heel sticks?

Marnie,

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:

http://www.vh.org/adult/provider/pathology/CLIA/Phlebotomy/Images/Image04.jpg

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.

Kidding. 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.

Two more little teensy things:

The outside of the foot (vs. the inside) has a better capillary bed, and you'll get better flow from this if it is available.

This can be uncomfortable to the babies, so find out if you're allowed to use something like a sucrose-dipped pacifier on your unit prior to sticking. Sucrose is like crack to them. It is highly effective and I would recommend this if your unit allows it. Nice, easy, non-invasive way to soothe the baby and decrease the trauma of your mean, brutal slicing-of-the-skin.

Kristi,

Excellent instructions. Maybe I should leave a copy of that lying around at work...... Our lancets leave a slice, and babies with frequent heelsticks really suffer. I hadn't thought about using toes, though. We would need smaller lancets to stick those.

California only allows safety devices, including lancets, needles, IV catheters...these have all improved over the last few years, but those little BD lancets were very useful, and now we can't get them any more.

Mimi,

Thank you. :kiss I'm developing an inservice as a review of phlebotomy techniques/PKU's for our education committee, so it's all fresh to me again.

Most of the lancets do leave a slice rather than a hole, so to speak; unfortunately, from what I've read, the slice is necessary to expose more of the capillaries and thus make available to you more blood for your sample. However! You can certainly minimize this by choosing the appropriate lancet, depending on the baby's size and weight and sub-q fat percentage. The lancets truly do vary from company to company, and most of the companies make more than one size for infants (some, like the Tenderfoot lancets for heelsticks, come in four sizes- toddler, infant, preemie, and micropreemie). All of the ones I've seen are self-retracting safety lancets with one-time only buttons that can't be depressed again after the initial use. Also, all of the devices I've seen are made specifically to go a certain depth, so you really, really minimize the trauma to the heel that way.

You can use a toe or finger for glucose (preferably a toe, but they make special lancets that only penetrate 0.25mm, I believe, just so you can do fingersticks on the babies), and I have, in a no-other-choice situation, used both toes and fingers to get CBG's, though I personally don't feel comfortable with that, as I think it's a bit too much blood for such a small area. Just MHO. Big toes are perfect, especially if you've got a baby whose heels are just raw. There is absolutely no sense in heelsticking a baby just for two tiny drops of blood. With a nice big toe and a small lancet, you get a fat drop of blood and a tiny puncture wound.

I have seen RT's and occasionally other nurses or phlebotomists using a well-baby lancet to do a heelstick on a preemie and I have gone ballistic (okay, my "ballistic" means smiling with my teeth clenched, but hey...I can seethe in private!). They make all these devices different for a reason! :)

I'll hush now, lest people think I am a bloodletting maniac.

Just want to point out that if you use the Tenderfoots like I do, that you should use the appropriate size. We have Preemie size on the unit, but if I have to get labs on a term baby, I'll go to the nursery and get Newborn size. If I'm only going to get a blood sugar, I'll use the Preemie.

With the preemies, if I'm only getting a blood sugar, I'll use the Micro size. Why jack up those heels more for just a drop of blood?

Also, don't fight gravity. You'll get that much more blood if you hold the foot down than if you have it waaayyy up in the air.

I just have to add...always check your protocols....we aren't permitted to do toe or fingersticks without a written order...because we had some docs and nurses that would use the larger lancets or a needle. A nice set up for osteo.

We aren't permitted to use those little lancets anymore because of the nonsafety issue.

Heelwarmers are a great invention :)

Originally posted by NicuGal

Heelwarmers are a great invention :)

Great for, "That time of the month" too!:roll

Thank you everybody for your input!

Kristi you are so awesome-you always have so much good information. The lancets in our unit don't look like any in the picture (I don't know the brand name either). We only have three types. All are the self-retracting with the one time only buttons. For the smallest babies, we use a purple lancet and for the larger babies we use a blue lancet. That is just to get a couple of drops of blood for the BS. For blood draws (CBC, bili, etc.), there is a large pink colored lancet. This is the only one used for obtaining blood for labwork, regardless of the baby's size. It makes a pretty large slice in the heel. And yes, so far I've taken care of two babies that needed blood transfusions! It is terrible that we take so much from them. And their poor heels look so sore.

I'm going to ask about using heel warmers. So far, I haven't seen such a thing used, but it won't hurt to ask. By the way, I work in a Catholic charity hospital and I get the feeling that there are a lot of things used in other hospitals that they can't afford here. Also, they don't let us use alcohol wipes. We have to use Betadine wipes, which I hate because they are so messy!

I'm going to use the good tips mentioned here. I find that I tend to pull the baby's foot up towards me, but I will now remember to let the foot dangle-gravity is my friend! I'll even try talking to the blood drops to coax them out. Believe me, I'll try anything! Seriously, I think my problem is the grip/squeezing technique. I will be practicing that.

Tomorrow I'm going to be in the well-baby nursery. They want me to see how healthy babies look, to be able to better see the differences in the babies in the NICU. But I am going to track down our unit educator, who is also an NNP. I will ask her about doing toe and fingersticks instead of heel sticks for glucose testing. And if it is possible to have more varied choices of lancets. And I'll also ask about heel warmers. And dipping the pacifier in sucrose-that sounds like a good idea! (I guess I'll be asking her a lot of questions!)

Thanks again everybody for your help!

Kristi thank you soooo much for that awesome detailed post. I did quite a few blood draws while I was precepting this spring, but like Marnie, I usually had trouble getting the mechanics down properly to get a good bloodflow. Your tips and explanation really help, and I feel more confident now - I take my boards Monday and start work August 6th. I can't wait to get back in the NICU!!!