First of all, I'm so happy that you love your job! Yay for the babies. Secondly, don't fret! there is indeed a technique, and you'll get it in no time, I promise. I felt exactly the same way when I first started, so you're not alone!! I promise you that if you are patient with yourself you will find that you'll be able to stick the babies with a minimum of pain and a minimum of blood loss! Remember, some babies may be dehydrated (and, thus, "bad bleeders") or simply small (no blood to spare!) or clot easily (you'll love your babies on Heparin for this fact alone). They may have vascular compromise, and some will make you pull your hair out. They may have a central line that you can draw from, making everything but glucoses easy to access (the glucose sample may become "contaminated" by the high dextrose content in their TPN- sometimes you can avoid this by turning the line off to the IVF's, flushing a bit, and then waiting a few minutes to get a "purer" sample).
But! Simple heelsticks. Let's talk about those.
Yes, you'll be checking blood levels of various things often in the NICU (blood draws alone can sap a baby of blood so quickly that it's not uncommon for your little ones to require transfusions just to replace the blood we end up taking! Boo on us!).
First of all, I'm not sure that you meant this, but you don't need to do a heelstick in order to get a capillary sample for a glucose level. Only a single drop of blood is needed for this (okay, two drops- always wipe away the first drop and get your reading on the second), and doing a heelstick, IMO, is unnecessary/excessive unless you're also obtaining other blood samples at the same time (ie, for AM labs or for a blood gas, which brings me to another point- CLUSTER YOUR STICKS! Coordinate your care with the respiratory team so that you can minimize the number of times the baby gets stuck whenever possible!). The lancets used for heelsticks (like the Tenderfoot lancets- the white/pink or blue/pink ones?) have longer blades that go a bit deeper; they're meant for larger blood samples. When getting a glucose sample only, you can use a smaller lancet (like the tiny pink lancets or the white ones with the blue push button- I've seen both and have no idea who makes them, but hopefully you'll know what I'm talking about). Also, you can get a glucose from the big toe or thumb, or, if you have to, any of the fingers or toes (and alternate your sites so that the puncture areas have a chance to heal). If your unit is doing heelsticks for just blood glucose, I would highly suggest that you talk to your supervisor about this in a non-confrontational, professional way and find out why. If people are doing this regularly, perhaps this is a practice that should be changed- maybe you can get an inservice from someone to teach everyone on the unit the proper way to draw blood? Someone from phlebotomy? An NNP? A nurse who has done her research? Don't be afraid to question! Advocate for the babies! No one can ever fault you for looking out for the best interest of the babies, even if you are incorrect!
So, for fingersticks, you should be using a lancet similar to one of these:
With heelsticks for larger blood draws, like a Chem7 or AM panel, a CBC, etc., you should use a larger lancet (like the Tenderfoot), but be sure to use one that is size appropriate- don't use the largest one (the pink/blue one) on your 25 weeker! They come in at least two sizes. Ideally, you want your puncture to be in between 2 and 2.4 mm long and NO MORE than about 2.4mm deep. 2.4mm deep is what you'd be looking for with your biggest term baby; preemies and micropreemies would be a lot smaller. Each lancet is different, and the heel blades go up to about 2.4mm deep, while the fingerstick lancets go less than half of this depth. They are all different, so be sure you know what you're using- check the manufacturer's packaging if you're unsure, or ask a phlebotomist or call the lab if no one can help you figure this out. With heelsticks, you should be using a lancet that looks like one of these:
Look at the heels and pick the one that is free for puncture and choose a site that has not been stuck already (don't re-puncture over a site that's still healing). You're looking at the lateral parts of the foot only, not the middle. Imagine the bottom of a baby's foot and draw an invisible "V" over it- only stick to the sides of the "V", never in the middle. You can nick the bone and cause nerve damage (and I've seen babies develop osteomyelitis from this- one required an amputation) if you puncture in the middle of the heel or too far up on the back of the heel (ie, in the achilles tendon area). Try this diagram:
(area shaded in green is where you would try for your sample):
Next, apply a heel warmer to the heel and ankle; secure it with the tabs or with a bit of tape if you have to. Make sure it is wrapped snugly to the skin; if you are able/so choose, use two- one on the calf and another on the foot. Leave this in place for 3-5 minutes (there aren't any shortcuts here! You can apply this while you collect the supplies or label your ID stickers or whatever) to let those capillaries vasodilate. Allowing this to occur will increase your blood flow up to SEVEN times compared to if you don't use the heat source. This makes a significant difference!
