Dermal Puncture & Equipment PDF

DERMAL PUNCTURE & EQUIPMENTS  DERMAL PUNCTURE Also known as “Skin Puncture” or “Capillary Puncture”. Method of choice for collecting blood from infants and children younger than 2 years.  Why is dermal puncture preferred for children below 2 years old? 1. Locatin...

DERMAL PUNCTURE & EQUIPMENTS  DERMAL PUNCTURE Also known as “Skin Puncture” or “Capillary Puncture”. Method of choice for collecting blood from infants and children younger than 2 years.  Why is dermal puncture preferred for children below 2 years old? 1. Locating superficial veins is difficult in these patients, and available veins may need to be reserved for intravenous therapy. 2. Use of deep veins are dangerous and may cause complications. 3. Drawing excessive amounts of blood from premature and small infants can rapidly cause iatrogenic anemia. 4. Certain test require capillary blood, such as newborn screening tests and capillary blood gases. 5. Injury may occur by restraining a child.  Dermal puncture may be required in many adult patients, including those who are: Burned or scarred Likely to have inaccessible Receiving chemotherapy veins and require frequent tests Obese and whose veins must be Apprehensive reserved for therapy Likely to be thrombotic Geriatric or have very fragile veins Receiving home glucose monitoring and POCT  PATIENT CONSIDERTATION Note: Patients who are severely dehydrated or who have poor peripheral circulation or swollen fingers. You may not be able to use dermal puncture for certain tests because of the larger amount of blood required, such as some coagulation studies that require plasma, erythrocyte sedimentation rate (ESR), and blood cultures.  IMPORTANCE OF CORRECT COLLECTION IN DERMAL PUNCTURE Dermal Puncture is critical because it: ✔Specimen contamination. ✔Will produce Microclots. ✔Hemolysis (more frequent)  HEMOLYSIS MAY OCCUR FOR THE FF. REASONS: Excessive squeezing of the puncture site (“milking”). Increased numbers of red blood cells (RBCs) and increased RBC fragility in newborns. Residual alcohol at the site Vigorous mixing of the microcollection tubes after collection  COMPOSITION OF CAPILLARY BLOOD Blood collected by dermal puncture comes from the capillaries, arterioles, and venules. Blood collected in dermal puncture is called CAPILLARY BLOOD. Capillary blood is a mixture of CAPILLARY, ARTERIAL and VENOUS BLOOD and small amounts of INTERSTITIAL FLUID and INTRACELLULAR FLUID.  DERMAL PUNCTURE EQUIPMENTS 1. Automatic retractable safety skin puncture devices. 2. Microcollection Containers 3. 70% isopropyl alcohol pads, gauze pads, bandages 4. Warming devices 5. Sealants 6. Sharps container 7. Glass slides 8. Heel warmer  DERMAL PUNCTURE EQUIPMENTS 1. Automatic retractable safety skin puncture devices. 2. Microcollection Containers 3. 70% isopropyl alcohol pads, gauze pads, bandages 4. Warming devices 5. Sealants 6. Sharps container 7. Glass slides 8. Heel warmer  1. DERMAL PUNCTURE DEVICES Lancets ▪ Sterile, disposable, sharp instruments used for capillary blood collection ▪ OSHA recommends that all dermal puncture devices must have the ability to retract and lock after use to prevent reuse and accidental puncture. Precautions: ▪ To prevent contact with bone, the depth of the puncture is critical. CLSI recommends that the incision depth should not exceed 2.0 mm in a device used to perform heelsticks (infants). Depth of capillary bed from skin: ▪ infants: 🡪 0.35 to 1.6 mm ▪ adults 🡪 3 mm  1. DERMAL PUNCTURE DEVICES Lancets ▪ Sterile, disposable, sharp instruments used for capillary blood collection ▪ OSHA recommends that all dermal puncture devices must have the ability to retract and lock after use to prevent reuse and accidental puncture. Precautions: ▪ To prevent contact with bone, the depth of the puncture is critical. CLSI recommends that the incision depth should not exceed 2.0 mm in a device used to perform heelsticks (infants). Depth of capillary bed from skin: ▪ infants: 🡪 0.35 to 1.6 mm ▪ adults 🡪 3 mm  1. DERMAL PUNCTURE DEVICES Lancets ▪ Sterile, disposable, sharp instruments used for capillary blood collection ▪ OSHA recommends that all dermal puncture devices must have the ability to retract and lock after