specimen 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

• Specimens cannot be processed because of inadequate blood volume.
• Laboratory results are not reliable.
• Specimen is hemolyzed.
• Patient or family is traumatized by the procedure.
• Significant hematoma or infection develops at the puncture site.
• Hemostasis is not achieved.
• 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 drawn
• Laboratory tests (e.g., complete blood count, blood culture)
• Patient’s tolerance of procedure
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), National Association of Neonatal Nurses (NANN). (2018). Skin disinfectants. In Neonatal skin care: Evidence-based clinical practice guidelines (4th ed., pp. 88-94). Washington, DC: AWHONN.
2. Bailey, T.B., Maltsberger, H.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.
3. Infusion Nurses Society (INS). (2024). Infusion therapy standards of practice. Standard 25: Vascular access device planning and site insertion. Journal of Infusion Nursing, 47(Suppl. 1), S85-S92.
4. Infusion Nurses Society (INS). (2024). Infusion therapy standards of practice. Standard 31: Vascular access site preparation and skin antisepsis. Journal of Infusion Nursing, 47(Suppl. 1), S106-S107.
5. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved July 29, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
6. 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.

Clinical Review: Sarah A. Martin, DNP, MS, RN, CPNP-AC/PC, CCRN

Published: September 2024