What is the most ideal puncture site for venipuncture among newborns?

The neonatal heel prick, also known as a dermal puncture, is by far the most popular way to collect blood from newborns and infants up to about six months of age. Dermal punctures are preferable because, when done correctly, they are guaranteed to produce blood, removing the uncertainty of needle sticks. The heel prick is used to fill small collection tubes called pediatric “bullet” tubes, named after their shape. The steps for a proper neonatal heel prick are as follows:

Table of Contents Show

ASSESSMENT AND PREPARATION
MONITORING AND CARE
EXPECTED OUTCOMES
UNEXPECTED OUTCOMES
DOCUMENTATION
Elsevier Skills Levels of Evidence

1 – Be sure to place the infant in a safe, comfortable position, face-up, either on an infant draw table or a parent’s lap. Leave the baby as swaddled as possible for comfort, only exposing one leg for the draw.

2 – Using an approved heel-warmer pad, heat the baby’s entire foot for approximately one minute until the skin is very warm to the touch. This technique dilates capillaries in the area, maximizing blood flow.

3 – Gently flexing the foot upward, encase the baby’s entire foot in one hand. Rather than pinching the heel directly, you will be using a full-foot massage technique to collect the blood. This ensures both the baby’s comfort and a much better blood flow.

4 – Wipe the heel with an alcohol pad and allow it to air dry. Do not blow on the foot as it dries. Softly squeeze the baby’s foot so that the skin of the heel is bunched up. Press the lancet flat against the inner, bottom edge of the heel, along the same side as the big toe, and depress the trigger. The lancet will make a quick swipe of the heel with a clicking sound.

5 – Wipe the first drop of blood away with a clean cotton pad. Then, using a massaging pattern, gently squeeze and release the foot several times, allowing blood drops to form a drip from the end of the heel.

6 – As the blood drops collect, let them flow openly into the bullet tube or PKU card without scraping the blood along the skin. This helps avoid damaging, or “hemolysing”, the red blood cells.

7 – When a sufficient amount of blood has been collected, place a clean cotton pad across the puncture site and apply moderate pressure for approximately one minute.
With your free hand, close the cap of the tube and gently invert it several times to mix the tube additive with the blood. Don’t shake too vigorously.

Heel sticks are not appropriate for every type of lab test. In the event that specialty testing is ordered for blood banking, blood culture, or tests that require larger amounts of product, you will need to perform a regular venipuncture with a needle. For babies, use a tourniquet that has been cut smaller, and spend extra time locating the antecubital vein on one or both arms. Use a 23g or 25g sized butterfly needle, and be sure that the arm is completely restrained for the duration of the draw to avoid an injury.

At the completion of the procedure, ensure that all choking hazards (e.g., syringe caps, port caps, adhesive bandages, bits of tape, twist-off caps from saline bullets) are removed from the patient’s linens and placed in the appropriate receptacle.

OVERVIEW

The primary methods of obtaining a blood specimen are through venipuncture, capillary draw, central venous access, arterial puncture, and arterial line.

Venipuncture involves inserting a needle into the lumen of a vein. The nurse may use a winged infusion set (Figure 1) attached to a small-volume syringe to collect the specimen. Before collecting blood specimens, the nurse should select the appropriate laboratory tubes and check the practitioner’s orders when obtaining several specimens of various types for the tests (e.g., chemistry, hematology, coagulation studies).

The nurse should also identify the best place to perform a venipuncture on the patient. For example, the antecubital fossa and the saphenous vein (Figure 2) (Figure 3) are common sites for venous access in children. The scalp veins can be used in infants. Veins of the foot can be used in infants who are not yet walking. The nurse must have a good understanding of the anatomy, physiology, and physics related to venipuncture.

Venipuncture can be a painful and stressful experience for a child. In most cases, venipuncture is viewed as a routine procedure, but just the appearance of a needle can be frightening to a child. A calm approach and skilled technique of the nurse can help to limit a child’s anxiety, pain, and stress during venipuncture.