When you're ready to stick, cleanse the entire heel surface with alchohol and rub it vigorously- the rubbing of the skin helps to increase the blood flow to the site. How to hold it: This will take a bit of imagination. Picture a baby in front of you on his/her back (you can also do this with them on their tummies, but for argument's sake, let's let gravity and anatomy help us, okay?)
Hold your hand with your fingers pointing at the baby's toes. Look at your left fist right now. Point your thumb and index finger like you're shooting a toy gun. The last three fingers will be wrapped around the baby's calf. The index finger will be in the little posterior ankle indentation (the achilles area) just below the heel (below to *your* perspective with the baby on his/her back). Your thumb will then go along the baby's plantar surface, with your thumbnail pointing towards their heel. Hold them firmly (but not hurting!) and use your right hand to place the lancet against their foot at the proper angle (following that diagram) and press it to the skin firmly. The firmer you press it, the deeper your cut will be. If you barely hold it to the skin, you'll only nick the surface and won't get a good sample because you haven't gone deep enough. Likewise, if you hold it with too much pressure, you're going deeper than you have to. It's judgement, but I PROMISE you that you'll learn to know exactly how deep to go with practice!
Depress the button and pierce the skin, but hold it there for just a millisecond before you remove it. Now, drop the lancet like a hot potato and wipe away the first drop (a- because if you're getting a glucose first, you can't use the first drop, and b- you want to make sure that your sample isn't contaminated by antiseptic/alchohol, which will cause the lab to call you up and make you do it all over again). Grab your collection tube/capillary tube/whatever you're doing and hold it under the puncture. Use gravity to your advantage- if you hold the extremity down, gravity helps you. If you hold their heel up in the air it's going to clot quick as cake and you'll be up a creek.
The first trick is preperation of the site. The second trick is to get the right grip- practice, practice. The third trick (sheesh- so many tricks!) is to SQUEEZE it properly. What you want to do is squeeze gently, release, squeeze, release, push that blood out gently, then release and let the blood flow, compress, release. Similar to milking a cow, start the squeeze high on the calf with your lower fingers, and then squeeze VERY GENTLY towards the heel, rolling motion from pinky to thumb. You'll see right away how much or little you have to squeeze- sometimes it flows like a river, sometimes you have to work it a teensy bit. Now, you don't want to ACTUALLY milk the foot, because this can cause contamination of the sample with serous fluid leaking from the surrounding tissue; I only put in the "milking" thing so you understand you're gently rolling your fingers in a fluid motion in the direction of the calf to the heel. Squeezing too hard will compress the vasculature, blocking blood flow to the site and causing it to clot. Think gentle, rolling motion. All you're doing is saying, "Come on little blood droplets, roll on out to mama." And yes, it's okay to say this out loud. I find chanting it while your co-worker drums on a dumbek behind you is quite effective.
When you're finished, I usually use one hand to gently rock my tubes and the other to hold a clean piece of gauze over the site to stop the bleeding. When it is stopped, use a new, clean piece of gauze and either tie it or wrap/tape it around the foot. I am NOT a band-aid advocate when it comes to infants- I've seen huge areas of skin just peel right off of a preemie's foot when removing a bandaid. STAY AWAY FROM THE BANDAIDS! I see people use them all the time, but they're not recommended by anything I've ever read, and gauze after pressure will do just fine.
In the AM, when I have multiple labs, I'll get my CBG for the respiratory therapist first so it's not fricked up because the baby is crying for ten minutes before I get it, then I'll get my glucose drop or have them get it for me, then you get your CBC and lastly, whatever other labs you have to get. Takes about five minutes or less, and I swear to you it is RARE for one of my babies to cry or fuss when I'm doing this. The key is GENTLE.
Almost like a massage. However, some of them will fight you, and this is why God created Ativan.
Or am I? Muhahaha. Look, I worked last night and my brain is Jell-O. Hope this helps.
**Note: I edited this after taking a much-needed nap to clarify the thoughts that were rattling around half-thunk. Sorry.