Venipuncture for Special Populations

• Venipuncture procedures and considerations for special populations

Special Populations for Venipuncture

• Pediatric patients
• Geriatric patients
• Dialysis patients
• Long-term care patients
• Home care patients
• Hospice patients

Pediatric Patients

• They are under 18 years
• Newborns are also known as neonates (under 28 days old)
• Infants are described as 0-1 year of age

Venipuncture in Children and Infants

• Venipuncture is necessary when tests require large blood amounts, such as coagulation studies, ESR and blood cultures.
• Also necessary if tests cannot be performed by skin puncture
• Limit venipuncture site to superficial veins such as the antecubital fossa, forearm, dorsal hand, dorsum of the foot, scalp. and medial ankle

Challenges for Pediatric Venipuncture

• Capillary collection is frequently recommended for newborns and infants up to 12 months
• No more than 3% of a child’s blood volume should be collected at one time
• No more than 10% in a month
• Removing more than 10% of an infant’s total blood volume can lead to shock and cardiac arrest.

Iatrogenic Anemias in Infants and Children

• Iatrogenic refers to illness or conditions caused by a medical procedure or treatment
• It occurs because of cumulative blood losses from repetitive blood draws
• Collect only the required volume needed to mitigate losses as much as possible

Hematological Features of Anemia

• Low Hemoglobin
• Low Hematocrit
• Normal MCV
• Hypochromic, normocytic RBCs

Dealing with Patients and Guardians

• Encourage their presence and involvement
• Display a calm, confident, and caring attitude to gain their trust
• Inquire about the child's experiences with blood collection from the parent or guardian

How to Deal with a Child

• Venipuncture results in a traumatic experience and can have lasting consequences
  • Increased sensitivity to pain
  • Decreased capacity to cope
  • Aichmophobia
• Approach them slowly and determine their anxiety or fear level
• Lower yourself physically to their level
• Explain what will happen using terms they understand, answering honestly
• Help them understand the importance of remaining still

Distractions for Children During The Procedure

• Hold the gauze or adhesive bandage
• Watch videos or movies,
• Play games
• Sing or count
• Offer a reward for being brave, without conditions for giving the reward

Key Reminders for Venipuncture With Children

• It is important to let children know it is alright to cry
• Never say it won't hurt; instead, say it might hurt a bit but will be quick

Tips for Teenagers

• Use adult language for identification and explaining the blood draw procedure
• Ask if they have fainted or had any reaction to previous venipunctures
• They may or may not want their parents present.

Pain Interventions

• Interventions minimize pain transmission or ease the pain of pediatric venipuncture
  • Cold or vibration
  • Topical anesthetics (EMLA)
  • Oral sucrose
  • Pacifiers

EMLA

• It is also known as Eutectic Mixture of Local Anesthetics applied before a procedure
• Ideal for apprehensive children before venipuncture
• It takes 60 minutes to anesthetize the area to a 5 mm depth, lasting 2-3 hours
• EMLA is a topical anesthetic containing lidocaine or prilocaine creams.

EMLA Restrictions

• Do not use on anyone allergic to local anesthetics
• Do not use on infants with a gestational age less than 37 weeks.
• Do not use on infants under 12 months receiving treatment with methemoglobin-inducing agents.

Oral Sucrose

• Glucose, dextrose, and sucrose have a calming effect on infants
• Administer a 12% to 24% solution prepared by mixing four teaspoons of water with one teaspoon of sugar.
• Administer oral sucrose prior to venipuncture and heel puncture
• Pain-relieving benefits last for 5 minutes
• Can be administered via dropper, nipple oral syringe, or pacifier

Mechanism of Methemoglobinemia

• Prilocaine metabolizes into o-toluidine, which oxidizes hemoglobin.

Selecting a Method of Restraint

• Immobilization is an important aspect to obtain an adequate specimen from children and infants
• Ensures safety for everyone involved in the procedure

Newborn or Infant Restraint Methods

• Wrap newborns or infants in a blanket
• Use an infant cradle pad

Toddler Restraint Methods

• Have them sit upright in a parent's lap
• Extend the arm for venipuncture to the front and downward
• The parent places an arm around the toddler over the arm not being used
• Support the venipuncture arm from behind
• The parents legs are wrapped around the toddler’s legs to prevent kicking

Equipment Selection

• Prepare equipment to ensure collecting the minimum blood amount for testing.
• A 23-gauge butterfly needle attached to an evacuated tube holder/syringe
• Use for small veins because the tubing allows flexibility
• Minimize clotting and inadequately filled tubes
• Label microtube specimens as venous blood, if used

Procedure

• In the same manner as a conventional method, but with a few considerations
• Attempts must be made to collect required amounts of blood because of low blood volume

Benefits of Collecting Minimum Amount of Blood

• Reduced risk of iatrogenic anemia
• Shortened time of the draw
• Shortened time under stress for the patient