Using interventions such as distraction, sucrose, topical analgesia, positioning, music, and family involvement significantly decreases a child’s anxiety, pain, and stress related to a venipuncture.undefined#ref1">1,6 Several topical agents may be used to provide analgesia for venipuncture (Table 1) Table 1 .

In infants younger than 6 months old, oral sucrose has been shown to work well to manage needle-related pain.4

A child may fear that the loss of blood is a threat to his or her life; therefore, developmentally appropriate language should be used to explain that blood is continually being made. An adhesive bandage may give the child assurance that the blood will not leak out through the puncture site. Make sure the bandage is removed if the child may chew or suck on the extremity as this may result in a choking hazard.

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).2,5
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.2
Povidone-iodine can cause alterations in thyroid function if absorbed through the skin.2

EDUCATION

Provide individualized, developmentally appropriate education to the family and patient based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Explain the procedure for obtaining laboratory samples via venipuncture, including the purpose, the steps, and the benefits.
Explain how the family can assist and support the patient.
Explain the risks related to the procedure, including pain, multiple venipuncture attempts, bruising, and hematoma.
Explain that the patient may experience pain or anxiety during the procedure.
Identify appropriate pain-relieving measures based on the patient’s age, developmental level, previous venipuncture experience, and the urgency of the test.
Instruct the patient or the family that pressure will be applied to the venipuncture site briefly. For a patient with a bleeding disorder or who is receiving anticoagulant therapy, explain that pressure will be applied until hemostasis is achieved.
Instruct the patient or the family to notify the nurse or practitioner if persistent or recurrent bleeding or an expanding hematoma develops at the venipuncture site.
Explain how the patient can assist with the procedure by remaining still (if appropriate).
Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
Introduce yourself to the patient and family.
Verify the correct patient using two identifiers.
Assess the patient’s developmental level and ability to interact.
Assess the patient’s history of similar procedures, the ability to tolerate the procedure, and the use of effective coping strategies.
1. Determine whether the patient has benefitted from the use of topical analgesia in the past.
2. Consider using a topical or local anesthetic (Table 1).
Assess the patient for conditions that can be aggravated or disrupted by venipuncture, such as anticoagulant therapy, low platelet count, and bleeding disorders.
Determine the patient’s history of injury and infection; assess the patient for contraindicated venipuncture sites because of a hematoma, IV line, a Blalock-Taussig or hemodialysis shunt, or renal grafts and fistulas in the extremities.
Determine if the patient has infusions via peripheral or central access.
Identify fasting restrictions for the ordered laboratory tests.
Review the patient’s medication history.
Assess the patient’s hydration and perfusion status.
Determine the patient’s desire for the family to be present during the procedure.
Determine the family’s desire to be present during the procedure.
Determine the patient’s ability to cooperate during the procedure.

Preparation

If time permits, engage a child life specialist to prepare the patient and assist with distraction during the procedure.
Obtain the patient’s weight in kilograms.
Verify the practitioner’s orders.
Identify the minimum blood volumes required for specimen collection.
Rationale: Drawing minimum volumes decreases the incidence of iatrogenic anemia.
Identify any special requirements regarding laboratory specimens (e.g., being placed on ice).
Collect and assemble the equipment and supplies for the procedure (Figure 1).
Use small-volume syringes to avoid vein collapse from the negative pressure created by a larger syringe.
If using a topical anesthetic cream, don gloves and apply it as ordered and per the manufacturer’s instructions. Cover the cream with a transparent semipermeable dressing or apply a topical anesthetic patch.
Rationale: Onset of action of these agents requires application before the procedure begins.
Discard supplies, remove PPE (if worn), and perform hand hygiene.