use to prevent reuse and accidental puncture. Precautions: ▪ To prevent contact with bone, the depth of the puncture is critical. CLSI recommends that the incision depth should not exceed 2.0 mm in a device used to perform heelsticks (infants). Depth of capillary bed from skin: ▪ infants: 🡪 0.35 to 1.6 mm ▪ adults 🡪 3 mm  1. DERMAL PUNCTURE DEVICES Precautions: ▪The amount of blood collected via dermal puncture is more dependent on the incision width rather than on the incision depth. ▪Incision width pertains to number of severed or damaged capillaries upon puncture. ▪The recommended incision is width limit is up to 2.5 mm. ▪Longer incisions should be avoided so as to prevent unnecessary damage to the heel or finger of the patient.  2. MICROSAMPLE CONTAINERS A. Capillary Tubes ▪Frequently referred to as the microhematocrit tubes ▪Small tubes used to collect approximately 50 to 75 µL of blood for the primary purpose of performing a microhematocrit test. ▪Tubes are available as plain or coated with ammonium heparin, and they are color coded: ✍Blue microhematocrit tubes ✍No anticoagulant ✍Red microhematocrit tubes ✍Coated with heparin  2. MICROSAMPLE CONTAINERS A. Capillary Tubes ▪Frequently referred to as the microhematocrit tubes ▪Small tubes used to collect approximately 50 to 75 µL of blood for the primary purpose of performing a microhematocrit test. ▪Tubes are available as plain or coated with ammonium heparin, and they are color coded: ✍Blue microhematocrit tubes ✍No anticoagulant ✍Red microhematocrit tubes ✍Coated with heparin  2. MICROSAMPLE CONTAINERS B. Microcollection Tubes ▪Small collection tubes often referred to as “bullets” ▪Made up of plastic; (present no danger from broken glass) ▪ Provide larger collection volumes (up to approximately 600 uL of blood. ▪They are color coded; with minimum and maximum fill levels.  2. MICROSAMPLE CONTAINERS B. Microcollection Tubes ▪Small collection tubes often referred to as “bullets” ▪Made up of plastic; (present no danger from broken glass) ▪ Provide larger collection volumes (up to approximately 600 uL of blood. ▪They are color coded; with minimum and maximum fill levels.  3. ALCOHOL PADS/GAUZE/BANDAGES ▪CLSI recommends 70% alcohol ▪Gauze / cotton is used to wipe away the first drop of blood: ▪to eliminate alcohol residue ▪to eliminate excess tissue fluid ▪It is also used to hold site after collection 4. WARMING DEVICES ▪Increases blood flow seven times. ▪Can be a towel or a diaper dampened with warm water o (must not exceed 42 C for it might scald the patient). ▪One can also use a commercial heel warmer (a packet containing sodium thiosulfate and glycerin which when mixed together by gentle squeezing will generate heat). 5. SEALANTS ▪Clay-like substances used in sealing microhematocrit tubes.  DERMAL PROCEDURES PREPARED BY: ZAIRA MAE ARRIETA, RMT, DTA  1. PHLEBOTOMIST PREPARATION Phlebotomist must have a presence of mind and mentally prepared. Must have a REQUISITION FORM before starting the procedure. When you collect a specimen by dermal puncture, you must note this on the requisition form because few analytes where the reference value may differ between venous and capillary blood. Note: Glucose conc. is higher in capillary blood than in venous blood. Concentration of K+, TP, and Ca are lower.  2. PATIENT IDENTIFICATION AND PREPARATION Identify patient with REQUISITION FORM, VERBAL IDENTIFICATION, and ID BAND. For infants: ID Band must be present. For pediatric outpatients: verbal identification from parents/guardians. Note: When approaching pediatric patients, maintain a friendly and confident demeanor while explaining the procedure, emphasizing the importance of staying still without saying it won't hurt. Offer parents the choice to stay and assist with comforting or restraining the child, and document parental consent if restraints are used.  3. PATIENT POSITION The patient must be seated or lying down with his or her nondominant hand supported on a firm surface, palm up and fingers pointed downward for finger punctures. For heel punctures, an infant should be lying on his or her back with the heel lower than the torso in a downward position.  