Geriatric Patients

• Geriatric refers to old age of 65 years and older.
• It will be associated with physical, psychological, and social changes with aging
• Ensure that venipuncture is atraumatic, without bruising or excessive bleeding
• Treat geriatric patients with compassion, kindness, patience, and respect

Common Tests Ordered On Geriatric Patients

• Involves diagnosis and monitoring of nervous impairment or systemic conditions:
  • ANA, RF
  • CBC
  • BUN/Creatinine
  • Electrolytes
  • ESR
  • Glucose
  • PT/aPTT
  • SPEP/IPEP
  • VDRL/FTA-ABS

What an ANA indicates

• Antinuclear antibody used to diagnose a systemic autoimmune disease such as SLE

Aging Physical Changes

• Changes that may pose a challenge when taking a blood draw:
  • Skin changes
  • Hearing problems
  • Vision problems
  • Non-communicable/chronic diseases
  • Mental and emotional conditions

Skin Changes

• Loss of collagen and subcutaneous fat
• Increased fragility through narrowing of blood vessels
• Aging skin cells replacement occurs more slowly
• Sagging skin and decreased muscle tone makes it harder to anchor veins

Hearing Problems

• Loss of auditor hair cells and trouble distinguishing sounds such as “ch”, “s”, “sh”, and “z”

Tips for Hearing Issues

• Face the patient when speaking
• DO NOT SHOUT
• Be mindful of nonverbal messages
• Give the patient enough time to confirm their responses
• If a relativelattendant accompanies a patient, do not speak directly as if the patient is not present

Vision Problems

• Conditions include farsightedness, cataract formation, light intolerance, and poor night vision

Tips To Avoid Vision Problems

• Have adequate lighting without glare
• Guide elderly patients to the drawing chair
• Escort them to the restroom if they request a urine specimen.
• Avoid using gestures when speaking
• Provice them with written instructions in large print

Non-Communicable Diseases

• Arthritis, use a butterfly needle with 12 inch tubing
• Coagulopathies, bleeding disorders cause at risk of hematoma formation and excessive bleeding
• Diabetes limits the use of leg, ankle, and foot veins
• Pulmonary function problems reduced elasticity of airway tissues and weakened respiratory defense system
• Parkinson's and stroke is a neurological disorder affecting balance and coordination

Mental and Emotional Conditions from Aging

• Slower learning, slower reaction times, and a diminished perception of pain
• Reduced cerebral circulation can lead to loss of balance and frequent falls

Venipuncture with Wheelchair Patients

• Ensure you are careful when they move
• Lock the wheelchair wheels during the draw

Procedure for Venipuncture With Geriatric Patients

• Always confirm patients' identification.
• Always check for verbal responses, or verify their information if possible

Equipment Selection for Geriatric Patients

• Usually requires the use of butterfly needles, or short draw tubes.
• Use a syringe or finger puncture for fragile veins

Tourniquet Use with Geriatric Patients

• Apply it snuggly, but never too tight
• It is acceptable to apply a tourniquet over the patient’s sleeve

Venipuncture Site Selection

• Choose a needle entry point below the bruising
• Gently massage the arm starting from the wrist up to the elbow, or wrap a warm, wet towel around the arm

Cleaning the Venipuncture Site

• Do not rub too vigorously
• Clean the site a second time for patients who are unable to bathe regularly

Performing the Venipuncture:

• When performing the venipuncture, you must anchor the veins firmly.
• Make sure your needle entry is shallow and quick.
• If skin is loose and the vein is poorly fixed in the tissue, you can pull the skin taut from both sides.

Holding Pressure & Bandaging

• Check for bleeding cessation before bandaging
• Do not apply too much pressure
• Potential challenges include rolling, fragile or inelastic veins. anchor their veins securely and use low-volume blood tubes and small needles

Dialysis Patients

• Dialysis is a treatment procedure that removes waste and excess fluid because of dysfunctional kidneys.
• Hemodialysis is when the procedure filters the blood through a special machine
• The most common causes are ESRD with a primary diagnosis being Diabetes, and secondary being High blood pressure
• During dialysis an AV Fistula will give a large bulging vein in the forearm above the wrist causing a buzzing sensation when you palpate

Restrictions for Venipuncture With a Fistula

• Never take blood pressure or perform venipuncture on the arm with a fistula

Long-Term Care Patients

• Long-term care refers to healthcare and social services required by patients with functional disabilities, but do not require hospitalization.
• Long-term care is for the elderly, adult daycares, nursing homes, assisted living centers, and private homes

Home Care Patients

• Often called domiciliaries
• Often need assistance with healthcare services in their own homes
• Phlebotomists may be required to be mobile
• Medical staff must carry necessary supplies, such as sharps containers, biohazard bags, and transport containers for specimens

Hospice Patients

• Deals with people who are terminally ill
• Provides specialized physical and emotional comfort for people nearing the end of life
• Involves maintaining a peaceful environment that values patient management and will keep them comfortable
• Patients are treated with kindness, care, and respect