PROCEDURE

Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
Verify the correct patient using two identifiers.
Explain the procedure to the patient and family and ensure that they agree to treatment.
Provide privacy for the patient or use a designated treatment area.
Ensure adequate lighting. Consider using a transilluminator or vein finding ultrasound.
If a topical anesthetic is used, ensure that it is on the skin for the appropriate length of time per the manufacturer’s recommendations (Table 1). Don clean gloves and remove the topical anesthetic from the skin completely after the allotted time. If a topical anesthetic is not used, consider using oral sucrose in infants younger than 6 months old.4
Discard supplies, remove gloves (if worn), and perform hand hygiene.
Identify an appropriate venipuncture site (Figure 2) (Figure 3).
1. Use veins in the hand, forearm, or the antecubital fossa.
2. Consider using the veins of the scalp for an infant or the veins of the foot (if not walking) for infants and toddlers. Use these sites only if other sites are not available.
3. Avoid using veins in the right arm after procedures treating congenital cardiac defects that may have decreased blood flow to the subclavian artery.
4. If the patient can participate in activities of daily living or sucks a thumb, avoid the dominant or preferred hand.
Ensure that the site is warm and well perfused. Consider applying an organization-approved hot pack or warm compress to help dilate the blood vessels.
Rationale: Obtaining a sample from a cool extremity may be difficult because of vasoconstriction.
With the help of another health care team member or a family member, position the patient based on age and developmental level (Figure 4). Use distraction techniques for pain reduction, as developmentally appropriate.1
1. Have the health care team member or family member hold the patient and position the extremity to be used for the venipuncture site (Figure 4).
  Rationale: Holding the patient ensures that the position is maintained and the site is not contaminated.
2. For an infant receiving a venipuncture in the foot, have the health care team member or family member hold the patient against his or her body on the edge of the table.1
  Do not offer a bottle to an infant during the procedure because choking may occur.
Perform hand hygiene and don clean gloves.
If unable to observe or palpate a vein, apply a tourniquet a few inches above one of the selected venipuncture sites.
If possible, avoid using a tourniquet to reduce the risk of injury to the vascular endothelium. If a tourniquet is required, limit the time of use to reduce the risk of hemolysis and inaccurate laboratory results.
1. Encircle the extremity and pull one end of the tourniquet over the other, looping one end under the other (Figure 5).
2. Apply the tourniquet so that it can be removed by pulling the end with a single motion (Figure 6).
  Do not keep the tourniquet on the patient longer than needed.
Palpate the venipuncture site (Figure 7).
1. If the vein cannot be palpated and the tourniquet is in place longer than 1 minute, remove it and either assess another vein site or wait 1 minute before reapplying it.8
2. If the alternate vein cannot be palpated or viewed easily, remove the tourniquet and apply a warm compress over the extremity.1
  Rationale: Heat causes local dilation and makes the vein more visible.
Prepare the venipuncture site.
1. Cleanse the site with friction using a gauze pad and a 70% isopropyl alcohol solution.3
2. Allow the area to air-dry.
  If the specimen is being collected for a blood alcohol level, use a nonalcohol-based cleanser.3
  
  Do not touch the site after preparation unless sterile gloves are worn.3
If using a butterfly needle, hold it by the wings (Figure 8). Enter the vein at a slight angle from the arm with the bevel facing upward just distal to the exact site selected for vein penetration and look for blood return (Figure 9).
Rationale: This technique allows controlled entry into the vein after the skin has been pierced. Entering the skin distal to the vein prevents unanticipated vein puncture, which may result in inadequate blood specimen retrieval and development of a hematoma.
While applying slight traction to the skin and vein, insert the tip of the needle distal to the site selected for vein penetration, holding the needle at a slight angle with the bevel facing up.
Rationale: Applying traction serves to stabilize and straighten the vein, allowing easier penetration without going through the vein. The patient may move slightly, even when well immobilized, in response to the initial puncture. Entering the skin distal to the vein prevents unanticipated vein puncture, which may result in inadequate blood specimen retrieval and a large hematoma.
Enter the vein using a quick, small thrust to penetrate the skin. A slight popping sensation may be felt as the needle enters the vein.
Rationale: Entering the vein using a quick, small motion allows a controlled entry into the vein to avoid through-and-through penetration of the vein and extravasation of blood into the surrounding tissues.
Verify entry into the vein by watching for a flashback of blood into the tubing of the butterfly system.
Withdraw the blood volume needed for the ordered laboratory tests by pulling gently on the syringe plunger to fill the syringe with blood.
Release the tourniquet (if applied) before removing the needle.
Rationale: Venous distention is no longer required; removing the tourniquet decreases hematoma formation.
Apply a clean gauze pad over the puncture site without applying pressure and quickly but carefully withdraw the needle from the vein, activating the safety lock system.
Rationale: Pressure over the needle can cause discomfort. Carefully removing the needle minimizes discomfort and vein trauma.
Immediately apply pressure over the venipuncture site with gauze or an antiseptic pad until the bleeding stops. Instruct the patient or family member to hold the gauze in place and to apply direct pressure.
If blood was collected in syringes, transferred the blood to the appropriate laboratory specimen tubes using a blood transfer device.
Follow the order of the draw specified by the laboratory to ensure that the specimens are processed correctly and yield accurate results.
In the presence of the patient, label the specimen per the organization’s practice.7
Place the labeled specimen in a biohazard bag and transport the specimen to the laboratory immediately, per the organization’s practice.
Apply an adhesive bandage to the site when hemostasis is achieved. If there is a risk of aspiration, remove the bandage.
Praise the patient for cooperating and holding still. Encourage the family to comfort the patient.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.