4. SITE SELECTION Choose the puncture site on the basis of AGE and SIZE of the patient. Primary danger in dermal puncture is accidental contact with the bone followed by infection (osteomyelitis) or inflammation (osteochondritis). Primary dermal sites: Infants: Lateral plantar surface of the heel. Adults & children older than 1yr old: 3rd and 4th fingers on the palmar side of the non-dominant hand.  4. SITE SELECTION Choose the puncture site on the basis of AGE and SIZE of the patient. Primary danger in dermal puncture is accidental contact with the bone followed by infection (osteomyelitis) or inflammation (osteochondritis). Primary dermal sites: Infants: Lateral plantar surface of the heel. Adults & children older than 1yr old: 3rd and 4th fingers on the palmar side of the non-dominant hand.  4. SITE SELECTION Note: ▪Problems associated with use of the other fingers include: Possible calluses on the thumb Increased nerve endings in the index finger Decreased tissue in the fifth finger ▪A swollen or previously punctured site is unacceptable because the increased tissue fluid will contaminate the specimen. ▪Performing dermal punctures on EARLOBES is not recommended.  4. SITE SELECTION Note: ▪Problems associated with use of the other fingers include: Possible calluses on the thumb Increased nerve endings in the index finger Decreased tissue in the fifth finger ▪A swollen or previously punctured site is unacceptable because the increased tissue fluid will contaminate the specimen. ▪Performing dermal punctures on EARLOBES is not recommended.  5. WARMING THE SITE (OPTIONAL) For optimal blood flow, you may warm the finger or heel. Warming dilates the blood vessels and increases arterial blood flow. Required primarily for patients with very cold or cyanotic fingers, for heel punctures to collect multiple specimens, and for the collection of CBGs. Moistening a towel with warm water (42°C) or activating a commercial heel warmer and covering the site for 3 to 5 minutes effectively warms the site. Note: Do not warm the site for longer than 10 minutes, or test results may be altered.  6. CLEANING THE SITE Clean the site with 70 percent isopropyl alcohol. Allow the alcohol to dry on the skin and then remove the excess with gauze to prevent interference with certain tests. Failure to allow the alcohol to dry will: 1. Causes a stinging sensation for the patient. 2. Contaminates the specimen. 3. Hemolyzes RBCs. 4. Prevents formation of a rounded blood drop because blood will mix with the alcohol and run down the patient’s finger.  6. CLEANING THE SITE POVIDONE IODINE is not used in routine extraction. However, it is used in BLOOD CULTURE COLLECTION and BLOOD DONATION. Note: Do not use povidone-iodine for dermal punctures because specimen contamination may elevate some test results, including bilirubin, phosphorus, uric acid, and potassium levels  7. PERFORMING THE PUNCTURE Be sure the patient’s heel or finger is well supported and held firmly, without squeezing the puncture area. Apply gentle pressure to the area before the puncture in order to increase blood flow to the area. HEEL PUNCTURE: Hold the patient’s heel between the thumb and index finger of your nondominant hand, with your index finger around the arch and your thumb below the bottom of the heel. Wrap your other fingers around the top of the foot.  7. PERFORMING THE PUNCTURE Be sure the patient’s heel or finger is well supported and held firmly, without squeezing the puncture area. Apply gentle pressure to the area before the puncture in order to increase blood flow to the area. HEEL PUNCTURE: Hold the patient’s heel between the thumb and index finger of your nondominant hand, with your index finger around the arch and your thumb below the bottom of the heel. Wrap your other fingers around the top of the foot.  7. PERFORMING THE PUNCTURE FINGER PUNCTURE: Hold the patient’s finger between the thumb and index finger of your nondominant hand, with the palmar surface facing up and the patient’s finger pointing downward to increase blood flow. Note: For patients with small fingers, you may find it easier to hold three or four fingers for better control.  