CHAPTER 10 Pediatric and Geriatric Procedures Pediatric Patients

CHAPTER 10 Pediatric and Geriatric Procedures

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 Preparing Child and Parent • A calm, confident approach • Correctly identify the patient – A hospitalized infant usually has the 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 optimal success in blood collection. • Place yourself at the child’s eye level to explain and demonstrate the procedure. • 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. – 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.

Preparing Child and Parent • Room Location – The 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 • Holding the child may be required to ensure that the child does not move his/her limb during blood collection. • Restraining techniques should be compassionate and safe, and should be performed quickly. • A supportive parent who has been properly instructed can assist with restraining while providing comfort to the child. • Neonates and infants younger than 3 months usually do not require restraint and can be managed by the health care worker. • Swaddling helps to control and comfort an upset 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 • EMLA– A topical anesthetic– Applied to the skin as a patch or a cream that is then covered with a transparent adhesive dressing – Optimal anesthesia occurs after 45 to 60 minutes and may last as long as 2 to 3 hours – Do not use if the child is allergic to local anesthetics • 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 is given two minutes before heel sticks. – Its action lasts about five minutes. Precautions to Protect the Child • PPE, gowns, gloves, and masks will be worn as indicated before entering the room. • Remove the PPE according to policy and dispose of it in the appropriately marked container. • Wash your hands or sanitize them.

Pediatric Phlebotomy Procedures • Micro capillary Skin Puncture – Collect only the smallest amounts of blood so that the effects of reductions in blood volume are minimal. – Over collecting during phlebotomy may require packed cell transfusion in an infant. – To avoid over collection, record the amount of blood collected from an infant or small child. – Order of Test Collection 1 st Collect the hematology specimens first to minimize platelet clumping. 2 nd Chemistry specimens 3 rd Blood bank specimens • Skin Puncture Sites – The heel is the most desirable site for skin puncture of the infant or neonate. – Use the most medial or lateral plantar surface of the heel. – Do NOT use the central area of the infant’s heel for blood collection. – For children older than one year, the palmar surface of the tip of the third or fourth finger is most frequently used

Heel stick Procedure • 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 with an alcohol hand rinse, 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, pre-warm 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 • Pre-warming 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. • Encase the towel in a plastic bag to help retain heat and keep the patient’s bed dry. • Pre-warm the site for 3 to 5 minutes. • Depending on the institution’s policy, call in advance to pre-warm the infant’s heel.

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

Heel stick Procedure Con’t…. • 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. • 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. • Remove gloves, gown, and mask, if worn, and perform hand hygiene before proceeding to the next patient. • Dispose of the used skin-puncture devices in a sharps container with a biohazard label. • Check the 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 that are not from isolation rooms in the regular trash. • Wash or sanitize your hands after removing the gloves.

Capillary Blood Gases • Skin Puncture Blood Less Desirable – Arterial blood is the specimen of choice for blood gas testing. – Skin puncture blood contains blood from capillaries, venules, arterioles, and tissue fluids. – Skin puncture is an open collection system. The specimen is temporarily exposed to room air. Allows for a brief exchange of gases(both O 2 and CO 2) before sealing the specimen from the air.

Collection for Capillary Blood Gas Testing • 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 with an alcohol hand rinse, then put on gloves. • If required, don a gown and a mask. • Use a heparinized safety plastic capillary tube for the collection. • Perform the capillary (skin) puncture and wipe away the first drop. • Fill the capillary tube with blood end-to-end to obtain the stated fill volume of the tube.

Collection for Capillary Blood Gas Testing Con’t • The specimen must be collected with no air bubbles, which can cause inaccuracies in the values obtained from the specimen. • Cap one end of the capillary tube, insert a small metal filing (referred to as a “flea”) into the filled capillary tube. • Place the magnet over the tube and use the magnet to draw the metal filing(flea) back and forth across the length of the tube to mix the specimen. • Label the tube and place it in a transport bag for immediate transfer to the laboratory. • Notify laboratory personnel of the urgent blood gas test to be performed. • Press the skin puncture site with a clean gauze sponge. • Elevate the heel slightly above 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 the 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 a troom temperature will affect the results.

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

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 • Prepare and assemble supplies. • Appropriate collection cards are kept in the hospital laboratory or the nursery. • Circles are printed on the filter paper portion of the card. • 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. • Wash your hands and put on gloves. • Position the baby in a supine (lying)position with the knee at the open end of the bassinet. • Clean the incision site 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.

Collection of Capillary Blood for Neonatal Screening Con’t • Once the puncture is made, wipe off the first drop of blood with sterile gauze. • 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. • 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 a sterile gauze sponge against the puncture site until the bleeding stops. • Elevate the heel above the body. • Check the infant’s heel site for late bleeding and inflammation. • Dispose of the used skin-puncture device in a sharps container with a biohazard label. • Check the 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 that are not from isolation rooms in the regular trash. • Wash or sanitize your hands after removing the 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.

Venipuncture on Children • 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. • 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. Your finger can be used as a “finger tourniquet. ” • The procedure for performing venipuncture on older children is similar to that for adults (see Chapter 8). • Special Considerations May Include: – Special preparation of the child and parent – Assistance in restraining the child – The use of special pediatric-size needles and safety winged infusion sets.

Geriatric Patients • Geriatric population is growing at an amazing rate since 75 million U. S. American 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 (i. e. , diabetes, cardiovascular diseases, COPD, arthritis, etc. ). • Elderly Population Is Increasing and Will Demand More Health Care – Increase in point-of-care testing by skin puncture due to the difficulty of obtaining blood by venipuncture – Increase in point-of-care testing in homes, nursing homes, and other long-term care facilities • Physical Problems Common in Older Individuals – Hearing loss – Failing eyesight – Loss of taste, smell, and feeling – Memory loss – 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 – 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 the blood collection –Wait for the puncture site to stop bleeding – Properly discard all trash and used supplies – Label the specimens and place them in leak-proof containers with the biohazard sign – Check the appropriate temperatures for transport – Use security precautions – Document delayed specimens