MONITORING AND CARE

Monitor the venipuncture site for active bleeding.
Rationale: Bleeding may occur after the vein is punctured if inadequate pressure is applied, particularly in an active patient.

Reportable condition: Persistent active bleeding
Monitor perfusion distal to the puncture site.
Rationale: Inadvertent arterial puncture may affect perfusion distal to the puncture site.

Reportable condition: Decreased or absent perfusion distal to the puncture site
Determine whether the patient remains anxious or fearful. Give stickers or other rewards for good behavior as developmentally appropriate.
Rationale: The patient may require more blood tests in the future. Anxiety or concerns should be expressed and addressed.
Assess, treat, and reassess pain.

EXPECTED OUTCOMES

Venipuncture is performed successfully with one attempt.
Desired laboratory specimens and accurate results are obtained.
Pain and anxiety are controlled adequately during the procedure.
Patient remains free from complications of venipuncture.
Patient and family tolerate the procedure with minimal distress.

UNEXPECTED OUTCOMES

More than one attempt is needed to obtain samples.
Pain and anxiety are inadequately managed.
Inadequate blood volume is obtained; specimens cannot be processed.
Specimen is contaminated by IV fluids infused at another site in the extremity.
Specimen is hemolyzed.
Significant hematoma or infection develops at the puncture site.
Hemostasis is not achieved.
Patient or family member becomes dizzy or faints during venipuncture.

DOCUMENTATION

Date and time of venipuncture, specimens obtained, disposition of the specimen
Gauge and type of needle used to perform venipuncture
Number of attempts, and name and credentials of person performing the procedure
Site of venipuncture
Techniques used to facilitate procedure (e.g., distraction or positioning techniques)
Patient's tolerance of procedure
Patient's weight in kilograms
Unexpected outcomes and related interventions
Education

REFERENCES

Anderson, C.E., Herring, R.A. (2022). Chapter 20: Pediatric variations of nursing interventions. In M.J. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 551-618). St. Louis: Elsevier.
Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). (2018). Skin disinfectants. In Neonatal skin care: Evidence-based clinical practice guidelines (4th ed., pp. 88-94). Washington, DC: Author. (Level I)
Ernst, D.J., and others. (2017). Chapter 2: Blood specimen collection process. Collecting cultures: In GP41: Collection of diagnostic venous blood specimen (7th ed., pp. 5-30). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
Hellsten, M. (2022). Chapter 5: Pain assessment and management in children. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 114-147). St. Louis: Elsevier.
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 I)
Johnstone, B.A. (2020). Chapter 12: Pain assessment and management. In Emergency nursing pediatric course: Provider manual. (5th ed., pp. 119-127) Burlington, MA: Jones and Bartlett Learning. (Level VII)
Joint Commission, The. (2022). National Patient Safety Goals® for the hospital program. Retrieved April 29, 2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf (Level VII)
Perry, A.G. (2018). Chapter 7: Specimen collection. In A.G. Perry and others (Eds.), Clinical nursing skills and techniques (10th ed., pp. 178-215). St. Louis: Elsevier.