7. PERFORMING THE PUNCTURE FINGER PUNCTURE: Hold the patient’s finger between the thumb and index finger of your nondominant hand, with the palmar surface facing up and the patient’s finger pointing downward to increase blood flow. Note: For patients with small fingers, you may find it easier to hold three or four fingers for better control.  7. PERFORMING THE PUNCTURE PUNCTURE DEVICE POSITION: Choose a puncture device that corresponds to the size of the patient. Align the blade of the puncture device to cut across (perpendicular to) the grooves of the fingerprint or heel print. This aids in the formation of a rounded drop because the blood will not have a tendency to run into the grooves. Puncture the site with lancet and hold for a moment and then release. Note: Be sure to maintain pressure because the elasticity of the skin naturally inhibits penetration of the blade. Removing the lancet before the puncture is complete will yield a low blood flow.  7. PERFORMING THE PUNCTURE PUNCTURE DEVICE POSITION: Choose a puncture device that corresponds to the size of the patient. Align the blade of the puncture device to cut across (perpendicular to) the grooves of the fingerprint or heel print. This aids in the formation of a rounded drop because the blood will not have a tendency to run into the grooves. Puncture the site with lancet and hold for a moment and then release. Note: Be sure to maintain pressure because the elasticity of the skin naturally inhibits penetration of the blade. Removing the lancet before the puncture is complete will yield a low blood flow.  8. PUNCTURE DEVICE DISPOSAL Discard the puncture device in an approved sharps container immediately after completing the puncture. You must use a new puncture device when an additional puncture is required.  8. PUNCTURE DEVICE DISPOSAL Discard the puncture device in an approved sharps container immediately after completing the puncture. You must use a new puncture device when an additional puncture is required.  9. SPECIMEN COLLECTION Wipe away the first drop of blood with a clean gauze before beginning the blood collection. This prevents contamination of the specimen with residual alcohol and tissue fluid released during the puncture. Note: Even a minute amount of contamination can severely affect specimen quality. Blood should be flowing freely from the puncture site as a result of firm pressure and should not be obtained by milking of the surrounding tissue, which will release tissue fluid. Alternately applying pressure to and releasing pressure from the area will produce the most satisfactory blood flow. Tightly squeezing the area with no relaxation cuts off blood flow to the puncture site.  9. SPECIMEN COLLECTION Note: Applying pressure about 1 ⁄2 in. away from the puncture site frequently produces better blood flow than applying pressure very close to the site. Lancet should not touch the puncture site nor scrape it over to the skin because this will produce specimen contamination and hemolysis. Position the patient’s fingers slightly downward with the palmar surface facing up during the collection procedure to allow gravity to fill the capillaries. Note: Do not use a scooping motion to collect the blood. Scraping the scoop of the collection tube across the skin can hemolyze the specimen.  10. CAPILLARY TUBES & MICROPIPETTES Using the capillary tube, touch the collection tip lightly to the drop of blood, which will draw the blood into the tube. To prevent air bubbles hold capillary tubes and micropipettes horizontally while they are filling. Removing the microhematocrit tube from the drop of blood causes air bubbles in the specimen. Note: Air bubbles interferes with blood gas determinations. When the tubes are filled, seal them with sealant clay or designated plastic caps. When using a sealant tray, place the end that has not been contaminated with blood into the clay, taking care to not break the tube. Remove the tube with a slight twisting action to firmly plug the microhematocrit tube.  10. CAPILLARY TUBES & MICROPIPETTES Using the capillary tube, touch the collection tip lightly to the drop of blood, which will draw the blood into the tube. To prevent air bubbles hold capillary tubes and micropipettes horizontally while they are filling. Removing the microhematocrit tube from the drop of blood causes air bubbles in the specimen. Note: Air bubbles interferes with blood gas determinations. When the tubes are filled, seal them with sealant clay or designated plastic caps. When using a sealant tray, place the end that has not been contaminated with blood into the clay, taking care to not break the tube. Remove the tube with a slight twisting action to firmly plug the microhematocrit tube.  11. MICROCOLLECTION TUBES Hold microcollection tubes at a slant during collection so the blood flows smoothly through the scoop and down the tube's side. Place the tip of the collection tube beneath the puncture site so that it touches the underside of the drop. The first three drops of blood provide the channel to allow blood to flow freely into the tube. Gently tapping the bottom of the tube may be necessary to force blood to the bottom. When a tube is filled, attach the color-coded top. Invert tubes with anticoagulants five to 10 times or per manufacturer’s instructions.  11. MICROCOLLECTION TUBES Hold microcollection tubes at a slant during collection so the blood flows smoothly through the scoop and down the tube's side. Place the tip of the collection tube beneath the puncture site so that it touches the underside of the drop. The first three drops of blood provide the channel to allow blood to flow freely into the tube. Gently tapping the bottom of the tube may be necessary to force blood to the bottom. When a tube is filled, attach the color-coded top. Invert tubes with anticoagulants five to 10 times or per manufacturer’s instructions.  11. MICROCOLLECTION TUBES When blood flow is slow, it may be necessary to mix the tube while the collection is in progress. It is important to work quickly because blood that takes more than 2 minutes to collect may form microclots in an anticoagulated microcollection tube. Collect the correct amount of blood indicated by the minimum and maximum marks on the tube. An overfilled tube may clot, whereas an under filled tube can cause morphological changes in cells.  12. ORDER OF COLLECTION Order of draw for collecting multiple specimens from a dermal puncture is important because of the tendency of platelets to accumulate at the site of a wound. First collect blood for tests to evaluate platelets, such as the blood smear, platelet count, and complete blood count (CBC). Make the blood smear first, and then collect the lavender EDTA tube.  12. ORDER OF COLLECTION Order of collection: 1. CBGs 2. Blood smear 3. Lavender EDTA tubes 4. Green, light green, amber lithium heparin tubes 5. Gray EDTA tubes 6. Gold, amber, red serum tubes  12. ORDER OF COLLECTION Order of collection: 1. CBGs 2. Blood smear 3. Lavender EDTA tubes 4. Green, light green, amber lithium heparin tubes 5. Gray EDTA tubes 6. Gold, amber, red serum tubes  13. BANDAGING THE PATIENT When you have collected a sufficient amount of blood, apply pressure to the puncture site with gauze. Elevate the patient’s finger or heel, and apply pressure until the bleeding stops. Confirm that bleeding has stopped before removing the pressure and applying the bandage. Instruct patients to leave the bandage on for at least 15 minutes. Note: Do not use bandages for children younger than 2 years because a child may remove the bandages, place them in his or her mouth, and possibly aspirate the bandages. Also, adhesive may cause irritation to or tear sensitive skin, particularly the fragile skin of a new born or older adult patient.  14. LABELING THE SPECIMEN Label the microcollection tubes with the same information required for venipuncture specimens. Labels can be wrapped around microcollection tubes or groups of capillary pipettes. Then, for transport, place the capillary pipettes in a large tube because the outside of the capillary pipettes may be contaminated with blood. This procedure also helps to prevent breakage. Label specimens before leaving the patient area. 15. COMPLETION OF THE PROCEDURE The dermal puncture procedure is completed in the same manner as the venipuncture by disposing of all used materials in appropriate containers, removing your gloves, sanitizing your hands, and thanking the patient and/or the parents for their cooperation.  “COLLECTION OF CAPILLARY BLOOD FROM A FINGER PUNCTURE” PREPARED BY: ZAIRA MAE ARRIETA, RMT, DTA “COLLECTION OF BLOOD BY HEEL PUNCTURE” PREPARED BY: ZAIRA MAE ARRIETA, RMT, DTA SPECIAL DERMAL PUNCTURE PREPARED BY: ZAIRA MAE ARRIETA, RMT, DTA  1. COLLECTION OF NEWBORN BILIRUBIN Bilirubin levels are determined to check the infant survival and mental health because the blood-brain barrier is not fully developed in neonates and may allow bilirubin to accumulate in the brain and cause permanent or lethal damage. Hyperbilirubinemia is caused by: HDN Newborns' livers are not fully developed to process the bilirubin from the normal breakdown of red blood cells. (particularly premature infants.)  1. COLLECTION OF NEWBORN BILIRUBIN Precautions: Bilirubin is a very light-sensitive chemical and is destroyed rapidly when exposed to light. Specimens must be collected quickly and protected from light during and after the collection. Infants who appear jaundiced (yellow skin color) frequently are placed under an ultraviolet (UV) light to lower the level of circulating bilirubin. Amber-colored microcollection tubes are available for collecting bilirubin.  1. COLLECTION OF NEWBORN BILIRUBIN Precautions: Bilirubin is a very light-sensitive chemical and is destroyed rapidly when exposed to light. Specimens must be collected quickly and protected from light during and after the collection. Infants who appear jaundiced (yellow skin color) frequently are placed under an ultraviolet (UV) light to lower the level of circulating bilirubin. Amber-colored microcollection tubes are available for collecting bilirubin.  2. NEWBORN SCREENING Embodied in REPUBLIC ACT 9288 This is known as the Newborn Screening Act of 2004 Is a public health program that involves testing of the newborn babies for genetic, metabolic, hormonal, and functional disorders that can cause physical disabilities, mental retardation, or even death, if not detected or treated early.  2. NEWBORN SCREENING Blood is typically collected by a med tech, a nurse or the physician in-charge via heel puncture 24-72 hours after birth of the baby. Special collection kits are used, consisting of a patient information form attached to specifically designed filter paper that has been preprinted with an appropriate number of circles that are part of the requisition. Must be careful not to touch or contaminate the area inside the circles or to touch the dried blood spots. Avoid contaminating the specimen with water, formula, alcohol, urine, lotions, or powder  2. NEWBORN SCREENING Blood is typically collected by a med tech, a nurse or the physician in-charge via heel puncture 24-72 hours after birth of the baby. Special collection kits are used, consisting of a patient information form attached to specifically designed filter paper that has been preprinted with an appropriate number of circles that are part of the requisition. Must be careful not to touch or contaminate the area inside the circles or to touch the dried blood spots. Avoid contaminating the specimen with water, formula, alcohol, urine, lotions, or powder  2. NEWBORN SCREENING Blood is typically collected by a med tech, a nurse or the physician in-charge via heel puncture 24-72 hours after birth of the baby. Special collection kits are used, consisting of a patient information form attached to specifically designed filter paper that has been preprinted with an appropriate number of circles that are part of the requisition. Must be careful not to touch or contaminate the area inside the circles or to touch the dried blood spots. Avoid contaminating the specimen with water, formula, alcohol, urine, lotions, or powder  DISEASES SCREENED IN THE NEWBORN SCREENING PANEL 1. Congenital Hypothyroidism (CH) - Lack or absence of thyroid hormone which is essential for physical and mental development of a child. 2. Congenital Adrenal Hyperplasia (CAH) – causes severe salt loss, dehydration and high levels of male sex hormones in both male and female. 3. Galactosemia (GAL) – inability to process galactose 4. Phenylketonuria (PKU) – inability to properly use the amino acid phenylalanine 5. Glucose-6-Phosphate Dehydrogenase Deficiency (G-6-PD def) – lack or absence of the enzyme G-6-PD needed by RBC’s; most common. THE END.